The KICA Carer: informant information to enhance the Kimberley Indigenous Cognitive Assessment.

BACKGROUND: A quality dementia-screening tool is required for older remote Aboriginal Australians who have high rates of dementia and limited access to appropriate medical equipment and clinicians. The Kimberley Indigenous Cognitive Assessment (KICA Cog) is a valid cognitive test for dementia in Aboriginal and Torres Strait Islander peoples. The KICA cognitive informant questionnaire (KICA Carer) had yet to be analyzed to determine validity alone or in combination with the KICA Cog. METHODS: The KICA Carer was completed by nominated informants of 349 remote-living Aboriginal Australians in the Kimberley region, Western Australia. Validity was assessed by comparing KICA Carer with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and International Classification of Diseases (ICD-10) consensus diagnoses based on a blinded specialist review. KICA Carer and KICA Cog were then compared to determine joint validity. RESULTS: A KICA Carer score of ≥3/16 gave optimum sensitivity (76.2%) and specificity (81.4%), area under curve (AUC) 0.89 (95% CI = 0.85, 0.94) with positive predictive value (PPV) of 35.8%, and negative predictive value (NPV) of 96.2%. A KICA Cog score of ≤33/39 gave a sensitivity of 92.9% and specificity of 89.9%, AUC 0.96 (95% CI = 0.94, 0.98), with PPV of 55.6% and NPV of 98.9%. Cut-off scores of KICA Cog ≤ 33/39 and KICA Carer ≥ 2/16 in series indicate possible dementia, with sensitivity of 90.5% and specificity of 93.5%. In this setting, PPV was 66.5% and NPV was 98.6%. CONCLUSIONS: The KICA Carer is an important tool to accurately screen dementia in remote Aboriginal Australians when the KICA Cog is unable to be used for a patient. It is readily accepted by caregivers. KEY POINTS: • For the best practice in the cognitive assessment of an Aboriginal Australian aged over 45 years, KICA Cog should be utilized. • In cases where Aboriginal patients are not assessed directly, KICA Carer should be conducted with an informant. A cut-off score of ≥3/16 should be used (these tools can be downloaded from www.wacha.org.au/kica.html).

Dementia in older people: an update.

Dementia is a common condition of the elderly characterised by multiple cognitive deficits resulting in a decline from previous level of function. In the older person, multiple pathologies contribute, including changes commonly seen in Alzheimer disease, dementia with Lewy bodies in addition to vascular changes. Comorbid factors, such as depression, delirium and polypharmacy can contribute to cognitive decline. Novel biomarkers and neuroimaging techniques may assist in the near future to improve accuracy of diagnosis. To date, pharmacological therapies have been largely unsuccessful and provide symptomatic relief only. The timely diagnosis of dementia can facilitate important discussions regarding personal and financial planning and introduce education and supports to the person with dementia and their carers. The person with dementia commonly experiences behavioural and psychological symptoms of dementia that may cause much distress, including to families and carers. Clinical guidelines indicate non-pharmacological approaches as first line measures, including attention to pain, nutrition and the environment. Dementia is recognised as a National Health Priority in Australia, and efforts to target risk factors as preventative measures to delay onset of dementia require further urgent consideration.

Lungurra Ngoora--a pilot model of care for aged and disabled in a remote Aboriginal community--can it work?

INTRODUCTION: The literature on the health of and services for older Aboriginal and Torres Strait Islander populations is relatively sparse. This study explored the development and implementation of a locally designed community service model of care for older people, and people with disability and/or mental health problems in remote Aboriginal Australia. METHODS: Based on extensive community consultation with older people, families, carers, community members and stakeholders, a model of care was developed to address unmet needs for the target population and their carers in the remote community of Looma, in the Kimberley region of Australia. The model was implemented and evaluated over 12 months. The main outcome measures included the number of services (including home services, meals, transport, respite, personal care and advocacy) provided. Outcomes of community participation, capacity building, resources, partnerships, workforce, service delivery and cultural protection were assessed qualitatively by an external evaluator. RESULTS: The number of people receiving community care services in Looma increased from eight to 22, and services increased in all domains from 140 total services delivered for 1 month at baseline to 2356 by the final month of the program. CONCLUSIONS: The Lungurra Ngoora community care service model pilot project demonstrated a successful collaborative service model that addressed the care needs of older persons, those with disability and mental illness, and their carers in this remote community. The developmental approach, and model structure, could serve as a template for future delivery of services in remote Aboriginal communities.

