Pre-existing neurological conditions and COVID-19 co-infection: Data from systematic reviews, meta-analyses, and scoping reviews

BACKGROUND

Pre-existing neurological diseases have been identified as risk factors for severe COVID-19 infection and death. There is a lack of comprehensive literature review assessing the relationship between pre-existing neurological conditions and COVID-19 outcomes. Identification of high risk groups is critical for optimal treatment and care.

METHODS

A literature review was conducted for systematic reviews, meta-analyses, and scoping reviews published between January 1, 2020 and January 1, 2023. Literature assessing individuals with pre-existing neurological diseases and COVID-19 infection was included. Information regarding infection severity was extracted, and potential limitations were identified.

RESULTS

Thirty-nine articles met inclusion criteria, with data assessing >3 million patients from 51 countries. 26/51 (50.9%) of countries analyzed were classified as high income, while the remaining represented middle-low income countries (25/51; 49.0%). A majority of evidence focused on the impact of cerebrovascular disease (17/39; 43.5%) and dementia (5/39; 12.8%) on COVID-19 severity and mortality. 92.3% of the articles (36/39) suggested a significant association between neurological conditions and increased risk of severe COVID-19 and mortality. Cerebrovascular disease, dementia, Parkinson's disease, and epilepsy were associated with increased COVID severity and mortality.

CONCLUSION

Pre-existing neurological diseases including cerebrovascular disease, Alzheimer's disease and other dementias, epilepsy, and Parkinson's disease are significant risk factors for severity of COVID-19 infection and mortality in the acute infectious period. Given that 61.5% (24/39) of the current evidence only includes data from 2020, further updated literature is crucial to identify the relationship between chronic neurological conditions and clinical characteristics of COVID-19 variants.

A Systematic Review of Quality Dementia Clinical Guidelines for the Development of WHO's Package of Interventions for Rehabilitation

BACKGROUND AND OBJECTIVES

As part of the WHO Rehabilitation 2030 call for action, the WHO Rehabilitation Programme is developing its Package of Interventions for Rehabilitation (PIR) to support ministries of health around the globe in integrating rehabilitation services into health systems. As a vital step for this PIR development, we conducted a systematic review of clinical practice guidelines (CPGs) for dementia to identify interventions for rehabilitation and related evidence.

RESEARCH DESIGN AND METHODS

Following WHO Rehabilitation Programme and Cochrane Rehabilitation's methodology, quality CPGs published in English between January 2010 and March 2020 were identified using PubMed, Embase, CINAHL, PEDro, Google Scholar, guideline databases, and professional society websites. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (II).

RESULTS

Of the 22 CPGs that met the selection criteria, 6 satisfied the quality evaluation. Three hundred and thirty rehabilitation-related recommendations were identified, mostly concentrated in the areas of cognition, emotion, and carer support. There were many strong interventions, with moderate- to high-quality evidence that could be easily introduced in routine practice. However, major limitations were found both in the quality of evidence and scope, especially in areas such as education and vocation, community and social life, and lifestyle modifications.

DISCUSSION AND IMPLICATIONS

Further rigorous research is needed to build quality evidence in dementia rehabilitation in general, and especially in neglected areas for rehabilitation. Future work should also focus on the development of CPGs for dementia rehabilitation. A multipronged approach is needed to achieve Universal Health Coverage for dementia rehabilitation.

The worldwide costs of dementia in 2019

INTRODUCTION

Dementia is a leading cause of death and disability globally. Estimating total societal costs demonstrates the wide impact of dementia and its main direct and indirect economic components.

METHODS

We constructed a global cost model for dementia, presenting costs as cumulated global and regional costs.

RESULTS

In 2019, the annual global societal costs of dementia were estimated at US $1313.4 billion for 55.2 million people with dementia, corresponding to US $23,796 per person with dementia. Of the total, US $213.2 billion (16%) were direct medical costs, US $448.7 billion (34%) direct social sector costs (including long-term care), and US $651.4 billion (50%) costs of informal care.

