Stay with me

“Hello, I'm from the memory service. I'm looking for Mr Sheppard?” The door swings wide open and a relieved smile beckons me inside. “Oh yes doctor, we've been expecting you. My husband's just in the living room. This way.

Improving the diagnosis and prediction of progression in mild cognitive impairment

Mild cognitive impairment (MCI) is a clinical condition conceptualized as a stage between normal cognition and dementia. To diagnose it requires subjective cognitive impairment, evidence of cognitive impairment on cognitive testing but no abnormality in a person's functioning and no evidence of dementia (American Psychiatric Association, 2013). There has been growing interest in the condition over the past two decades or so because people with MCI are much more likely than people with no cognitive impairment to progress to dementia (Roberts et al., 2013). However, a significant percentage of people with MCI will not progress to dementia and some will revert to having normal cognition. Rates of progression and reversion to normal cognition vary widely in different studies (Manly et al., 2008). People with MCI experience worry about their symptoms and this is partly alleviated by receiving a diagnosis of MCI and being reassured they do not have dementia (Gomersall et al., 2017). The benefits of diagnosis also include gaining a greater understanding of their symptoms and accessing clinical support but a significant amount of uncertainty remains with regards to the risk of progression and recipients of the diagnosis remain frustrated at the lack of treatments for MCI (Gomersall et al., 2017). There has been much interest in improving the prediction of progression to dementia from MCI but to date, the best predictors of progression remain structured clinical and functional assessments, with some additional benefit from measures of cortical volume/thickness from brain imaging (Korolev et al., 2016). As yet, however, there are no interventions that can prevent (Kane et al., 2017) or treat (Cooper et al., 2013) MCI so it seems set to remain an important clinical entity for the foreseeable future

Evaluating risk of dementia in older people: a pathway to personalized prevention?

This editorial refers to ‘Impact of cardiovascular risk factors and genetics on 10-year absolute risk of dementia: risk charts for targeted prevention’, by R. Rasmussen et al., on page 4024

The Relationship of Bilingualism Compared to Monolingualism to the Risk of Cognitive Decline or Dementia: A Systematic Review and Meta-Analysis

BACKGROUND: Bilingualism may contribute to cognitive reserve, protect against cognitive decline, and delay the onset of dementia. OBJECTIVE: We systematically reviewed evidence about the effect of bilingualism on subsequent cognitive decline or dementia. METHODS: We searched electronic databases and references for longitudinal studies comparing cognitive decline in people who were bilingual with those who were monolingual and evaluated study quality. We conducted meta-analyses using random effects models to calculate pooled odds ratio of incident dementia. RESULTS: We included 13/1,156 eligible articles. Meta-analysis of prospective studies of the effects of bilingualism on future dementia gave a combined Odds Ratio of dementia of 0.96 (95% CI 0.74-1.23) in bilingual participants (n = 5,527) compared to monolinguals. Most retrospective studies found that bilingual people were reported to develop symptoms of cognitive decline at a later age than monolingual participants. CONCLUSION: We did not find that bilingualism protects from cognitive decline or dementia from prospective studies. Retrospective studies are more prone to confounding by education, or cultural differences in presentation to dementia services and are therefore not suited to establishing causative links between risk factors and outcomes

A national memory clinic survey to assess provision for people from diverse ethnic backgrounds in England and Wales

English national guidelines regarding dementia assessment and management recommend consideration of cultural and linguistic diversity when assessing people with cognitive complaints. To date there has been no assessment of adherence to these guidelines. We aimed to assess whether current services provided in memory assessment services (MAS) adhere to national policy, in their approach to the assessment and management of individuals with memory problems from minority ethnic backgrounds. We sent a survey to 213 memory services in England and Wales. Twenty MAS from seven regions responded to the survey. We found that 80% (16) provided translated resources, 70% (14) used cognitive assessment tools that are culturally sensitive and appropriate, and 65% (13) showed good use of sufficiently skilled and knowledgeable interpreters. Communication barriers, particularly language, were raised as a potential obstacle to diagnosing minority ethnic patients. Memory clinics appear to reflect national policy for the assessment and management of memory problems in minority ethnic patients. However, only a minority of services responded and they may be more engaged in considering these populations. We need wider knowledge of practice to explore how guidelines support healthcare professional’s assessment of patients from minority ethnic groups in memory service diagnostic procedures

