South Asian older adults with memory impairment: improving assessment and access to dementia care

Improving Conversations about Parkinson's Dementia

BACKGROUND

People with Parkinson's disease (PD) have an increased risk of dementia, yet patients and clinicians frequently avoid talking about it due to associated stigma, and the perception that "nothing can be done about it". However, open conversations about PD dementia may allow people with the condition to access treatment and support, and may increase participation in research aimed at understanding PD dementia.

OBJECTIVES

To co-produce information resources for patients and healthcare professionals to improve conversations about PD dementia.

METHODS

We worked with people with PD, engagement experts, artists, and a PD charity to open up these conversations. 34 participants (16 PD; 6 PD dementia; 1 Parkinsonism, 11 caregivers) attended creative workshops to examine fears about PD dementia and develop information resources. 25 PD experts contributed to the resources.

RESULTS

While most people with PD (70%) and caregivers (81%) shared worries about cognitive changes prior to the workshops, only 38% and 30%, respectively, had raised these concerns with a healthcare professional. 91% of people with PD and 73% of caregivers agreed that PD clinicians should ask about cognitive changes routinely through direct questions and perform cognitive tests at clinic appointments. We used insights from the creative workshops, and input from a network of PD experts to co-develop two open-access resources: one for people with PD and their families, and one for healthcare professionals.

CONCLUSION

Using artistic and creative workshops, co-learning and striving for diverse voices, we co-produced relevant resources for a wider audience to improve conversations about PD dementia.

The association between memory, COVID-19 testing, and COVID-19 incidence in middle-aged and older adults: a prospective analysis of the CLSA

We investigated the association between pre-COVID-19 memory function and (a) receipt of a COVID-19 test and (b) incidence of COVID-19 using the COVID-19 Questionnaire Study (CQS) of the Canadian Longitudinal Study on Aging (CLSA). The CQS included 28,565 middle-aged and older adults. We regressed receipt of a COVID-19 test on participants' immediate and delayed recall memory scores and re-ran the regression models with COVID-19 incidence as the outcome. All regression models were adjusted for sociodemographic, lifestyle, and health covariates. In the analytical sample (n = 21,930), higher delayed recall memory (better memory) was significantly associated with lower COVID-19 incidence. However, this association was not significant for immediate recall memory. Immediate and delayed recall memory were not associated with receipt of a COVID-19 test. Health policymakers and practitioners may viewmemory status as a potential risk for COVID-19. Memory status may not be a barrier to COVID-19 testing.

A qualitative study exploring nurses' experiences of supporting South Asian people with dementia and their family carers

AIMS

To explore nurses' experiences of providing support to South Asian (SA) people with dementia and their family carers and to identify barriers and enablers of good transcultural care.

DESIGN

A qualitative, phenomenological design was used.

METHODS

Fifteen registered community and in-patient nurses were recruited via one NHS Mental Health Foundation Trust. Nurses were from diverse backgrounds (Black, Ghanaian, Irish, Mauritian and White), 13 females and 2 males, and had been qualified from between 2 and 49 years. One-to-one semi-structured interviews were conducted between July and October 2019.

RESULTS

A thematic analysis identified three themes. 'Communication challenges' highlighted the impact of language barriers and the consequences of misunderstandings due to a dissonance in cultural values between nurses and interpreters. 'The bi-directional impact of culture' identified the two-way dynamics of transcultural work, the process of countering mutual stigma, and revealed an original perspective on how 'cultural desire' grows through practice experiences rather than being a prior motivation for learning. 'Learning experiences' showed that most learning was informal, experiential and prolonged, with nurses feeling they had unmet learning needs.

CONCLUSION

Nurses have minimal training opportunities and are under-supported in their transcultural work, potentially perpetuating the disadvantages that SA people with dementia and their families face in relation to healthcare. Enhanced cultural understanding of self and others and application of specific communication strategies could support nurses, together with interpreters, to build rapport and effective working relationships with each other and service users.

IMPACT

Transcultural nursing is a key competency, but nurses experience difficulties with providing care which is recognized as effective by SA family carers. The development of more acceptable and effective services requires improved mutual cultural understanding between nurses, interpreters and families, underpinned by joint brief training interventions, leading to more effective professional communication, better care outcomes and improved satisfaction with services.

'Here, we describe them as forgetful, confused, and absent-minded': dementia knowledge, stigma, and care plan among Vietnamese adults in rural area

OBJECTIVES

This study aims to investigate dementia knowledge, dementia stigma, and self-rated importance of dementia plan, and their associated factors among Vietnamese adults in rural Vietnam.

METHODS

A total of 325 participants completed the survey. The first section presented two vignettes and related open-ended questions. Participants described what terms local people in their community use, and what potential disease they thought the persons in the vignettes may have. Conventional content analysis was used to search for the key categories. The second section of the survey consisted of closed-ended questions from different measures. Two multivariate regression models were performed on dementia stigma and prioritizing dementia care plan.

RESULTS

The study results show that participants held a moderate level of knowledge about dementia, yet they tended to use symptom- and stigma-connoted language to describe people with dementia. Their dementia stigma was reported at a middling level and was positively associated with age, number of older adults they have currently lived with, and anxiety about aging, and negatively associated with being married, knowing someone with dementia, and having greater Alzheimer's disease knowledge. Most participants prioritized a future dementia care plan. The odds of this intention increased among those who have known someone with dementia, worried about getting dementia and caring for someone with dementia in the future, and had a higher level of Alzheimer's disease knowledge.

CONCLUSION

The study results highlight the importance of dementia knowledge and exposure to people with dementia in reducing dementia stigma and increasing the chance for dementia care planning.