DISCUSSION

The huge costs of dementia worldwide place enormous strains on care systems and families alike. Although most people with dementia live in low- and middle-income countries, highest total and per-person costs are seen in high-income countries.

HIGHLIGHTS

Global economic costs of dementia were estimated to reach US $1313.4 in 2019. Sixty-one percent of people with dementia live in low-and middle-income countries, whereas 74% of the costs occur in high-income countries. The impact of informal care accounts for about 50% of the global costs. The development of a long-term care infrastructure is a great challenge for low-and middle-income countries. There is a great need for more cost studies, particularly in low- and middle-income countries. Discussions of a framework for global cost comparisons are needed.

Brain health as a global priority

Brain health is an evolving concept that has become increasingly popular within clinical and academic centers, journalism and the general public. It can be defined as the state of brain functioning across cognitive, sensory, social-emotional, behavioural and motor domains, allowing a person to realize their full potential over the life course. Multiple, interconnected determinants play a role in shaping brain health from pre-conception through the end of life. Brain health can be optimized by addressing the following determinants: physical health, healthy environments, safety and security, learning and social connection, and access to quality services. Optimizing brain health improves brain structure and functioning across all domains and benefits health by lowering rates of neurological disorders, mental health conditions, and substance use; improving quality of life for people with lived experience of these conditions; and improving physical health (particularly through improved endocrine and immunological functioning and lower rates of stress-related physical health conditions). Additionally, optimizing brain health can lead to social and economic benefits including increased school retention and academic achievement, lower rates of teenage pregnancies, lower rates of incarceration, lower health care costs and rates of disability, higher productivity, and greater wealth. Optimizing brain health for all is paramount to ensuring human health and well-being globally. It is central to achieving global commitments outlined in the Intersectoral global action plan on epilepsy and other neurological disorders 2022-2031, WHO's Triple Billion targets, the UN SDGs and the 2021 Geneva Charter for Well-being. Efforts to optimize brain health require multi-stakeholder collaborations and must be integrated across all sectors of society: health and social care; education; legislature and governance; finance and economy; employment; infrastructure, urban planning and housing; and ecology, nature and climate. In return, robust investments in actions that optimize brain health across the life course promise to improve multiple health outcomes and lift development and well-being globally. Multisectoral engagement and collaboration are urgently needed in order to move the brain health agenda forward for all people.

Harmonizing neuropsychological assessment for mild neurocognitive disorders in Europe

INTRODUCTION

Harmonized neuropsychological assessment for neurocognitive disorders, an international priority for valid and reliable diagnostic procedures, has been achieved only in specific countries or research contexts.

METHODS

To harmonize the assessment of mild cognitive impairment in Europe, a workshop (Geneva, May 2018) convened stakeholders, methodologists, academic, and non-academic clinicians and experts from European, US, and Australian harmonization initiatives.

RESULTS

With formal presentations and thematic working-groups we defined a standard battery consistent with the U.S. Uniform DataSet, version 3, and homogeneous methodology to obtain consistent normative data across tests and languages. Adaptations consist of including two tests specific to typical Alzheimer's disease and behavioral variant frontotemporal dementia. The methodology for harmonized normative data includes consensus definition of cognitively normal controls, classification of confounding factors (age, sex, and education), and calculation of minimum sample sizes.

DISCUSSION

This expert consensus allows harmonizing the diagnosis of neurocognitive disorders across European countries and possibly beyond.

Empowering Dementia Carers With an iSupport Virtual Assistant (e-DiVA) in Asia-Pacific Regional Countries: Protocol for a Pilot Multisite Randomized Controlled Trial

Background

Dementia is a global public health priority with an estimated prevalence of 150 million by 2050, nearly two-thirds of whom will live in the Asia-Pacific region. Dementia creates significant care needs for people with the disease, their families, and carers. iSupport is a self-help platform developed by the World Health Organization (WHO) to provide education, skills training, and support to dementia carers. It has been adapted in some contexts (Australia, India, the Netherlands, and Portugal). Carers using the existing adapted versions have identified the need to have a more user-friendly version that enables them to identify solutions for immediate problems quickly in real time. The iSupport virtual assistant (iSupport VA) is being developed to address this gap and will be evaluated in a randomized controlled trial (RCT).