Phenomenology of squalor, hoarding and self-neglect: an Australian aged care perspective.

Aged care health professionals in Australia are increasingly referred patients whose standard of cleanliness and self-care has deteriorated to levels resulting in public health concern. This paper describes three illustrative case studies of people referred to an Australian Aged Care Assessment Service who present with 'Diogenes Syndrome'. The diversity and complexity of these cases reflect variable underlying diagnoses. Symptoms of self-neglect, hoarding and domestic squalor and combinations thereof may provide a more useful classification system of the older person who presents in such circumstances than the frequently used term Diogenes syndrome. Practical guidelines are required for appropriate assessment and management of these conditions.

Preliminary evaluation of the prevalence of falls, pain and urinary incontinence in remote living Indigenous Australians over the age of 45 years.

AIMS: To report on the prevalence of falls, urinary incontinence, pain and associated factors in remote living Indigenous Australians over the age of 45 years. METHODS: A cross-sectional, semi-purposeful sample of 363 indigenous men and women aged over 45 years living in six remote communities and one town in Kimberley, Australia. Participants were assessed for self- or informant-reported rates of falls, urinary incontinence and pain. RESULTS: The prevalence of self- or informant-reported falls was 31% (95% CI 25.3, 36.7), pain 55% (95% CI 47.4, 62.6) and urinary incontinence 9% (95% CI 5.9, 12.1%). Associations with falls after adjustment for age, sex and education included alcohol use (OR 2.4, 95% CI 1.4, 4.2), stroke (OR 2.4, 95% CI 1.1, 5.0), epilepsy (OR 3.5, 95% CI 1.1, 11.6), head injury (OR 2.1, 95% CI 1.3, 3.3) and poor hearing (OR 2.5, 95% CI 1.4, 4.1); for urinary incontinence epilepsy (OR 6.0, 95% CI 1.7, 21.2) and stroke (OR 16.7, 95% CI 6.0, 46.3); and for pain, poor hearing (OR 1.9, 95% CI 1.0, 3.3) and female sex (OR 1.8, 95% CI 1.2, 2.7). CONCLUSIONS: Falls, urinary incontinence and pain are common and reported for the first time in older indigenous people living in remote regions. The presence of these syndromes in ages over 45 may be due to accumulation of health insults during the life course.

Contrasting perceptions of health professionals and older people in Australia: what constitutes elder abuse?

OBJECTIVES: To explore the perceptions of family carers, older people and health professionals in Australia about what constitutes elder abuse. METHODS: The Caregiving Scenario Questionnaire (CSQ) was disseminated to health professionals from two metropolitan hospitals, older volunteers and carers of older people with dementia recruited for other studies. RESULTS: One hundred and twenty health professionals, 361 older people and 89 carers returned the surveys. χ(2) analyses indicated that significantly more health professionals than older people identified locking someone in the house alone all day (χ(2) (2) = 10.20, p = 0.006, Cramer's V = 0.14), restraining someone in a chair (χ(2) (2) = 19.984, p = 0.0005, Cramer's V = 0.19) and hiding medication in food (χ(2) (2) = 8.72, p = 0.013, Cramer's V = 0.13) as abusive. There were no significant differences between healthy volunteer older people and carers in their perceptions of elder abuse. A significant minority (40.8%) of health professionals and over 50% of carers did not identify locking the care recipient alone in the house all day as abusive. CONCLUSION: In Australia, there is limited consensus between older people, carers and health professionals regarding what constitutes elder abuse. Health professionals were more likely to identify abusive and potentially abusive strategies correctly than carers or healthy older people, but nonetheless between one quarter and two-fifths [correction made here after initial online publication] of health professionals did not identify the abusive strategies.

Hospital doctors' attitudes towards older people.