Factors influencing access to nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia: An integrative review

WHAT IS KNOWN ON THE SUBJECT

Research has shown effectiveness of nonpharmacological interventions in improving or maintaining cognition, mood, functioning, self-efficacy and quality of life for persons with mild-to-moderate dementia (PWDs). These interventions are critical during the earlier stages of dementia. However, Canadian and international literature report underutilization of and difficulty accessing the interventions.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

To our knowledge, this is the first review that explored factors influencing seniors' utilization of nonpharmacological interventions in the earlier stages of dementia. This review contributed to the discovery of unique factors such as PWDs' beliefs, fears, perceptions, and acceptability of nonpharmacological interventions and environmental influences on intervention provision. PWDs' intervention uptake may appear as a matter of personal choices related to individuals' knowledge, beliefs and perceptions. However, the analysis of the research evidence suggests that PWDs' choices are shaped by environmental factors such as formal and informal caregiver support, acceptability and accessibility of nonpharmacological interventions, dementia care workforce, community's attitudes towards dementia and funding. The complex interplay among factors highlights the importance of targeting health promotion strategies at both individuals and their environments.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The review findings feature opportunities for healthcare practitioners, including mental health nurses, in advocating for PWDs' evidence-informed decision-making and access to desired nonpharmacological treatments. Involvement of patients and families in care-planning through ongoing assessment of health and learning needs, as well as enablers and barriers to using interventions, continuing information provision, and personalized referrals to appropriate services can promote PWDs' rights to healthcare.

ABSTRACT

INTRODUCTION: Despite the significance of nonpharmacological interventions in optimal management of mild-to-moderate dementia, it remains unclear in the literature how persons with mild-to-moderate dementia (PWDs) view, understand and access nonpharmacological interventions.

AIM

The purpose of this review was to explore the extent and nature of evidence concerning factors that influence the use of nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia.

METHOD

An integrative review was undertaken following Toronto and Remington (A step-by-step guide to conducting an integrative review, 2020)'s instruction which expanded Torraco (Human Resource Development Review, 2016, 15, 404)'s and Whittemore and Knafl (Journal of Advanced Nursing, 2005, 52, 546)'s guidance.

RESULTS

The review of 16 studies suggests that PWDs' use of nonpharmacological interventions is shaped by a complex interplay of various personal, interpersonal, organizational, community and political influences.

DISCUSSION

The findings highlight the complex, interrelated relationships among multiple factors and subsequent limitations of behaviour-oriented health promotion strategies. To assist PWDs in making healthier choices, health promotion strategies need to direct attention to both individuals' behaviours and environmental conditions impacting the behaviours.

IMPLICATIONS FOR PRACTICE

The findings of this review can inform multidisciplinary health practitioners' (including mental health nurses) practice with seniors living with mild-to-moderate dementia. We recommend actionable ways in which they can empower patients and their families in dementia management.

Cultural inclusivity and diversity in dementia friendly communities: An integrative review

People with dementia from culturally and linguistically diverse backgrounds often face poor health and social outcomes such as stigma, depression, and reduced help seeking behaviours. Dementia friendly communities have been shown to reduce stigma, and the gap in health and social outcomes for people impacted by dementia. Despite the large presence of established dementia friendly communities, their functioning in multicultural communities remains underexplored. The aim of this review was to identify the barriers and facilitators of cultural inclusivity to inform the development of a multicultural dementia friendly community. We systematically searched for academic and grey literature regarding existing and prospective age or dementia-friendly communities that engaged with culturally and linguistically diverse communities. Using the matrix method, data on the barriers and facilitators to engagement were extracted. Papers were analysed for common themes and findings were integrated in a narrative format. A total of 3,164 papers were identified, 11 of which met inclusion criteria. There were 6 dementia friendly communities in North America, 3 in Europe, 1 in Australia and 1 in Asia. Analyses revealed that barriers to cultural inclusivity were centered around the accessibility of services, sociocultural factors, and the environment, including issues such as low awareness of dementia and stigma, language barriers, isolation, and the inaccessibility of transport and buildings. Leveraging existing cultural leaders and social structures to target culturally and linguistically diverse populations and develop tailored dementia friendly initiatives were key facilitators. To foster cultural inclusivity in dementia friendly communities, a culturally specific lens that addresses these barriers and utilises facilitators must be applied from the design stage through to implementation and evaluation.

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.

Equity in care and support provision for people affected by dementia: experiences of people from UK South Asian and White British backgrounds

OBJECTIVES

To explore the care and support received and wanted by United Kingdom (UK) South Asian and White British people affected by dementia and whether access to it is equitable.

DESIGN

Semi-structured interviews using a topic guide.

SETTING

Eight memory clinics across four UK National Health Service Trusts; three in London and one in Leicester.

PARTICIPANTS

We purposefully recruited a maximum variation sample of people living with dementia from South Asian or White British backgrounds, their family carers, and memory clinic clinicians. We interviewed 62 participants including 13 people living with dementia, 24 family carers, and 25 clinicians.

MEASUREMENTS

We audio-recorded interviews, transcribed them, and analyzed them using reflexive thematic analysis.

RESULTS

People from either background were willing to accept needed care and wanted competence and communication from carers. South Asian people frequently discussed needing care from someone with a shared language, but language differences could also be an issue for White British people. Some clinicians thought South Asian people had a stronger preference to provide care within the family. We found that preferences for who provides care varied across families regardless of ethnicity. Those with more financial resources and English language have more options for care that meets their needs.

CONCLUSIONS

People of the same background make differing choices about care. Equitable access to care is impacted by people's personal resources, and people from South Asian backgrounds may experience the double disadvantage of having fewer options for care that meets their needs and fewer resources to seek care elsewhere.

Ethnic Variations in Patient Outcomes in a Memory Clinic Setting Between 2013 and 2021

BACKGROUND

The incidence of dementia in Black and Asian populations in the UK is set to rise. There is concern surrounding differences in services provided for different ethnic groups.

OBJECTIVE

This study aimed to examine ethnic variations in survival, services accessed, and medication use across White, Black, and Asian groups in routine memory clinic setting.

METHODS

We retrospectively examined referrals to a memory service between 2013 and 2021. A random sample of 104 White, 99 Asian, and 74 Black patients were analyzed for differences in support services, voluntary services, medication use, and survival rate.