Objective

This paper reports the protocol of a pilot RCT evaluating the iSupport VA.

Methods

Seven versions of iSupport VA will be evaluated in Australia, Indonesia, New Zealand, and Vietnam in a pilot RCT. Feasibility, acceptability, intention to use, and preliminary impact on carer-perceived stress of the iSupport VA intervention will be assessed.

Results

This study was funded by the e-ASIA Joint Research Program in November 2020. From January to July 2023, we will enroll 140 dementia carers (20 carers per iSupport VA version) for the pilot RCT. The study has been approved by the Human Research Committee, University of South Australia, Australia (203455).

Conclusions

This protocol outlines how a technologically enhanced version of the WHO iSupport program—the iSupport VA—will be evaluated. The findings from this intervention study will provide evidence on the feasibility and acceptability of the iSupport VA intervention, which will be the basis for conducting a full RCT to assess the effectiveness of the iSupport VA. The study will be an important reference for countries planning to adapt and enhance the WHO iSupport program using digital health solutions.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12621001452886; https://tinyurl.com/afum5tjz

International Registered Report Identifier (IRRID)

PRR1-10.2196/33572

The Process of Developing a WHO Dementia-Friendly Community Global Toolkit: Input From Multiple Stakeholders

This study examined the process that the Department of Mental Health and Substance Abuse of WHO used to develop a global toolkit for dementia friendly initiatives (DFI). Data were collected through a mix-method approach consisting of individual interviews of 20 DFI leaders, four focus group interviews of persons living with dementia (PWD), three group interviews of professionals, and an online survey of 129 participants from 46 countries. Data from multiple sources were examined. The meaning of DFIs centered on the needs of PWD, multi-sector collaboration, and physical and social environmental changes. Over 70% participants in the survey reported their DFIs targeted PWD and included PWD as important partners. The EASTT model can be used to summarize DFI strategies including Education, Advocacy, Support, Training and Transforming environment. Countries advanced in DFI tended to focus on enhancing professional capacity and environmental adaptation, while countries launching DFI appeared to prioritize dementia awareness campaigns.

Training and support for caregivers of people with dementia: The process of culturally adapting the World Health Organization iSupport programme to Portugal

BACKGROUND

Informal caregivers of people with dementia often struggle with several stressors, and their mental and physical health can be negatively affected by providing care. iSupport is an online self-help programme designed by the World Health Organization to provide education, skills training, and support to those caregivers.

PURPOSE

This paper describes the development of an adapted version of iSupport to the Portuguese culture. We present the adaptation process, methods used and results for the country-specific version.

METHODS

The adaptation of iSupport was operationalised in five steps: needs assessment; content translation by an authorised translator and technical accuracy check by health professionals; cultural adaptation; independent appraisal of contents by an expert panel; and fidelity check by programme authors.

RESULTS

Findings indicated the adjustments needed in the original iSupport contents. Overall, 323 text excerpts were proposed to adaptation, comprising semantic and conceptual equivalence of expressions, and adjustments to cultural habits, customs, traditions, local resources, and practices. The expert panel identified the need to reformulate definitions, designations, recommendations, and case studies to fine-tune the original contents to local knowledge and practices. Most adaptations were considered to be in line with the core concepts of the original programme.

CONCLUSIONS

iSupport is an innovative tool capturing the attention of several organisations around the world interested in translating, adapting, and using the programme. This paper is the first describing the methodological approach for culturally adapting iSupport, constituting an essential resource for those aiming to replicate the process or culturally adapting evidence-based interventions. Tailoring iSupport to the Portuguese context was critical to accommodate the cultural experiences of the target group as well as the knowledge, theoretical approaches, and practices of local professionals. The European-Portuguese version of iSupport introduces the adjustments needed to implement a useful new intervention programme aimed at minimising the psychological distress of Portuguese caregivers.