The EAST-Dem study: Encouraging Access for South Asians to Timely Dementia Diagnosis

BACKGROUND: People from Black and Minority Ethnic backgrounds tend to seek help later in the course of dementia than people from the majority ethnic population. Aim: To develop an intervention to encourage people from South Asian backgrounds to seek help earlier for memory problems and test its acceptability and feasibility. Methods: I systematically reviewed the literature and analysed routinely collected data to find interventions which improved dementia diagnostic rates. I then completed my qualitative study with South Asian community members to inform the development of an intervention to encourage earlier help seeking for memory difficulties by South Asian people. After piloting, I tested the intervention in a pilot cluster randomised controlled trial (RCT) with South Asian patients from participating GP practices. Primary outcomes were: 1. Feasibility - recruitment and retention rates 2. Acceptability - rating on a Likert scale. Results: No trials to increase dementia diagnosis rates have been successful, but rates increased significantly after implementation of the English National Dementia Strategy. South Asian community members said that understanding, through a story, that dementia was a physical illness, would normalise dutiful family members seeking interventions. I developed a bilingual leaflet and trilingual DVD with this content. I recruited and randomised 8 GP practices; 78/102 (76%) patients who allowed me to contact them, consented to the study (37 treatment-as-usual and 41 intervention). 76 (97%) participated in follow-up. 37/41 (90%) who received the intervention found it acceptable. Conclusion: I designed the first culturally-appropriate intervention to encourage help-seeking for dementia in the South Asian population. Participants found it acceptable. It was feasible to recruit and follow-up participants. A full-scale RCT would require a very large number of GP practices to participate so is likely to be expensive. It may be preferable to make this acceptable and simple intervention available and disseminate it

Longitudinal association of apolipoprotein E and sleep with incident dementia

Introduction: Few longitudinal studies have explored the association between apolipoprotein E gene (APOE) status, sleep disturbances, and incident dementia among middle-aged participants. / Methods: Cox regression analyses explored the association of sleep duration, insomnia, and daytime napping with incident all-cause dementia and their interaction with APOE genetic risk among 397,777 middle-aged adults. / Results: During a median of 10.8 years follow-up, sleeping more or fewer than 7 hours was associated with a higher dementia risk (hazard ratio [HR] for 5 vs 7 hours: 1.35, 95% confidence interval [CI] 1.11–1.64; HR for 9 vs 7 hours: 1.59; 95% CI 1.37–1.85) as was daytime napping (HR for often/all of the time vs never/rarely: 1.67; 95% CI 1.37–2.03). Stratified analyses revealed that the effects of sleep disturbances were similar across all APOE genetic risk groups. / Discussion: Short and long sleep duration and daytime napping in middle-aged individuals are associated with the development of dementia in later life. Sleep duration and quality are important for everyone regardless of their genetic risk by APOE genotype

Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study

Background and objectives: COVID-19 has had a profound effect on mental health. Liaison psychiatry teams assess and treat people in mental health crises in emergency departments (EDs) and on hospital wards. During the first pandemic wave, new Mental Health Crisis Assessment Services (MHCAS) were created to divert people away from EDs. Our objective was to describe patterns in referrals to psychiatric liaison services across the North Central London care sector (NCL) and explore the impact of a new MHCAS. / Methods: Retrospective study using routinely collected data (ED and ward referrals) from five liaison psychiatry services across NCL (total population 1.5 million people). We described referrals (per week and month) by individual liaison services and cross-sector, and patterns of activity (January 1st 2020 -September 31st 2020, weeks 1-39) compared with the same period in 2019. We calculated changes in the proportion of ED attendees (all-cause) referred to liaison psychiatry. / Results: From 2019-2020, total referrals decreased by 16.5% (12,265 to 10,247), a 16.4% decrease in ED referrals (9528 to 7965) and 16.6% decrease in ward referrals (2737 to 2282). There was a marked decrease in referrals during the first pandemic wave (March/April 2020), which increased after lockdown ended. The proportion of ED attendees referred to liaison psychiatry services increased compared to 2019. / Conclusions: People in mental health crisis continued to seek help via ED/MHCAS and a higher proportion of people attending ED were referred to liaison psychiatry services just after the first pandemic wave. MHCAS absorbed sector ED activity during the pandemic