RESULTS

There were statistically significant differences in survival of the Asian compared to the White group (Hazard ratio (HR = 2.17,95% confidence interval (CI) 1.23-3.85, p = 0.008)) following adjustment for age, gender, diagnosis, cognitive impairment, severity, access to support and voluntary services, and use of cholinesterase inhibitors, N-methyl-D-aspartate antagonists, and antipsychotics. The Asian group showed a statistically significantly reduction in access to support services compared to the White group (HR = 0.05, 95% CI 0.01-0.37, p = 0.003). In contrast, the survival rate was similar between the White and Black dementia patients.

CONCLUSION

We found significantly reduced survival and reduced access to support services in Asian compared to White patients with dementia. Further research is needed to investigate the generalizability of our results, and determine the cause, and consequent remedies of these associations in ethnic minority groups.

Taking the 'care' out of care homes: The moral dilemma of institutional long-term care provision during COVID-19

Little is known on how the pandemic has changed care home care delivery. The aim of this study was to explore the impact of COVID-19 on care provision and visits in care homes from staff and family members' perspectives. For this purpose, we conducted a telephone- and zoom-based qualitative semi-structured interview study. Care home staff and family carers of people living with dementia (PLWD) across the UK were recruited via convenience sampling and participated via telephone or online. Participants took part in a semi-structured remote interview. Data were collected between October and November 2020. Anonymised transcripts were analysed separately by two research team members using thematic analysis, with codes discussed and themes generated jointly, supported by research team input. 42 participants (26 family carers and 16 care home staff) took part. Five themes were generated: (a) Care home reputation and financial implications; (b) Lack of care; (c) Communication or lack thereof; (d) Visiting rights/changes based on residents' needs; (e) Deterioration of residents. With a lack of clear guidance throughout the pandemic, care homes delivered care differently with disparities in the levels and types of visiting allowed for family members. Lack of communication between care homes and family members, but also government and care homes, led to family carers feeling excluded and concerned about the well-being of their relative. Improved communication and clear guidance for care homes and the public are required to negate the potentially damaging effects of COVID-19 restrictions upon residents, their families and the carers who support them.

Exploring the factors that influence equitable access to and social participation in dementia care programs by foreign-born population living in Toronto and Durham region

This paper reports the findings of a qualitative study conducted in Ontario, Canada with the purpose of identifying the barriers and facilitating factors of access to dementia care by foreign-born individuals, including immigrants and refugees. Interview data revealed seven overarching themes related to access and participation in dementia care programs by migrants, including structural, process, and outcome barriers. Our study findings suggest that incorporating culturally inclusive activity components in recreational dementia care programs will promote program participation by individuals from ethno-cultural backgrounds. It is essential to train health care providers to assist with building competence in working with people from different cultural and linguistic backgrounds. To prevent normalization of symptoms of dementia and promote timely access to dementia care, it is important to focus on generating awareness and acknowledgement of dementia as an illness rather than as a normal part of aging or a condition associated with stigmatization.

Using digital media to improve dementia care in India: A pilot randomised control trial (Preprint)

Background

Objective

Methods

Results

Conclusions

Trial Registration

International Registered Report Identifier (IRRID)

Dementia services for people from Black, Asian and Minority Ethnic and White-British communities: Does a primary care based model contribute to equality in service provision?

This study set out to investigate whether there were disparities in service provision for people from Black, Asian and Minority Ethnic (BAME) communities compared to White British (WB) communities within a primary care led dementia service in the UK. Data were extracted from 30 cases from three BAME (African-Caribbean, South Asian and Chinese) communities who had been referred to a dementia service between April 2016 and December 2017. We then extracted data from 30 WB cases matched for gender, age (within 5 years) and General Practitioner surgery. We compared service provision for both samples around assessment, diagnosis and post-diagnostic support. The primary source of information in the BAME sample was less likely to be recorded as being the main carer and more likely to be an adult child. Cases from both samples were equally likely to have a CT scan. People from BAME communities were less likely to receive a cognitive assessment, and when they did they scored at a lower level. There was no difference between samples for the diagnoses that cases received, but BAME cases were more likely to be assessed as being low rather than medium or high risk. While cases from both samples were equally likely to receive medication, BAME cases were more likely to be seen by a psychiatrist. Significantly more people from the WB sample were recorded as using or being offered more than one form of community support. This study of a primary care-based dementia service suggests that while many areas of service provision showed no evidence of inequality, important differences remain including the time at which people present for assessment and the range of post-diagnostic services which are discussed. Further research is required to establish the likely causes of these disparities.

Understanding help-seeking decisions in people with subjective cognitive decline: A systematic review of qualitative studies

OBJECTIVE

To synthesize the findings of qualitative research on help-seeking in people with subjective cognitive decline.

METHODS

Relevant qualitative studies were identified by searching the PubMed, CINAHL, Ovid Medline, PsycInfo, Embase, and Web of Science databases. Studies that investigated help-seeking behavior in older adults with subjective cognitive decline were retrieved. The systematic review was conducted in line with JBI methodology for systematic reviews of qualitative evidence.

RESULTS

11 studies were included and three themes related to the process of help-seeking for cognitive problems emerged. These themes included: detected changes, challenges in identifying the need for help and decision to seek professional help.

CONCLUSION

Making decisions to seek help for people with subjective cognitive decline is a multi-stage process. A better understanding of the complex psychological responses to subjective cognitive decline among older adults may help health care professionals to develop strategies to improve help-seeking in clinical practice.

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.

Boundary-crossers: How providers facilitate ethnic minority families' access to dementia services

BACKGROUND

Providers who work closely with ethnic minority people with dementia and their families are pivotal in helping them access services. However, few studies have examined how these providers actually do this work. Using the concept of 'boundary crossers,' this article investigates the strategies applied by these providers to facilitate access to dementia services for ethnic minority people with dementia and their families.

METHODS

Between 2017 and 2020, in-depth video-recorded interviews were conducted with 27 health, aged care, and community service providers working with ethnic minority people living with dementia across Australia. Interviews were conducted in language and in English, then translated and transcribed verbatim. The data were analyzed thematically.