Dementia and caregiver burden: A three-year longitudinal study

OBJECTIVES

Dementia, with its progressive cognitive and functional decline and associated neuropsychiatric symptoms, places a large burden on caregivers. While frequently studied, longitudinal findings about the overall trajectory of burden are mixed. The study sought to characterize caregiver burden over a 3-year period and identify predictors of this burden.

METHODS

Seven-hundred-and-eighty-one patients with dementia were recruited from nine memory clinics around Australia. Measures of caregiver burden, cognition, function, and neuropsychiatric symptoms were completed with patients and their caregivers at regular intervals over a 3-year period. Patients' level of services and medication use were also recorded.

RESULTS

Of the 720 patients with measures of caregiver burden at baseline, 47.4% of caregivers had clinically significant levels of burden. This proportion increased over time, with 56.8% affected at 3 years. Overall levels of burden increased for caregivers of patients without services, though did not change for caregivers of patients receiving services or residential care after controlling for other variables. Patient characteristics-including greater neuropsychiatric symptoms, lower functional ability, fewer medications, lack of driving ability-and female sex of caregivers were associated with greater burden.

CONCLUSIONS

High levels of caregiver burden are present in a large proportion of caregivers of people with dementia and this increases over time for those without services. Clinical characteristics of patients (including neuropsychiatric symptoms, function, overall health, driving status), level of services, and caregiver sex appear to be the best predictors of this burden. These characteristics may help identify caregivers at greater risk of burden to target for intervention.

Online training and support program (iSupport) for informal dementia caregivers: protocol for an intervention study in Portugal

BACKGROUND

Informal caregivers (IC) of people with dementia (PwD) are at greater risk of developing physical and mental health problems when compared to the general population and to IC of people with other chronic diseases. Internet-based interventions have been explored for their potential to minimize the negative effects of caring, accounting for their ubiquitous nature, convenient delivery, potential scalability and presumed (cost) effectiveness. iSupport is a self-help online program developed by the World Health Organization (WHO) to provide education, skills training and support to IC of PwD. This paper describes the design of an intervention study aimed at determining the effectiveness of a Portuguese culturally adapted version of iSupport on mental health and other well-being outcomes.

METHODS

The study follows an experimental parallel between-group design with two arms: access to the five modules and twenty-three lessons of "iSupport" for three months (intervention group); or access to an education-only e-book (comparison group). One hundred and eighty four participants will be recruited by referral from national associations. Inclusion criteria are: being 18 years or older and provide e-consent; being a self-reported non-paid caregiver for at least six months; of a person with a formal diagnosis of dementia; being skilled to use internet; and experience a clinically relevant level of burden (≥ 21 on Zarit Burden Interview) or depression or anxiety symptoms (≥ 8 on Hospital Anxiety and Depression Scale). Data is collected online, resorting to self-administered instruments, at baseline, 3 and 6 months after baseline. The primary outcome is caregiver burden, measured by the Zarit Burden Interview. Symptoms of depression and anxiety, quality of life, positive aspects of caregiving and general self-efficacy are secondary study outcomes. The data analysis will follow an Intention-to-treat (ITT) protocol.

DISCUSSION

This protocol is an important resource for the many organizations in several countries aiming to replicate iSupport. Findings from this intervention study will offer evidence to bolster an informed decision making on scaling up iSupport as a new intervention program with minimal costs aimed at minimizing the psychological distress of IC of PwD in Portugal and elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04104568. Registered 26 September 2019.

DEVELOPING A DEMENTIA-FRIENDLY COMMUNITY GLOBAL TOOLKIT: INSIGHTS FROM STAKEHOLDERS IN WHO MEMBER COUNTRIES

Drawing on perspectives from stakeholders involved in dementia friendly initiatives (DFIs) in WHO member countries, this paper describes the characteristics of DFIs around the world and summarizes success factors and barriers to implementation. Data were collected through an online consultation survey of 129 stakeholders from 46 countries in all six regions of WHO. Most DFIs present three essential features of WHO’s definition for DFI, that is, centering on the needs of persons living with dementia (PWD), multi-sector collaboration, and physical and social environmental changes. Over 70% participants reported their DFIs targeted PWD and included PWD as important partners. High-income countries tend to focus on enhancing professional capacity and environmental adaptation, while low-middle income countries prioritize dementia awareness campaigns. This corresponds to the reported disparities in levels of inclusion of PWD in societies, support to PWD, and service access for PWD found between low-middle income countries and high-income countries.

