Neuroimaging referral for dementia diagnosis: The specialist's perspective in Ireland

Ciblis, A.S., Butler, M.L., Bokde, A.L., Mullins, P.G., O'Neill, D. and McNulty, J.P.
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring
Dementia remains underdiagnosed and neuroimaging is acknowledged as a key step in the diagnosis process. It is used to rule out other causes, establish differential diagnosis and dementia sub type. Ciblis et al.
(2015) surveyed geriatricians, old age psychiatrists and neurologists to explore their perspectives on access to neuroimaging for dementia diagnosis in Ireland When it came to how specialists felt about the proficiency of diagnosis in their Health Service Executive region, nearly half of respondents rated this as fair or poor, while most rated neuroimaging as important or very important. Although all participants reported having access to CT and most to MRI, two thirds did not have access to other modalities they would like to use, such as PET and SPECT. Respondents reported confidence in selection of the appropriate modality and in understanding neuroimaging in dementia. However responses reflected a lack of awareness of dementia specific protocols and of the use of any guidelines so that the authors comment on the need for national guidelines, standardisation of protocols and training.

Trends in diagnosis and treatment for people with dementia in the UK from 2005 to 2015: a longitudinal retrospective cohort study.

Donegan, K., Fox, N., Black, N., Livingston, G., Banerjee, S. and Burns, A.
The Lancet Public Health
In this longitudinal study Donegan et al.(2017) explore the impact of policy on dementia diagnosis and treatment between 2005 and 2015 and describe changes in the proportion of people diagnosed with dementia and the pharmacological treatments prescribed in the same period.
Across the UK there was a significant increase in the number of people diagnosed, with figures in Northern Ireland and Scotland being consistently higher, altough more recent figures indicate an upward trend for England and Wales. Prescription rates for anti-dementia drugs have increased with rates being consistently higher in Northern Ireland. This increase began before the release of the National Strategy n 2009 and was continuing to rise at the end of 2015. The general increase across the UK may be in part related to a change in NICE guidelines giving people with mild dementia access to these drugs. Prescription of anti-psychotic drugs significantly decreased from 22.1% in 2005 to 11.4% in 2015. The authors highlight the potential impact of 2004 guidance from the Committee on Safety of Medicines and the Time for Change Report 2009. While acknowledging that this study can not confidently link any changes to specific initiatives, the authors suggest that national initiatives appear to have had a positive impact.

The challenges of diagnosis and treatment of dementia in Down’s syndrome.

Vaughan, R.M., McGee, C., Guerin, S., Tyrrell, J. and Dodd, P.
Irish Journal of Psychological Medicine
This study analysed retrospective data on twenty adults with Down’s syndrome (DS), who are clients of a specialist service in Dublin.
The aim was to compare the practice of this service on diagnosis and treatment of dementia, with the consensus recommendations of the Royal College of Psychiatry, British Psychological Society and National Institute for Health and Care Excellence. Further aims were to establish average time to make a diagnosis and commence pharmacotherapy, and to describe tolerability to acetylcholinesterase inhibitors. Vaughan et al. (2016) found that screening for dementia did not take place before the age of 30yrs with the mean age for first assessment being 48yrs and average age at diagnosis being 51yrs. Average length of time from first identified symptoms to diagnosis was 1.3yrs. Of those diagnosed, 83% were prescribed acetylcholinesterase inhibitors but the authors were concerned at the continued use of the drug even when there appeared to be no benefit to the person. They found that a wide range of assessments were in use and that longitudinal assessment and follow up were not practiced. The authors recommend the streamlining of assessment tools and repeating assessment on a longitudinal basis.

The diagnosis if delirium superimposed on Dementia; An emerging challenge

Morandi, A., Davis, D., Bellelli, G., Arora, R.C., Caplan, G.A., Kamholz, B., Kolanowski, A., Fick, D.M., Kreisel, S., MacLullich, A. and Meagher, D.
Journal of the American Medical Directors Association
Delirium is defined in both DSM-5 and ISD-10 but no criteria is provided for it's assessment, nor for the assessment of pre existing cognitive impairment.
This lack of standardised assessment has clinical and research implications and prompted the establishment of a task force to review any evidence of DSD diagnosis, clarify key elements of diagnosis and formulate a path for the future direction of research in this area. Morandi et al. (2017) describe key features of DSD, such as attentional deficits, the role of arousal and motor fluctuations, reviewing related approaches to assessment.. They also discuss the potential overlap between symptoms of specific dementias and delirium, particualry dementia with Lewy bodies. They conclude with a suggested framework for improving diagnosis of DSD and details of the research needed to support the framework.

What do people with dementia and their carers want to know about neuroimaging for dementia?