RESULTS

Family and community stigma associated with dementia and extra-familial care were significant barriers to families engaging with services. To overcome these barriers, participants worked at the boundaries of culture and dementia, community and systems, strategically using English and other vernaculars, clinical and cultural terminology, building trust and rapport, and assisting with service navigation to improve access. Concurrently, they were cognizant of familial boundaries and were careful to provide services that were culturally appropriate without supplanting the families' role.

CONCLUSIONS

In negotiating cultural, social, and professional boundaries, providers undertake multidimensional and complex work that involves education, advocacy, negotiation, navigation, creativity, and emotional engagement. This work is largely under-valued but offers a model of care that facilitates social and community development as well as service integration across health, aged care, and social services.

Projections of Older European Migrant Populations in Australia, 2016-56

Many of the European migrant populations which settled in Australia in the three decades after World War Two are now much older, and their aged care and health care needs are changing. While there is a considerable literature on individual aspects of ageing in many migrant groups (particularly as it pertains to culturally appropriate aged care), little research attention has been given to population aspects of ageing and its implications. The aim of this paper is to address this lacuna by presenting projections of Australia's Europe-born older migrant population from 2016 to 2056. The population projections were created by a cohort-component model modified to accommodate multiple birthplace populations. Findings show the older Europe-born population is projected to experience a slight increase over the next few years, reach a peak of just under one million in the early 2030s, and then undergo a gradual decline thereafter. The Europe-born share of Australia's 65+ population will fall, from 25.5% in 2016 to 10% by 2056. Populations born in Western and Southern Europe are likely to decline throughout the projection horizon while, the Northern Europe-born and Ireland-born older populations are projected to grow continually. The populations born in the UK and South Eastern Europe initially grow before decline sets in. To a large extent the future population size of these older migrant groups will be the result of cohort flow. We discuss the implications of the coming demographic changes for government policy and culturally appropriate service provision.

How is migration background considered in the treatment and care of people? A comparison of national dementia care guidelines in Europe

Background

People with a migration background are vulnerable to dementia. Due to problems such as underdiagnosis or access barriers, the care of this population is a public health challenge in Europe. Many countries are issuing care guidelines, but a systematic overview of their references to migration groups is lacking. This study aims to analyze national dementia care guidelines regarding their focus on people with a migration background, what specific actions to ensure healthcare have been undertaken at the national level, and whether recommendations for action are made for this population.

Methods

This study is a systematic analysis of national dementia care guidelines of the EU and EFTA (European Free Trade Association) countries. Using the discourse analysis model by Keller (2011), 43 documents from 24 EU and 3 EFTA countries were systematically screened for migration references via keyword and context analysis. The content of the migration-related section was paraphrased, memos and comments were added, and the individual text passages were coded using the strategy of open coding.

Results

Twenty-seven of the 35 EU and EFTA countries have guidelines or similar documents on care for people with dementia, and 12 refer to migration. Norway, Sweden, and Northern Ireland refer to this topic in detail. The focus of the migration-related guidelines is on the early detection and diagnosis of dementia. The main message is that standardized diagnostic tools such as the MMSE (Mini-Mental State Examination) or the clock test are not suitable for linguistic minorities. Nine countries make recommendations for the care of people with a migration background and dementia, but only Norway, Sweden, and Denmark point to available healthcare services. A key recommendation is that the linguistic and cultural background of people should be considered when selecting diagnostic tests. Several countries refer to the validity of the RUDAS (Rowland Universal Dementia Assessment Scale) for migrants.

Conclusions

The topic of migration plays a subordinate role in the dementia care guidelines of European countries. Almost all countries lack appropriate diagnostic tools and healthcare services for people with a migration background. Consequently, this group is vulnerable to underdiagnosis and a lower level of care.

Experiences of People With Dementia in Pakistan: Help-Seeking, Understanding, Stigma, and Religion

BACKGROUND AND OBJECTIVES

The prevalence of dementia will increase in low- and middle-income countries like Pakistan. Specialist dementia services are rare in Pakistan. Public awareness of dementia is low, and norms about family care can lead to stigma. Religion plays a role in caregiving, but the interaction between dementia and Islam is less clear.

RESEARCH DESIGN AND METHODS

Qualitative interviews were carried out with 20 people with dementia in Karachi and Lahore. Interviews were conducted in Urdu, translated to English, and respondents' views on help-seeking experiences, understanding of diagnosis, stigma, and religion were analyzed thematically.

RESULTS

Although some people with dementia understood what dementia is, others did not. This finding shows a more positive perspective on diagnosis in Pakistan than previously thought. Help-seeking was facilitated by social and financial capital, and clinical practice. Stigma was more common within the family than in the community. Dementia symptoms had a serious impact on religious obligations such as daily prayers. Participants were unaware that dementia exempts them from certain religious obligations.

DISCUSSION AND IMPLICATIONS

Understanding of dementia was incomplete despite all participants having a formal diagnosis. Pathways to help-seeking need to be more widely accessible. Clarification is needed about exemption from religious obligations due to cognitive impairment, and policy makers would benefit from engaging with community and religious leaders on this topic. The study is novel in identifying the interaction between dementia symptoms and Islamic obligatory daily prayers, and how this causes distress among people living with dementia and family caregivers.

Ethnic variations in referrals to the Leicester memory and dementia assessment service, 2010 to 2017

BACKGROUND

The incidence of dementia in Black, Asian and minority ethnic (BAME) groups is increasing in the UK, with concern about underdiagnosis and late presentation.

AIMS

By reviewing referrals to memory clinics from Leicester City we examined whether the following differed by ethnicity: the proportion with a diagnosis of dementia, type of dementia and severity at presentation.

METHOD

We examined referrals between 2010 and 2017: all those whose ethnicity was recorded as Black (n = 131) and a random sample of 260 Asian and 259 White British referrals. Severity of dementia was assessed by record review. Odds ratios (ORs) were adjusted for general practice, age, gender and year of referral.

