The Effect of Translation and Cultural Adaptations on Diagnostic Accuracy and Test Performance in Dementia Cognitive Screening Tools: A Systematic Review.

Background: The current cognitive tests have been developed based on and standardized against Western constructs and normative data. With older people of minority ethnic background increasing across Western countries, there is a need for cognitive screening tests to address factors which influence performance bias and timely diagnostic dementia accuracy. The diagnostic accuracy in translated and culturally adapted cognitive screening tests and their impact on test performance in diverse populations have not been well addressed to date. Objective: This review aims to highlight considerations relating to the adaptation processes, language, cultural influences, impact of immigration, and level of education to assess for dementia in non-Western and/or non-English speaking populations. Methods: We conducted a systematic search for studies addressing the effects of translation and cultural adaptations of cognitive screening tests (developed in a Western context) upon their diagnostic accuracy and test performance across diverse populations. Four electronic databases and manual searches were conducted, using a predefined search strategy. A narrative synthesis of findings was conducted. Results: Search strategy yielded 2,890 articles, and seventeen studies (4,463 participants) met the inclusion criteria. There was variability in the sensitivity and specificity of cognitive tests, irrespective of whether they were translated only, culturally adapted only, or both. Cognitive test performance was affected by education, linguistic ability, and aspects of acculturation. Conclusions: We highlight the importance of translating and culturally adapting tests that have been developed in the Western context. However, these findings should be interpreted with caution as results varied due to the broad selection of included cognitive tests.

Culture-Fair Cognitive Screening Tools for Assessment of Cognitive Impairment: A Systematic Review.

Background: Cognitive screening tools are important in the detection of dementia, including Alzheimer's disease; however, they may contain cultural biases. Objective: This review examines culture-fair cognitive screening tools and evaluates their screening accuracy, strengths, and limitations. Methods: Medline, Embase, PsychINFO and CINAHL were searched. The protocol was registered on PROSPERO (CRD42021288776). Included studies used a culture-fair tool to assess cognition in older adults from varying ethnicities. Narrative synthesis was conducted. Results: 28 studies were included assessing eleven different tools. The Rowland Universal Dementia Assessment Scale (RUDAS) was as accurate as the Mini-Mental State Examination (MMSE) (AUC 0.62-0.93), with a similar sensitivity (52-94%) and better specificity (70-98%), and the Multicultural Cognitive Examination (MCE) had improved screening accuracy (AUC 0.99) compared to RUDAS (AUC 0.92). The Visual Cognitive Assessment Test (VCAT) was equivalent to MMSE (AUC 0.84-0.91). The Kimberley Indigenous Cognitive Assessment tool (KICA) had AUC of 0.93-0.95; sensitivity of 90.6%, specificity 92.6%. Conclusions: The RUDAS, KICA and VCAT were superior to MMSE for screening dementia in ethnic minorities. Other tools also showed good screening accuracy. Further research should be done to validate tools in different populations.

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.

The Cognition and Flow Study (CogFlowS): A Mixed Method Evaluation of a Randomized Feasibility Trial of Cognitive Training in Dementia.

BACKGROUND: Cognitive training (CT) may be beneficial in delaying the onset or slowing dementia progression. CT has been evaluated quantitatively and qualitatively, but none have used mixed methods approaches. OBJECTIVE: The aim of this study was to use a mixed methods approach to identify those who may selectively benefit from CT. METHODS: This was an explanatory sequential mixed methods study involving a quantitative randomized trial of 12 weeks multi-domain CT in healthy older adults (HC, n = 20), and people living with mild cognitive impairment (MCI; n = 12) and dementia (n = 24). Quantitative outcomes included: cognition, mood, quality of life, and activities of daily living. 28 (10 HC, 6 MCI, 12 dementia) training participants completed semi-structured interviews with their carer. Quantitative and qualitative data were integrated using joint displays. RESULTS: Three participants dropped out from the training early-on, leaving 25 participants with follow-up data for full integration (10 HC, 6 MCI, 9 dementia). Dropouts and lower adherence to training were more common in dementia participants with greater non-modifiable barriers. High adherers were more resilient to negative emotions, and poorer or fluctuating performance. Integrated analysis found the majority of participants (n = 24) benefited across outcomes, with no clear profile of individuals who benefited more than others. Participants made a number of key recommendations to improve adherence and minimize dropout to CT. CONCLUSION: Reasons for dropout and low adherence were identified, with recommendations provided for the design of CT for dementia. An individual approach to training should be adopted and low adherence should not preclude engagement with CT.

Investigating the association between depression and cerebral haemodynamics-A systematic review and meta-analysis.