Mild Cognitive Impairment and Caregiver Burden: A 3-Year-Longitudinal Study

OBJECTIVES

Mild cognitive impairment (MCI) is common, affecting 10%-35% of people over 65, and poses unique challenges for patients and their caregivers. Comparatively little research has examined caregiver burden in this population, with longitudinal research, in particular, lacking. We examined caregiver burden in a sample of people with MCI over 3 years.

DESIGN

Three-year observational study.

SETTING

Nine memory clinics in Australia.

PARTICIPANTS

One-hundred-and-eighty-five people with MCI and their caregivers.

MEASUREMENTS

Measures of caregiver burden, cognition, function, neuropsychiatric symptoms, driving status, and medication use were completed with patients and their caregivers at regular intervals over a 3-year period.

RESULTS

Between 21.1% and 29.5% of caregivers reported a clinically significant level of burden over the study. Patients' higher levels of neuropsychiatric symptoms, lower functional ability, and lack of driving ability, and caregivers' employment were associated with greater caregiver burden over time. Caregiver burden did not increase over time when controlling for patient and caregiver characteristics.

CONCLUSIONS

High levels of caregiver burden are present in a significant proportion of caregivers of people with MCI. Clinical characteristics of patients - including severity of neuropsychiatric symptoms and functional impairment - and the employment status of caregivers predict burden. Such characteristics may help identify caregivers at greater risk of burden to target for intervention.

Validity and reliability of the Persian version of general practitioner assessment of cognition (P-GPCOG)

Objectives: The study aimed to examine the validity, reliability, and practicality of the Persian version of the General Practitioner Assessment of Cognition (P-GPCOG) as a brief, efficient cognitive assessment instrument in Iranian older adults. Method: The sample comprised 151 community-dwelling older adults and 79 nursing home residents (aged ≥60 years). The English GPCOG was translated, back-translated, and revised to prepare the final P-GPCOG. The Abbreviated Mental Test score (AMTs) and the Depression in Old Age Scale (DIA-S) were administered to the two different samples to establish the convergent and discriminant validity of the P-GPCOG. Results: The mean age of the sample was 70.67 (SD = 9.51); 57.4% were male. The mean P-GPCOG scores for the total, cognitive and informant subscales were 7.67 (SD = 4.59), 4.18 (SD = 2.73), and 3.49 (SD = 2.24), respectively. Cognitive (P < 0.001), informant (P < 0.001) and total scores (P < 0.001) differed significantly between community-dwelling participants and nursing home residents. Worse cognitive performance on the P-GPCOG correlated significantly with worse scores on the AMTs (r = 0.61, P < 0.001) and less so with depressive symptoms as measured with the DIA-S (r = -0.20, P < 0.05). Cronbach's alpha for the P-GPCOG cognitive and informant subscales were 0.90 and 0.83 respectively, indicating a high degree of internal consistency and homogeneity between items. The test-retest correlation for the total P-GPCOG score was 0.82 in 30 participants after 19 days. P-GPCOG cognitive scores correlated significantly with education. Conclusion: The P-GPCOG displayed strong psychometric properties, offering healthcare professionals a quick and efficient cognitive instrument for older Persian speakers. As with other cognitive assessment tools, the P-GPCOG cognitive score is affected by a person's level of education.

Cognitive screening test in primary care: cut points for low education

OBJECTIVE

To establish the diagnostic accuracy of the Brazilian version of the General Practitioner Assessment of Cognition (GPCOG-Br) compared to the Mini-Mental State Examination (MMSE) in individuals with low educational level.

METHODS

Ninety-three patients (≥ 60 years old) from Brazilian primary care units provided sociodemographic, cognitive, and functional data. Receiver operating characteristics, areas under the curve (AUC) and logistic regressions were conducted.