RESULTS

A diagnosis of dementia was recorded in 193 (74.5%) White British, 96 (73.3%) Black and 160 (61.5%) Asian referrals. Compared with Asians, White British had twice the adjusted odds of a dementia diagnosis (OR = 1.99 (1.23-3.22). Of those with dementia, Alzheimer's disease was more common in White British (57.0%) than in Asian (43.8%) and Black referrals (51.0%): adjusted OR White British versus Asian 1.76 (1.11-2.77). Of those with dementia, the proportion with moderate/severe disease was highest in White British (66.8%), compared with 61.9% in Asian and 45.8% in Black groups. The adjusted OR for the White versus Black groups was 2.03 (1.10-3.72), with no significant difference between Asian and White British groups.

CONCLUSIONS

Differences in confirmed dementia suggest general practitioners have a lower threshold for referral for possible dementia in some BAME groups. Unlike other centres, we found no evidence of greater severity at presentation in Asian and Black groups.

The Barts Explanatory Model Inventory for Dementia: An item reduction approach based on responses from South Asian communities

BACKGROUND

Cultural differences in how the symptoms, causes, consequences, and treatments of dementia are understood and interpreted by South Asian people are a commonly expressed reason for late- or nonuse of mental health and care services. However, systematic collection of information on South Asian perceptions of dementia is hindered by a lack of appropriate instrumentation.

OBJECTIVES

To produce a shortened version of the Barts Explanatory Model Inventory for Dementia (BEMI-D) schedule.

METHODS

A two stage item reduction approach was employed first using multidimensional scaling categorizing items as core, intermediate, or outlier. Then, item review was undertaken using three criteria: literature importance, clinical face validity, and sub-group prevalence. The analysis followed a nonmetric multidimensional scaling method based on a two-way proximity matrix.

RESULTS

The original BEMI-D had 197 items allocated to four checklists: symptoms, causes, consequences, and treatments. The two stage item reduction approach resulted in the removal of 75 items. These reductions were achieved across all four checklists in relatively equal proportions. There was no evidence of substantive content loss in the revised schedule. The reduced version of the schedule comprises 122 items.

CONCLUSIONS

A condensed version of the BEMI-D is more efficient as an assessment schedule that captures the culturally diverse perceptions of memory problems for South Asians offering a balanced trade-off between feasibility of use and content validity.

Occupational Therapy for South Asian Older Adults in the United Kingdom: Cross-Cultural Issues

Introduction

There is limited understanding of the cultural needs of diverse Black and Minority Ethnic populations such as South Asian older adults, which may be perpetuating occupational injustices and health inequalities faced by these groups. Although cultural considerations are intrinsic to person-centred occupational therapy and increasingly relevant to the changing landscape of health and social care, the profession is criticised for its western-centric focus. This study aimed to gain understanding of the current cross-cultural issues in supporting South Asian older adults in the UK, as perceived by occupational therapists.

Method

A constructivist qualitative design supported by thematic analysis was used, involving seven occupational therapists in the United Kingdom who participated in semi-structured interviews via Skype/telephone.

Findings

Cross-cultural issues were illustrated through the following themes: ‘when the barriers go down’ – cultural mismatch in individualist vs. collectivist worldviews; ‘invasion of the family home’ – cultural inappropriateness of standard interventions; and ‘I go into every assessment assuming nothing’ – recognition of and response to challenges.

Conclusion

This study provides insight into cross-cultural issues in occupational therapy for South Asian older adults, revealing a gap between theory and practice in integrating cultural humility. It highlights the need for a more inclusive, person-centred approach to support culturally diverse populations.

Ethnic disparity in access to the memory assessment service between South Asian and white British older adults in the United Kingdom: A cohort study

BACKGROUND

Equality of access to memory assessment services by older adults from ethnic minorities is both an ethical imperative and a public health priority.

OBJECTIVE

To investigate whether timeliness of access to memory assessment service differs between older people of white British and South Asian ethnicity.

DESIGN

Longitudinal cohort.

SETTING

Nottingham Memory Study; outpatient secondary mental healthcare.

SUBJECTS

Our cohort comprised 3654 white British and 32 South Asian older outpatients.

METHODS

The criterion for timely access to memory assessment service was set at 90 days from referral. Relationships between ethnicity and likelihood of timely access to memory assessment service were analysed using binary logistic regression. Analyses were adjusted for socio-demographic factors, deprivation and previous access to rapid response mental health services.

RESULTS

Among white British outpatients, 2272 people (62.2%) achieved timely access to memory assessment service. Among South Asian outpatients, fourteen people (43.8%) achieved timely access to memory assessment service. After full adjustment, South Asian outpatients had a 0.47-fold reduced likelihood of timely access, compared to white British outpatients (odds ratio 0.47, 95% confidence interval 0.23-0.95, P value = .035). The difference became non-significant when restricting analyses to outpatients reporting British nationality or English as first language. Older age, lower index of deprivation and previous access to rapid response mental health services were associated with reduced likelihood of timely access, while gender was not.

CONCLUSIONS

In a UK mental healthcare service, older South Asian outpatients are less likely to access dementia diagnostic services in a timely way, compared to white British outpatients.

Dementia awareness, beliefs and barriers among family caregivers in Pakistan

OBJECTIVES

Dementia research and services in Pakistan are limited. The following was explored in experiences of family caregivers of people with dementia in Pakistan: (a) to determine whether culture and religion play a role in caregiving; (b) to draw insights on how family caregivers cope, what barriers they face and what help they would be willing to accept and (c) to determine how these findings could be used to raise awareness and influence public policies in improving the lives of families living with dementia.

METHODS

The experiences of family caregivers of people with dementia in Pakistan were explored via semi-structured interviews (10 in Lahore; 10 in Karachi). This was part of a larger qualitative study conducted about dementia in Pakistan. Caregivers interviewed were aged 35-80 (14 female). Most caregivers in the study were educated and affluent. Interviews were conducted in Urdu, translated into English and thematically analysed.