BACKGROUND: Vascular mechanisms may play a role in depression. The aim of this review is to summarise the evidence on alterations in cerebral haemodynamics in depression. METHODS: MEDLINE (1946- present), Embase (1947-present), Web of Science (1970-present), PsycINFO (1984-present), CINAHL (1976-present) and CENTRAL were searched using a predefined search strategy. A meta-analysis was conducted in four groups: 1) global cerebral blood flow (CBF) in ml/min/100 g, 2) CBF velocity (CBFv) in cm/s (maximum flow of left middle cerebral artery, 3) combined CBF and CBFv, 4) Ratio of uptake of Tc 99 m HMPAO (region of interest compared to whole brain). Data are presented as mean difference or standardised mean difference and 95% confidence interval (95% CI). A narrative synthesis of the remaining studies was performed. RESULTS: 87 studies were included. CBF was significantly reduced in depressed patients compared to HC [15 studies, 538 patients, 416 HC, MD: -2.24 (95% CI -4.12, -0.36), p = 0.02, I2 = 64%]. There were no statistically significant differences in other parameters. The narrative synthesis revealed variable changes in CBF in depressed patients, particularly affecting the anterior cingulate and prefrontal cortices. LIMITATIONS: There were various sources of heterogeneity including the severity of depression, use of antidepressant medication, imaging modality used and reporting of outcomes. All of these factors made direct comparisons between studies difficult. CONCLUSIONS: The reduction in CBF in depressed patients compared to HCs may indicate a role for assessment and CBF altering interventions in high-risk groups. However, results were inconsistent across studies, warranting further work to investigate specific subgroups.

Qualitative Analysis of the Cognition and Flow (CoGFlowS) Study: An Individualized Approach to Cognitive Training for Dementia Is Needed.

BACKGROUND: Cognitive training (CT) may have benefits for both healthy older adults (HC) and those with early cognitive disorders [mild cognitive impairment (MCI) and dementia]. However, few studies have qualitatively evaluated home-based, computerized CT programs. OBJECTIVE: We present the qualitative arm of a feasibility randomized controlled trial evaluating a CT program for HC and people living with MCI or dementia. METHODS: Participants underwent semi-structured interviews after 12 weeks of CT. Where possible, participants were interviewed with their carers. The interview schedule and analysis were underpinned by the health belief model. Interviews were audio-recorded, transcribed, open-coded, and categorized into themes. The analytical framework was developed, and themes were condensed under five major categories: benefits, barriers, threat, self-efficacy, and cues to action. RESULTS: 37 participants underwent interviews. CT was feasible and acceptable to participants. Benefits included: enjoyment, improved awareness, benchmarking cognitive function, reassurance of abilities and giving back control. Barriers were more prevalent among those with dementia: problems with technology, frustration, conflict between patients and carers, apathy and lack of insight, anxiety or low mood, and lack of portability. HC and MCI perceived the severity of dementia risk as high, partially mitigated by CT. Participants living with dementia valued a more individualized approach to training, accounting for baseline characteristics. CONCLUSION: CT was a feasible intervention for HC and people living with dementia and MCI. Benefits were present, but the identified barriers need to be addressed for CT to be implemented successfully.

The Cognition and Flow Study: A Feasibility Randomized Controlled Trial of the Effects of Cognitive Training on Cerebral Blood Flow.

BACKGROUND: Cognitive training (CT) has demonstrated benefits for healthy older adults (HG) and mild cognitive impairment (MCI), but the effects on vascular function are unknown. OBJECTIVE: This is a feasibility trial investigating the effects of CT on cerebral blood flow velocity (CBFv). METHODS: Twenty HG, 24 with Alzheimer's disease (AD), and 12 with MCI were randomized to 12 weeks of multi-domain CT or control. Outcomes included: cognition (Addenbrooke's Cognitive Examination III), mood, quality of life (QoL), physical, and neurovascular function (transcranial Doppler ultrasonography measured task activation of CBFv responses). Data are presented as mean difference (MD) and 95% confidence interval (CI). RESULTS: 47 participants completed the trial. There were three dropouts from the training arm in the AD group, and one in the HG group. The intervention was acceptable and feasible to the majority of participants with a high completion rate (89%). The dropout rate was higher among participants with dementia. Few changes were identified on secondary analyses, but QoL was significantly improved in HG post-training (MD: 4.83 [95% CI: 1.13, 8.54]). CBFv response rate was not significantly different in HG (MD: 1.84 [95% CI: -4.81, 1.12]), but a significant increase was seen in the patient group (MD: 1.79 [95% CI: 0.005, 3.58]), requiring sample sizes of 56 and 84 participants respectively for a fully-powered trial. CONCLUSION: A 12-week CT program was acceptable and feasible in HG, AD, and MCI. CT may be associated with alterations in vascular physiology which require further investigation in an appropriately powered randomized controlled trial.