BACKGROUND: Ageism among health professionals is increasingly recognized, but few studies investigated hospital doctors' attitudes towards older people. The aims of this study were to investigate hospital doctors' attitudes towards older people and to determine whether factors, which were identified in studies on other health professionals, influence hospital doctors' attitudes. METHODS: Hospital doctors who worked in General Medicine or Aged Care units in two tertiary public hospitals in metropolitan Victoria, Australia, in 2008 were surveyed with Fraboni's Scale of Ageism (FSA), a validated instrument used to investigate attitudes towards older people. Demographic data from participants were collected. RESULTS: Of the 235 questionnaires distributed, 122 were returned (overall response rate 51.9%). Response rate was highest among consultants (80.4%), followed by registrars (64.1%) and lowest among interns and residents (35.2%). The mean FSA score attained by the respondents was 61.5 (SD 11.0), representing a point between a neutral and a positive disposition. Doctors' characteristics that were associated with more positive attitudes towards older people included age of 30years or older (P < 0.001), female gender (P= 0.003), more senior in position (P < 0.001), postgraduate years of 10 or more (P < 0.001), previous working experience in Aged Care (P < 0.001), interest in Aged Care (P < 0.001) and more frequent social contacts with healthy older people (P < 0.001). CONCLUSION: Hospital doctors of different demographic features and background characteristics display different attitudes towards older people. These findings can be used to inform future development of undergraduate and postgraduate medical curricula and form a basis for future studies on the effectiveness of these interventions in improving doctors' attitudes.

High prevalence of dementia and cognitive impairment in Indigenous Australians.

OBJECTIVES: To determine the prevalence of dementia and cognitive impairment among older Indigenous Australians. METHODS: A total of 363 Indigenous Australians aged over 45 years from the Kimberley region in the far north of Western Australia were assessed with the Kimberley Indigenous Cognitive Assessment (KICA). All those scoring less than 37 on the KICA and a percentage of those scoring 37 or more were reviewed by specialist clinicians and DSM-IV consensus diagnoses were obtained from two other specialists blinded to KICA results. RESULTS: The prevalence of dementia was 12.4%, substantially higher than in the Australian general population. The prevalence of cognitive impairment not dementia was 8.0%. CONCLUSIONS: The prevalence of dementia among Indigenous Australians is substantially higher than that found in non-Indigenous Australians and all other studied populations.

Delirium in elderly general medical inpatients: a prospective study.

BACKGROUND: More than 49% of all US hospital days are spent caring for patients with delirium. There are few Australian data on this important condition. The aim of the study was to determine the prevalence and incidence of delirium in older medical inpatients in a metropolitan teaching hospital, the incidence of known risk factors and current practice in identifying and managing patients at risk of this condition. METHODS: Patients aged 65 years or more, and admitted to a general medical unit, were eligible for study inclusion. Participants were screened with an Abbreviated Mental Test Score (AMTS) and chart review. Confusion Assessment Method was used to diagnose delirium if confusion was documented or AMTS < 8. Barthel Index (BI), demographics, delirium risk factors and management were recorded. RESULTS: Prevalent delirium was diagnosed in 19 of 104 (18%) and incident delirium in 2 of 85 (2%) participants. Pre-existing cognitive impairment and admission AMTS < 8 were strongly associated with prevalent delirium (P-values < 0.01). Age > 80 years, Barthel Index < or = 50, use of high-risk medications and electrolyte disturbance were also associated with prevalent delirium. Prevalent delirium was not recognized by the treating unit in 4 of 19 cases (21%). Five of 104 (4.8%) of participants had a formal cognitive assessment on admission. One of 19 patients (5.3%) with prevalent delirium had an orientation device in their room. CONCLUSION: Pre-existing cognitive impairment and admission AMTS are strong predictors of delirium. Despite this, formal cognitive assessment is not routinely carried out in elderly medical patients. Recognition of delirium may be improved by routine cognitive assessment in elderly medical patients.

Impaired peripheral endothelial microvascular responsiveness in Alzheimer's disease.

BACKGROUND: The concept that the neurotoxicity of amyloid beta protein could partly result from vascular effects that may be detected in peripheral microcirculation is new. METHODS: We compared peripheral endothelial vascular responses of patients with early clinically confirmed Alzheimer's disease (AD) to that of people with normal cognition and those with other forms of dementia. Acetylcholine (ACh) was iontophoresed into the skin and the resultant vasodilator response was measured using laser Doppler flowmetery. RESULTS: The ratio of ACh response to saline (ratio E/S) was determined. Mean +/- SEM of ratios E/S were 8.8 +/- 0.9 for controls (n=168), 1.4 +/- 0.1 for AD patients (n=80) and 3.1 +/- 0.5 for other dementia (n=84). Using the optimal cut-off point of E/S ratio of 1.9, an 80% diagnostic sensitivity and specificity for AD have been observed. When the control sample was filtered for those with cardiovascular diseases and with MMSE < 28, this improved the specificity to 90% (n=119). Furthermore, 15 subjects were randomly drawn from a longitudinal healthy ageing study. Five of those subjects met the criteria for mild cognitive impairment (MCI) after eight years of follow up using a battery of cognitive tests. When tested for their E/S ratio in a blind fashion, the skin test successfully identified those subjects. CONCLUSIONS: The results support our hypothesis that endothelial alterations can be detected early in the course of the disease. We suggest that this simple skin test could potentially be applied as diagnostic adjunct in patients with mild cognitive symptoms or those with early clinical evidence of AD.