RESULTS

Five themes emerged: knowledge and awareness; stigma; importance of religion and duty to care; use of day care centres and home-help; and barriers. A lack of dementia awareness exists in Pakistan. The religious duty to care for family influenced caregiving decisions. Day care centres and home-help were accessed and viewed positively. The caregivers also wanted extracurricular activities for people with dementia, support groups for caregivers and better training for healthcare staff. Novel findings included that caregivers felt that dementia should not be stigmatised, and awareness should be raised in Pakistan via TV, radio and social media, but not inside mosques.

DISCUSSION

Additional research is necessary to determine if positive views of day care centres and home-help exist more widely. Attitudes and experiences regarding stigma may be different for caregivers of people with more advanced dementia. We recommend raising dementia awareness, allocating more funds to dementia services and an emphasis on home-based care.

Years Lived with Disability due to Alzheimer's Disease and Other Dementias in Asian and North African Countries: A Trend Analysis

In Asia, which has a rapidly aging population, dementia is the most prominent disease. This article presents an application of Latent Growth Mixture Model (LGMM) to identify classes of individual Alzheimer’s Disease (AD) and other dementias Years Lived with Disability (YLD) rates for Asian and North African countries based on the unobserved heterogeneity. The AD and other dementias YLD data for both sexes and age-standardized groups reported by the Global Burden of Disease (GBD) Study database during 1990–2015 for 55 Asian and North African countries were analyzed via LGMM. Findings of LGMMs identified four classes of YLD trajectories. Among the specified classes, a class was related to a single country (Turkey) with the highest starting point in 1990 (intercept of 218.52 per 100,000) and upward trend. Another class with increasing trend (a slope of 2.66 per 100,000) consisted of India, China, Singapore, Japan, and Egypt. Other countries in Asia and North Africa (Classes 3 and 4) had a downward trend of YLD rates. The upward trend for some parts of Asia and North Africa might be attributed to appropriate therapeutic strategies, higher levels of awareness, related medical cares, and increase in life expectancy in these countries.

Perspectives of dementia from Asian communities living in New Zealand: A focus group of Asian health care professionals

OBJECTIVE

The number of Asian New Zealanders with dementia is growing. The objective of this study was to explore with a group of Asian health care professionals about public attitudes towards dementia in Asian communities in New Zealand, the stigma of dementia, and how best to develop culturally appropriate services for Asian people and families living with dementia.

METHODS

A focus group was conducted with a group of bilingual Asian health care professionals. A topic guide was developed based on the discussion at a prior meeting with the Cross Cultural Interest Group. The data were independently analysed by three researchers using the thematic qualitative methodology.

RESULTS

Eleven overseas-born Asian health care professionals (Chinese: n = 9, 82%) participated in the focus group. Four main themes emerged from the data: (a) cultural interpretations of dementia; (b) stigma; (c) filial piety; and (d) inequity in the availability of resources.

CONCLUSION

Our findings suggest that much work is needed to destigmatise dementia in New Zealand Asian communities, through psychoeducation, public awareness, and the availability of readily accessible services that can meet their cultural and language needs.

Older Filipino immigrants' reconfiguration of traditional filial expectations: a focus ethnographic study

BACKGROUND

One of the many socio-cultural issues impacting older immigrants in host countries is the cultural expectations of filial piety from their adult children.

OBJECTIVE

To understand older Filipino immigrants' beliefs and values towards filial expectations.

DESIGN

Focused ethnography.

RESULTS

Two major themes were identified. The first theme 'moving away from filial expectations' drew out older Filipino's changing views of cultural expectations from their adult children. The second theme 'maintaining cultural values through good family relationships' highlighted the importance of acknowledging the cultural values considered to be most important by older Filipinos, which was having harmonious relationships and avoiding family conflict.

CONCLUSION

The reconfigured expectation was salient with participants' who identified 'not being a burden' to their adult children and the ardent desire to maintain positive family relationships. Impact Statement: Nurses need to be aware of changes to our current understanding of filial piety when providing care to older Filipinos.

Influences on the access to and use of formal community care by people with dementia and their informal caregivers: a scoping review

BACKGROUND

The literature describes the obstacles to sufficient care faced by people with dementia and their informal caregivers. Although factors influencing access and utilisation are frequently studied, the body of knowledge lacks an overview of aspects related to influence. The frequently used Behavioural Model of Health Care Use (BM) could be used to structure and explain these aspects. An adaptation of the BM emphasises psychosocial influences and appears to enrich the understanding of the use of long-term care for dementia.

METHODS

We conducted a scoping review with the aim of providing an overview of the aspects influencing the access to and utilisation of formal community care in dementia. Our search covered the PubMed, CINAHL, Social Science Citation Index and PsychInfo databases, as well as grey literature. Two researchers assessed the full texts for eligibility. A data extraction form was developed and tested. We analysed the main topics investigated by the studies and mapped and described the investigated psychosocial aspects according to the BM after narratively summarising the findings. We used the Mixed Method Appraisal Tool (MMAT) to critically appraise the included studies.

RESULTS

A total of 94 studies were included: n = 55 with quantitative designs, 35 with qualitative designs and four with mixed methods. The studies investigated different services, mainly focusing on health care services. One third of the studies provided information regarding the severity of dementia. The most frequently investigated main topics were ethnicity and attitudes towards services. Psychosocial aspects were frequently investigated, although few studies considered the perspectives of people with dementia. Approximately half of the studies reported a theoretical framework. The adapted BM facilitated the structuring and description of psychosocial aspects. However, this instrument did not address topics beyond the scope of psychosocial aspects, such as sociodemographic characteristics.

CONCLUSIONS

The access to and utilisation of formal community care for dementia can only be partly explained by individual influencing aspects. Therefore, a theoretical framework would likely help to describe this complex subject. Our findings indicate that the psychosocial categories of the adapted BM enriched the original BM, and that people with dementia should more often be included in healthcare service research to ensure a better understanding of the barriers to accessing formal community care.