RESULTS

Sixty-eight patients with 0-4 years of education. Cases (n = 44) were older (p = 0.006) and performed worse than controls (n = 49) on all cognitive or functional measures (p < 0.001). The GPCOG-Br demonstrated similar diagnostic accuracy to the MMSE (AUC = 0.90 and 0.91, respectively) and similar positive and negative predictive values (PPV/NPV, respectively: 0.79/0.86 for GPCOG-Br and 0.79/0.81 for MMSE). Adjusted cut-points displayed high sensitivity (all 86%) and satisfactory specificity (65%-80%). Lower educational level predicted lower cognitive performance.

CONCLUSIONS

The GPCOG-Br is clinically well-suited for use in primary care.

iSupport, an online training and support program for caregivers of people with dementia: study protocol for a randomized controlled trial in India

Background

Dementia has a huge physical, psychological, social and economic impact upon caregivers, families and societies at large. There has been a growing impetus to utilize Internet interventions given the potential scalability, and presumed cost-effectiveness and accessibility. In this paper, we describe the design of a randomized controlled trial (RCT) aiming to study the impact of online self-help programs on caregivers of people with dementia in India. The experimental group will receive an interactive training and support program and the comparison group will receive an education-only e-book. It will be among the first online support intervention RCTs for a mental health condition in a lower-middle income country.

Methods and design

Two hundred and eight participants are expected to be recruited via several strategies (email, Internet and social media, telephone and face-to-face) starting in the Bangalore region of India. The inclusion criteria for participation in the trial are: (1) being 18 years or older, (2) being a self-reported caregiver of a person with dementia, (3) self-report that a family member has a diagnosis of dementia (AD8 ≥ 2), and experience caregiver distress (≥ 4 on a 1-item burden scale ranging from 1 to 10 or ≥ 4 or < 20 on the Center for Epidemiologic Study-Depression (CES-D) scale (10-item) or ≥ 4 or < 15 on the Generalized Anxiety Disorder Scale (7-item).

The intervention group will be offered iSupport, an online self-help training and support program, enabling a personalized education plan with a maximum of 23 lessons. These modules present a range of topics from “what is dementia?” to “dealing with challenging behaviors like aggression.” The comparison group will receive an education-only e-book containing similar content. The outcomes of this trial are: caregiver burden as measured by the 22-item Zarit Burden Scale, depressive symptoms, anxiety symptoms (primary outcomes), quality of life, person-centered attitude, self-efficacy and mastery (secondary outcomes).

Discussion

Based on the findings of this trial, we will examine the potential use and scale up of iSupport for caregiver distress in India. This style of online self-help programs could be expanded to other regions or countries or to other suitable caregiver groups.

Trial registration

Clinical Trials Registry—India (CTRI), ID: CTRI/2017/02/007876.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2604-9) contains supplementary material, which is available to authorized users.

A Comprehensive Review of the Quality and Feasibility of Dementia Assessment Measures: The Dementia Outcomes Measurement Suite

The diagnosis of dementia and the management of its associated symptoms are aided by high-quality assessment tools. However, there is disagreement on the optimal tools among abundant alternatives and lack of consistent quality standards across the different domains of dementia-related change (ie, cognition, severity, function, behavioral and psychological symptoms, delirium, quality of life). Standardization is difficult because the relevance of a measurement tool for health professionals may depend on the clinical setting and on the dementia type and severity. To address this need, we conducted a comprehensive and clinically relevant evidence-based review of dementia-related tools and present a set of recommended tools, the Dementia Outcomes Measurement Suite. The review revealed that considerable development has occurred in terms of assessment of persons with mild cognitive impairment, executive dysfunction, cognitively mediated functional change, and apathy. More research is needed to develop and validate tools to assess health-related quality of life and specific symptoms of dementia including anxiety, wandering, and repetitive vocalizations. This extensive overview of the quality of different measures may serve as a guide for health professionals clinically and for researchers developing new or improved dementia assessment tools.