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.

Representation of Black, Asian and minority ethnic patients in secondary care mental health services: analysis of 7-year access to memory services in Leicester and Leicestershire.

AIMS AND METHOD: We aimed to explore access by Black, Asian and minority ethnic (BAME) elders to the memory services in Leicester and Leicestershire, examining any trends over time. We then compared the odds of referral by ethnicity, using observed versus expected referrals for the city of Leicester. We gathered data on a comprehensive county-wide memory clinic used by people with suspected dementia and memory problems from the Trust electronic record system during the period 2011-2017. For Leicester city, we compared referral rates for 2011-2017 and compared observed and expected referral rates with demographics from the UK Census 2011. RESULTS: In Leicester, there was a significant underrepresentation of referrals from the BAME population as compared with the White population in 2011, 2012 and 2013, when compared with population estimates of those aged ≥60 years from the 2011 UK Census Leicester city data. Data for the Black population were too small for comparisons. The odds of being referred to a memory clinic for the White group was double that of the Asian group in 2011 (odds ratio 2.15, 95% CI 1.52-3.02) and nearly 1.5 times in 2012 (odds ratio 1.40, 95% CI 1.01-1.93). This difference did not persist after 2014. However, this differential odds of referral changes when the age difference between the groups is accounted for. After adjusting for age, there were no differences between the two groups in their odds of referral to the memory clinic from 2011 to 2013, but from 2014 to 2017, members of the Asian group had higher odds of being referred. CLINICAL IMPLICATIONS: The relationship between BAME and access to memory services is complex. The relative lower prevalence of Asian people among referrals to memory services in Leicester from 2011 to 2013 may partly be explained by the lower ages of the Asian population at referral. The higher prevalence of Asian people in 2014-2017 may be owing to use of denominators from the 2011 UK Census, which are likely to be disproportionately low for this group. Further studies are needed to explore any potential barriers to the access of services by BAME communities.

Effects of brain training on brain blood flow (The Cognition and Flow Study-CogFlowS): protocol for a feasibility randomised controlled trial of cognitive training in dementia.

INTRODUCTION: Cognitive training is an emerging non-pharmacological treatment to improve cognitive and physical function in mild cognitive impairment (MCI) and early Alzheimer's disease (AD). Abnormal brain blood flow is a key process in the development of cognitive decline. However, no studies have explored the effects of cognitive training on brain blood flow in dementia. The primary aim of this study is to assess the feasibility for a large-scale, randomised controlled trial of cognitive training in healthy older adults (HC), MCI and early AD. METHODS AND ANALYSIS: This study will recruit 60 participants, in three subgroups of 20 (MCI, HC, AD), from primary, secondary and community services. Participants will be randomised to a 12-week computerised cognitive training programme (five × 30 min sessions per week), or waiting-list control. Participants will undergo baseline and follow-up assessments of: mood, cognition, quality of life and activities of daily living. Cerebral blood flow will be measured at rest and during task activation (pretraining and post-training) by bilateral transcranial Doppler ultrasonography, alongside heart rate (3-lead ECG), end-tidal CO2 (capnography) and beat-to-beat blood pressure (Finometer). Participants will be offered to join a focus group or semistructured interview to explore barriers and facilitators to cognitive training in patients with dementia. Qualitative data will be analysed using framework analysis, and data will be integrated using mixed methods matrices. ETHICS AND DISSEMINATION: Bradford Leeds Research Ethics committee awarded a favourable opinion (18/YH/0396). Results of the study will be published in peer-reviewed journals, and presented at national and international conferences on ageing and dementia. TRIALS REGISTRATION NUMBER: NCT03656107; Pre-results.

The Assessment of Cerebrovascular Response to a Language Task from the Addenbrooke's Cognitive Examination in Cognitive Impairment: A Feasibility Functional Transcranial Doppler Ultrasonography Study.