Age, memory loss and perceptions of dementia in South Asian ethnic minorities

BACKGROUND

South Asian older adults are represented less frequently in mainstream mental health services or those for people with dementia. This study aimed to explore in detail the perceptions of dementia (symptoms, causes, consequences, treatments) held by South Asians and to discern how these understandings vary by age and by the self-recognition of memory problems, as these influence help-seeking behaviour.

METHODS

Participants were allocated to three groups: younger adults; older adults; and older adults with subjective memory problems. They completed the semi-structured Barts Explanatory Model Inventory for Dementia schedule, whilst older adults also completed measures of cognition (MMSE), and depression (GDS). Interviews were conducted in English, Gujarati or Urdu.

RESULTS

Groups were similar in identifying unusual forgetting and confusion as the most frequent symptoms; stress and age as the most frequent causes; and talking to your GP/nurse, taking medication, and talking to family and friends as the most frequent treatments. Younger adults more often knew about risk factors and reported practical consequences more than older adults. Older adults with subjective memory problems were more likely to describe sleep related problems or symptoms commonly associated with depression. They more often cited as causes of dementia lack of sleep, side effects of medication and medical reasons, and mentioned religion as a means to cope.

CONCLUSIONS

Findings highlight variability in perceptions of dementia across the South Asian Community and identify specific areas where dementia awareness could be raised in South Asian sub-groups to improve timely diagnosis, treatment outcomes and service access.

A grounded theory analysis of the experiences of carers for people living with dementia from three BAME communities: Balancing the need for support against fears of being diminished

An estimated 25,000 people of Black, Asian and other Minority Ethnic (BAME) origins live with dementia in UK – a number which is expected to increase sevenfold by 2051. People from many BAME communities experience dementia in a markedly different way to their white British counterparts. For instance diagnosis is more likely to occur at an advanced stage of the illness, while there is a lower take-up of mainstream dementia services. This research study focused on the experiences of caregivers for family and friends living with dementia from South Asian, African Caribbean and Chinese communities in Bristol. Data were collected through interviews with 27 participants and 8 focus groups attended by 76 participants. Additionally, interviews were carried out with 16 paid staff and volunteers working for Voluntary and Community Sector Organisations (VCSOs) that provided services for older people from these three communities. As concepts emerged during data analysis, so these were checked with each community. The grounded theory, ‘fear of diminishment’ was present across all communities: participants both needed and wanted support, but they were reluctant to accept this if it came at the cost of being diminished as a person. To resolve this dilemma, informants turned to BAME-led VCSOs, which provided ongoing support and advocated on behalf of their members. However, the services provided by these VCSOs varied and reflected differences in the ways in which communities enacted the theory. Given the increasing importance of cultural diversity within dementia care, this study has important implications for communities across the UK and elsewhere, and points towards the need for sustainable and equitable resourcing of dementia care within BAME-led VCSOs.

Individual risk factors for possible undetected dementia amongst community-dwelling older people in New Zealand

There is general acknowledgement of the importance of early diagnosis of dementia, yet there are still high rates of undetected dementia internationally. The aim of this cross-sectional study was to determine the sociodemographic characteristics associated with possible undetected dementia in a large sample of community-dwelling older New Zealanders. The sample consisted of older people (age ≥ 65) who had received the homecare version of the international Residential Home Care Assessment version 9.1 over a two-year period and who were screened positive for possible dementia on the international Residential Assessment’s Cognitive Performance Scale. People with possible alternative explanations for impaired cognitive performance such as depression and other neurological conditions were excluded from analysis. The 5202 eligible individuals were categorized into two groups: (1) those with a recorded diagnosis of dementia (64%) and (2) those without a recorded diagnosis of dementia (i.e. possible undetected dementia group) (36%). Logistic regression was used to evaluate the association between individual characteristics and possible undetected dementia. Significant risk factors for being in the possible undetected dementia group included Asian ethnicity, living alone, not having participated in long-standing social activities recently, major life stressors, and limited accessibility of their house. The knowledge gained from this study could enable targeting of services and resources for the groups at risk of undetected dementia to have a more equitable access to early diagnosis.

Evaluation of a carers' information programme culturally adapted for South Asian families

OBJECTIVES

The Alzheimer's Society has culturally adapted an Information Programme for South Asian families (IPSAF) who support an individual living with dementia. The objectives of this evaluation were to establish whether IPSAF had an immediate and medium-term impact on those who attended and how it impacted on the wider family and the person with dementia.

METHODS

An inclusive, pluralistic approach was adopted. Seven focus groups were conducted with 42 participants, and 37 participated in a pre-post knowledge quiz. Seven family interviews were conducted with 17 participants, and 3 families were followed up after 6 months. Thematic analysis was conducted on the data.

FINDINGS

The IPSAF was found to improve participants' knowledge of dementia leading to increased understanding of the person with dementia. Participants became more aware of available services and accessed services to make use of practical support. IPSAF was reported to have an impact for people living with dementia, with carers' newfound understanding resulting in some changes in care practice that promoted empowerment and independence for people living with dementia. There was also some evidence to suggest that IPSAF had an impact on the wider family, with participants sharing information about dementia with family members who had not attended the programme. Families were continuing to make changes to improve the lives of people living with dementia 6 months later, suggesting IPSAF had a sustained impact.

CONCLUSION

This culturally adapted programme was found to have a significant impact on carers, the person with dementia, and the wider family.

Perceptions of dementia and use of services in minority ethnic communities: a scoping exercise

Despite the rapidly ageing population and a predicted sevenfold increase in the prevalence of dementia in minority ethnic communities, people from these communities remain under-represented in specialist dementia services. Leventhal's Model of Self-Regulation suggests perceptions of illness facilitate help-seeking behaviours such as the use of services. This scoping exercise makes use of the model to explore perceptions of dementia in British Indian, African and Caribbean, and East and Central European communities in the United Kingdom. Between August 2013 and April 2014, culturally specific dementia awareness roadshows were attended by people living with dementia, carers and members of the public. During the roadshows, 62 British Indian, 50 African and Caribbean, and 63 East and Central European attenders participated in discussion groups and a dementia knowledge quiz. Thematic and framework analysis were conducted on the discussion group data. Three main themes are presented: Perceptions of dementia, awareness of dementia in the wider family and community, and awareness and use of services. The findings suggest that although groups attributed a biological basis for memory loss, a number of misconceptions prevailed regarding the cause of dementia. Groups also made use of religion, as opposed to medical healthcare services, as a form of personal and treatment control. Seeking help from healthcare services was hindered by lack of awareness of services, and culturally specific barriers such as language. The findings have a number of implications for policy and practice including the development of public health interventions and the need to focus further on reducing barriers to accessing services.