Kimberley Indigenous Cognitive Assessment tool (KICA): development of a cognitive assessment tool for older indigenous Australians.

BACKGROUND: Indigenous Australians have a unique cultural heritage dating back many thousands of years. Unfortunately, there is no validated tool to assess cognition in older indigenous Australians. This study was designed to address this deficiency. The Kimberley Indigenous Cognitive Assessment (KICA) was developed with Indigenous health and aged care organizations, and comprises cognitive, informant and functional sections. The psychometric properties of the cognitive assessment section (KICA-Cog) are described in this paper. METHODS: The KICA-Cog was tested in 70 indigenous subjects, of varying cognitive abilities and diagnoses, over 45 years of age. Subjects were interviewed using the KICA-Cog and then independently assessed by expert clinical raters using DSM-IV and ICD-10 criteria. Interrater and internal reliability were determined. RESULTS: The KICA-Cog score showed no systematic interrater difference; the mean was -0.07 (SD = 1.83). Interrater reliability for 16 individual questions from the cognitive section revealed a kappa-value > or = 0.6 and intraclass correlations for 12 questions. Internal consistency, as assessed by Cronbach's alpha, was 0.88. Three items on the cognitive score (pension week, recall and free recall) effectively discriminated 85-7% of dementia cases. Sensitivity and specificity were 90.6% and 92.6%, respectively, using a cut-off score of 31/32. CONCLUSIONS: The KICA-Cog appears to be a reliable assessment tool for cognitive impairment in an Australian older traditionally living indigenous population.

Uncommon dementia and the carer's perspective.

There is much caregiving literature describing factors that affect carer burden, and interventions that may be useful for carers of those with common dementias such as Alzheimer's disease (AD). By contrast, relatively little information and few data are available on potentially diverse issues facing carers of those with uncommon dementias, such as frontotemporal dementia (FTD), Huntington's disease (HD) and human immunodeficiency virus (HIV) dementia. This paper highlights particular characteristics of caregiving for those with uncommon dementias, and the unique needs that may arise for this group of carers who often "fall between the net" of services and supports available. Further research into this area is required.

Dementia: an update to refresh your memory.

The number of people with dementia and cognitive impairment is predicted to rise exponentially in the future. The increasing awareness of dementia in the community has led to a better understanding of the impact of this condition on individuals, their families and their carers. There is burgeoning research in the pathogenesis of dementia, and advances have been made in pharmacological treatments for the management of symptoms, including behavioural and psychological disturbances. However, the mainstay of management rests in comprehensive clinical assessment, education, counselling and provision of support for those affected and their families. The present paper provides a clinical update on recent advances in diagnosis and management of the most common forms of dementia.

Equity of access to a memory clinic in Melbourne? Non-English speaking background attenders are more severely demented and have increased rates of psychiatric disorders.

OBJECTIVES: The aim of this study was to compare demographic and clinical features of patients from Non-English Speaking Background (NESB) with those from English Speaking Background (ESB) who attended a memory clinic in Melbourne, Australia. METHODS: Data on 556 consecutive patients attending the memory clinic were analysed retrospectively. All patients were assessed by a geriatrician (Italian speaking) or psychogeriatrician with the aid of Cambridge Examination for Mental Disorders in the Elderly (CAMDEX) interview schedule. Patients were classified into the categories of dementia, functional psychiatric disorder (including depression), cognitive impairment other than dementia and normal, using ICD 10 criteria. Severity of dementia was determined using the Clinical Dementia Rating scale. Demographic information and use of community services were also documented. RESULTS: Of those seen, 148 (28.8%) were of NESB, the majority Italian (69, 12.4%). Patients of NESB were younger (p = 0.001), less educated (p = 0.001) and less likely to live alone (p = 0.009) compared to persons of ESB. Those of NESB were more likely present with a functional psychiatric disorder (particularly depression) or normal cognition (p = 0.001). Patients of NESB with dementia presented at a later stage of their disease as determined by CDR (p = 0.003). Those of NESB scored significantly lower (more impaired) on CAMCOG in all patients seen (including normal and psychiatric groups) (p = 0.02). CONCLUSIONS: The clinical and demographic features of people of NESB referred to a memory clinic in Melbourne, Australia, differ from their ESB counterparts, with specific groups being under represented. This has implications for equity of assessment, service provision and utilisation for those of ethnically diverse backgrounds.