BACKGROUND: The incidence of dementia is predicted to rise rapidly, but sensitive diagnostic tests remain elusive. Changes in cerebral blood flow velocity (CBFv) can occur at an early stage of cognitive decline, and can be measured by transcranial Doppler ultrasonography (TCD). OBJECTIVE: The aim of this study was to characterize the CBFv changes that occur in healthy older adults (HC), mild cognitive impairment (MCI), and Alzheimer's disease (AD), in response to a language task from the Addenbrooke's cognitive examination (ACE-III). METHODS: Participants underwent bilateral TCD, continuous heart rate (ECG), end-tidal CO2 (capnography, ETCO2), and beat-to-beat blood pressure (Finometer, MAP), monitoring, during a 5-minute baseline, followed by cognitive tasks from the ACE-III. Data are presented for a language task (repeating words and phrases aloud), as peak percentage change in CBFv, HR, MAP, and ETCO2 from a normalized baseline. RESULTS: 30 participants (mean age 73.2 years, 20% female) were recruited; HC (n = 10), MCI (n = 10), AD (n = 10). Language scores did not differ between groups (p = 0.16). Peak percentage change in CBFv differed between groups with the language task (HC: 15.9 (7.5)%, MCI: 6.7 (4.5)%, AD: 0.1 (7.1)%; p < 0.005). However, changes in MAP (HC: 7.9 (4.6)%, MCI: -0.1 (0.9)%, AD: 0.9 (4.4)%; p < 0.005), HR (HC: 8.8 (8.2)%, MCI: 0.7 (4.3)%, AD: -0.5 (5.6)%; p = 0.005), and ETCO2 (HC: -0.9 (3.2)%, MCI: 0.9 (3.2)%, AD: -5.2 (5.7)%; p = 0.006), also occurred. CONCLUSIONS: TCD measured CBFv changes to a language task from the ACE-III was feasible in a cognitively impaired population, further work is required in a larger population.

The role of vascular risk factors in late onset bipolar disorder.

BACKGROUND: The association between late life depression and cerebro-vascular risk and cerebro-vascular disease is well established. Do similar links exist with late onset bipolar disorder? AIMS AND OBJECTIVES: Patients with early onset (less than 60 years of age) bipolar disorder were compared with those of late onset (aged 60 and above) in relation to cognitive function, physical health and vascular risk factors. METHOD: Cross-sectional survey of elderly bipolar disorder patients (above 65 years) involved with secondary care mental health services. Thirty patients with early onset were compared with 20 patients with a late onset bipolar disorder. Diagnosis of bipolar disorder was according to ICD-10 criteria and without an associated clinical diagnosis of dementia. Assessment of cognition included tests of frontal-executive function, and cerebro-vascular risk was quantified with the Framingham stroke risk score. RESULTS: The late onset group had a higher stroke risk score than the early onset group, this difference persisting despite taking age and gender differences into account. However, late onset patients' cognitive function (including frontal lobe tests) and physical health status was no different to the early onset group. CONCLUSION: There is higher 'cerebrovascular risk' in elderly patients with late onset bipolar disorder, compared to patients with an early onset. This suggests that cerebrovascular risk may be an important factor for the expression of bipolar disorders in later life, and has significant management implications for older bipolar patients.

Prognosis of depression in old age compared to middle age: a systematic review of comparative studies.

OBJECTIVE: Depression in old age has a poor long-term prognosis; equal evidence shows that the same is true of depression in middle age. The authors sought to identify research that has compared the prognosis of depression in late life with depression in midlife under similar conditions. METHOD: The authors separated studies that examined age at presentation/recruitment from studies of age at first episode of depression, studies that examined remission/response from those that examined relapse/recurrence, and those that examined mortality/risk of dementia. RESULTS: Evidence suggests that response and remission rates to pharmacotherapy and ECT are not sufficiently different in old-age depression and middle-age depression to be clinically significant. Older patients at study entry appear to have a higher risk of further episodes, which informs the debate about the duration of continuation treatment for depression in older people. However, older patients and patients with late-onset depression are at increased risk of medical comorbidity. Medical comorbidity is a risk factor for inferior treatment response and poor antidepressant tolerability. Elderly patients with early-onset depression are more likely to have had a higher number of previous episodes, which also adversely influences prognosis compared to elderly depressed patients with late onset of illness. CONCLUSIONS: With control for confounding variables, remission rates of depression in patients in late life are little different from those in midlife, but relapse rates appear higher. Findings underline the importance of assessing factors related to patient age and not just to age itself in evaluations of risk factors for poor prognosis.

Fear of persecution not adequate to claim refugee status.

In Delgadillo v Canada, the Federal Court of Canada upheld an Immigration and Refugee Board (IRB) decision to refuse refugee status to a Mexican gay male refugee claimant because he had an Internal Flight Alternative (IFA). Although the court reached this conclusion, it nevertheless agreed that Mr Delgadillo had a legitimate fear of persecution. As well, the court made an important finding--that people in Mexico who are living with HIV/AIDS do not have an IFA.