Adaptation of the Barts Explanatory Model Inventory to dementia understanding in South Asian ethnic minorities

OBJECTIVE

Studies indicate a limited understanding of dementia and its associated symptoms, causes and consequences among South Asian older adults. As a consequence, fewer people from this ethnic group receive a diagnosis of dementia. The aim of this study was to adapt the previously designed Barts Explanatory Model Inventory Checklist (BEMI-C), a tool designed to elicit perceptions of mental illness from people with different cultural backgrounds, for use with people with dementia in the South Asian population.

METHOD

Both a literature review and 25 qualitative interviews were conducted to find themes and perceptions that are relevant to the South Asian culture in recognising and dealing with symptoms of dementia. The emergent themes and perceptions were then added to the BEMI-C through synthesis of findings.

RESULTS

The initial four checklists of symptoms, causes, consequences and treatments from the BEMI-C were retained in the new BEMI-Dementia (BEMI-D) and expanded with six additional themes, including 123 new perceptions relevant to the understanding of dementia. All new themes emerged from the qualitative interviews, some of which were also found in the literature.

CONCLUSION

Given the national priority of improving dementia awareness and timely diagnosis, the BEMI-D can serve as a useful tool, in research and perhaps practice, to assess the barriers to dementia service uptake in this population and their understandings of dementia. Based on the detailed methodological description of the adaptation of the BEMI-C, this paper further suggests how this tool can be adapted to suit other ethnic minority groups.

Costs of formal and informal care at home for people with dementia: ‘Expert panel’ opinions from staff and informal carers

Effective home support in dementia is key in delaying nursing home admission. However, home support is frequently not tailored to the individual needs of people with dementia. Staff allocating home support services may not identify important care needs, which only be recognised by informal carers. The purpose of this study was to explore the balance of informal and formal home support and their associated costs from the perspectives of both informal carers and paid staff. Five case vignettes of people with dementia were designed based on an existing English data set from a European study into transition into long-term care (the RightTimePlaceCare programme), representing 42 per cent of the English sample. In total, 14 informal carers and 14 paid staff were consulted in separate groups, as expert panels, regarding their recommendations for home care services for each vignette. Care recommendations of carers and staff were costed based on nationally available unit costs and compared. Informal carers allocated fewer hours of care than staff. Personal and domestic home care and day care centres were the most frequently recommended formal services by both groups, and some vignettes of people with dementia were recommended for care home admission. The ratio of costs of informal versus formal support was relatively equal for paid staff, yet unbalanced from the perspectives of informal carers with a greater proportion of formal care costs. Recommendations from this study can help shape dementia care to be more tailored to the individual needs of people with dementia and their carers.

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.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Perceptions of self-defined memory problems vary in south Asian minority older people who consult a GP and those who do not: a mixed-method pilot study

OBJECTIVE

South Asian older adults access services for mental health problems and dementia less than other older people in the UK, unlike for physical health problems. This pilot study investigated how South Asians with self-defined memory problems, with and without GP consultation, construe the symptoms, causes, consequences and treatment of the condition.

METHODS

Participants were recruited through community centres, their networks and memory clinics in Greater Manchester. The newly developed Barts Explanatory Model Inventory for Dementia (BEMI-D) was administered to 33 (18 M, 15 F) older South Asians aged 65 or above with memory problems in English, Gujarati or Urdu. Furthermore, cognition, executive function and depression were assessed.

RESULTS

Perceptions of dementia varied by GP consultation for memory problems. A greater proportion of older adults without a consultation considered memory problems to be given by God, saw acceptance of fate as an alternative treatment and did not identify medical support as appropriate. Forgetfulness and loss of social meaning were identified as symptoms of dementia more by those with a consultation. Higher levels of diabetes, heart disease and depression were found in those without a consultation.

CONCLUSIONS

Differences in perceptions may influence the decision about consulting a GP. Similarly, consultation for memory problems appears linked to extent physical health problems and mental health consultation (depression). These variations reported on a small scale in this pilot study suggest the need to explore the impact of perceptions on rates of GP consultation, so as to improve timely diagnosis and access to appropriate services.

What would encourage help-seeking for memory problems among UK-based South Asians? A qualitative study

OBJECTIVES

People from Minority Ethnic groups tend to present late to dementia services, often in crisis. Culture-specific barriers to help-seeking seem to underlie this. We sought to determine these barriers to timely help-seeking for dementia among people from South Asian backgrounds and what the features of an intervention to overcome them would be.

STUDY DESIGN

Qualitative study to delineate barriers to and facilitators of help-seeking for South Asian adults with dementia through focus groups and individual interviews.

SETTING

Community settings in and around Greater London.

PARTICIPANTS

To achieve a maximum variation sample, we purposively recruited 53 English or Bengali speaking South Asian adults without a known diagnosis of dementia through community centres and snowballing.

RESULTS

Participants ranged in age from 18 to 83 years, were mostly female and were 60% Bangladeshi. We recruited people from different religions and occupational backgrounds and included those with experience of caring for someone with dementia as well as those without this experience. Participants identified four main barriers to timely diagnosis: barriers to help-seeking for memory problems; the threshold for seeking help for memory problems; ways to overcome barriers to help-seeking; what features an educational resource should have.

CONCLUSIONS

We have identified the features of an intervention with the potential to improve timely dementia diagnosis in South Asians. The next steps are to devise and test such an intervention.