Do memory clinics improve the quality of life of carers? A randomized pilot trial.

OBJECTIVE: To determine the effects of attendance at a memory clinic on the psychosocial health of carers. DESIGN: Randomized control trial. PARTICIPANTS: Fifty community dwelling subjects with mild to moderate dementia and their carers. MAIN OUTCOME MEASURES: Carer burden, psychological morbidity and psychosocial health related quality of life at 6 and 12 months post intervention. MAIN RESULTS: There was significant improvement in psychosocial health related quality of life of carers as measured by the psychosocial domain of the Functional Limitation Profile (FLP) at 6 months (p < 0.01), including improvement in the subgroups of alertness behaviour (p < 0.05) and social interaction (p < 0.01), after adjustment for age of subject and baseline scores. The improvement in social interaction was maintained at 12 months (p < 0.05). There was no significant difference in carer psychological morbidity (General Health Questionnaire), carer burden (Zarit family interview) or carer knowledge of dementia (Dementia Knowledge Test) at 6 or 12 months, between groups. CONCLUSIONS: These results demonstrate improved psychosocial health related quality of life for carers of those with mild to moderate cognitive impairment attending a memory clinic. Further research in this area is indicated, comparing memory clinic intervention with alternative support.

Is it dementia?

BACKGROUND: Dementia is a disorder of memory and thinking, severe enough to interfere with a person's life. In the early stages of the disease, an accurate diagnosis may be difficult to make. OBJECTIVE: To outline the assessment of people who present with cognitive difficulties, and discuss important conditions which may mimic dementia, and diagnostic criteria for dementia. DISCUSSION: The assessment of people with cognitive difficulties includes the exclusion of conditions such as depression, delirium and normal changes of ageing. The accurate diagnosis of dementia allows the institution of early and appropriate management and support of affected people and their families.

Clinical testing in general practice. What is the evidence?

BACKGROUND: Evidence based medicine (EBM) is a term being used widely in reference to diagnostic tests and treatments. In EBM a test or a treatment is only utilised when there is solid evidence that the likelihood of benefit to the patient outweighs the risk of harm. However, EBM is rarely considered in the clinical aspects of medicine: history taking and examination. In looking for clinical signs doctors need to consider the accuracy of those signs and the implications that false negative or false positive results will have for their patient. OBJECTIVE: The issues of sensitivity and specificity of clinical medicine are explored via the example of dementia testing in general practice. DISCUSSION: The article demonstrates that although two commonly used screening tests for dementia have a high sensitivity (75%) and specificity (70%), there is little benefit in the routine use of these assessments for screening in general practice. Clues from appropriate history taking may be of greater diagnostic use.

The psychosocial health status of carers of persons with dementia: a comparison with the chronically ill.

This project aimed to determine overall psychosocial health (measured using the psychosocial dimension of the Functional Limitations Profile) and factors which influence this in a group of carers of those with dementia and to compare their psychosocial health with that of older people attending general practitioners (GPs); arthritis support groups and a pain clinic (out-patients) and a group of community dwellers undergoing renal dialysis. The carer group showed a significant decrease in recreation and pastimes and social interactions compared to older GP attenders. The carers showed similar restrictions in social interactions and recreation to those with chronic arthritis, but the latter were more impaired in the domains of emotional behaviour and sleep and rest. The older people attending a pain clinic did not differ in the areas of alertness and social interactions compared to the carer group. The dialysis group demonstrated the greatest dysfunction overall. These results suggest that the psychosocial health of carers of those with dementia is impaired, the profile of which differs from those suffering with chronic diseases. Social and recreation activities appear most affected in the carers. Commensurate with studies exploring the health status of those suffering from diseases, the measurement of the psychosocial health status of carers should also be considered in the scope of assessment and intervention.