Featherstone, H., Butler, M.L., Ciblis, A., Bokde, A.L., Mullins, P.G. and McNulty, J.P.
Featherstone et al. (2015) used focus groups and structured interviews to investigate people with dementia and carers' knowledge of dementia diagnosis pathways, the role of neuroimaging in diagnosis and what might be included on a website providing neuroimaging information.
Results indicated very limited understanding of neuroimaging and its role in diagnosis. Participants felt that better explanations could reduce anxiety and also add validity to a diagnosis, with the potential for avoiding diagnosis denial. While both carers and people with dementia were keen to have more information on neuroimaging they pointed out that the information needs to be focused on the person with dementia and carer’s specific needs. People with dementia were found to be unlikely to use an internet resource, but carers were particularly interested in such a resource. Again, they wanted this to be specific to the stage and sub type of dementia they had experience of. Findings indicate a level of dissatisfaction with current resources on dementia and a need for any information to be perceived as trustworthy and accurate. The authors conclude there is a need for better neuroimaging information and that this research can inform the development of an online resource and the investigation of other methods for providing information.

Help Seeking Intentions for Early Dementia Diagnosis in a Sample of Irish Adults

Devoy, S. and Simpson, E.E.A
Aging and Mental Health
In a mixed methods study using the theory of planned behaviour, Devoy & Simpson (2017) set out to identify factors that might increase help seeking intentions for an early dementia diagnosis.
Three focus groups informed the development of a quantitative questionnaire administered to 95 community dwelling adults aged 50-69 years. They found good knowledge of dementia but poor knowledge of post diagnosis support. Fear, stigma and shame were identified as barriers to help seeking behaviours while family friends and peers were considered the most likely to support help seeking behaviour. The main predictors of help seeking intentions for early diagnosis were found to be indirect measures of subjective norms and knowledge of dementia.

The use of neuroimaging in dementia by Irish general practitioners.

Ciblis, A.S., Butler, M.L., Bokde, A.L.W., Mullins, P.G. and McNulty, J.P.
Irish Journal of Medical Science
This paper set out to investigate GP access to neuroimaging, referral patterns, GP confidence around referral and opinions on radiology reports. A postal survey was issued to Irish GP’s in rural, semi-rural and urban areas and 302 questionnaires were returned.
Most respondents rated diagnosis within their HSE region as excellent; two thirds of respondents in Dublin and Cork but 80% of respondents in Kildare and 100% in Monaghan rated this as poor. Almost half of respondents referred patients with suspected dementia for neuroimaging but one third did not have access to a MRI scan. Acess was found to be considerably easier for private patients than public patients. Most GPs did not follow clinical guidelines and were unaware of dementia specific guidelines. Of those who made referrals, most found radiology reports useful and were confident of their ability to understand the report. Ciblis et al. (2016) conclude that clear referral protocols are required with appropriate training for GPs and that access to neuroimaging should improve so that it is available to every patient regardless of location and of whether the GP practice is public or private.

Normative CERAD-NP Performance among Community-Dwelling Older Adults in Ireland

Clinical Gerontologist

Highlighting the need for good dementia screening tools, Murphy (2012) aimed to provide normative data for the Consortium to Establish a Registry for Alzheimer’s Disease Neuropsychological (CERAD-NP; Morris et al., 1989) test battery, derived from an Irish-based sample.

This test battery has been found effective in distinguishing between Alzheimer’s disease, dementia, mild cognitive impairment and normal ageing. Ninety-nine participants deemed cognitively normal (MMSE=23 or above) undertook the battery of tests and results were then spilt according to education and age. No significant relationship between age and cognitive performance was found. In line with other studies there were some differences between lower and higher education levels supporting the concept of cognitive reserve related to higher education.  While norms in the Irish sample are generally in line with the US and Australia, a significant difference is found in the test, confrontational naming. The mean of the Irish sample is more than one standard deviation less than US and Australian samples, and over two standard deviations lower for the more highly educated categories.  The authors suggest that item familiarity is important and that local and cultural norms should be considered for this test. The authors conclude that CERAD-NP norms generated for US and Australian samples can be used in Ireland with the exception of confrontational naming.

Genio Dementia Programme: Evaluation End of Year 1

O’Shea, Murphy, E
Irish Centre for Social Gerontology

This report by O’Shea and Murphy (2014) examines the workings of the Genio Dementia Programme at the end of its first year. The report is based on information provided by Genio, visits to the project sites and meetings with key personnel, and a structured questionnaire completed by each site.

The report outlines key learning outcomes in relation to public awareness, diagnosis, community-based supports, and integrated provision. It considers issues around sustainability and reflects on the implications for public policy.

An Evaluation Report on the Dementia Support Worker Initiative of the 5 Steps to Living Well with Dementia in South Tipperary Project

CAHILL, S., PIERCE, M., Bobersky, A.
Living Well with Dementia

This report published by Trinity College Dublin and Genio Ltd describes an evaluation of a new model of respite developed and offered by 5 Steps to Living Well with Dementia in South Tipperary, one of the Genio Dementia Project sites.

The initiative focused on providing individualised supports to people with dementia and their family carers, which were delivered by Dementia Support Workers. The evaluation, which was carried out when the Dementia Support Worker Initiative was in its early stages, drew largely on qualitative interview with eight people with dementia and twelve family carers availing of the supports, and was supplemented by quantitative data to explore the experiences and impact of the initiative on people with dementia and their family carers. 


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