Professor Annalena Venneri Professor Markus Reuber Accessible and acceptable care and support Understanding Dementia Age is the strongest risk factor South Asians are the largest BME group and the least studied when it comes to mental health research ID: 598476
Download Presentation The PPT/PDF document "Baber Malik" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Baber Malik
Professor Annalena Venneri
Professor Markus Reuber
Accessible and acceptable care and
supportSlide2
Understanding Dementia
Age
is the strongest risk factor
South Asians
are the largest BME group and the least studied when it comes to mental health research.They are considered to be at an age now where they are most at risk for dementia.
What is Dementia?
Dementia is an umbrella term for progressive disorder of cognition
Dementia is characterised by a decline of information processing abilities accompanied by changes in personality and behaviour
When translated into several different
S
outh Asian languages, it can sometimes translate to words such as madness or crazySlide3
Context: Dementia
Strategy (2009)
Improving awareness and understanding
Good quality early diagnosis and intervention for all
Is there a lack of access to care and support in the South Asian community? …If yes, why? Language barriers
Poor self-navigation through the health care system
Are the health care systems impractical and over-complicatedSlide4
Clinical pathway: Dementia diagnosis
GP
Consultation: Patient complains about memory related problems
Neurologist/Psychiatrist
: MRI scan, possible diagnosis reached at this stage
Neuropsychologist
: Extensive assessment – clinical history taking, memory, language, attention
Identify impact of demographic variables (age, gender, education, ethnicity) on test scores-
facilitates
more accurate interpretation
The purpose of the PhD was to identify cultural differences that may effect performance on cognitive tests and to modify assessment in order to aid a better clinical diagnosis of dementia for the Pakistani community. Slide5
Standardised tests are those for which normative values are available from a representative sample of normal individuals
Ideally this sample should come from the same sociocultural background as the patient
The availability of normative values is a problematic issue in neuropsychology:Most neuropsychological tests are not standardised on large cross-cultural samples
What are standardised tests?Slide6
Diagnosis is difficult especially given the increasing number of diverse populations
Cross-cultural research is rapidly gaining prominence as a means of enabling cross country comparisons and in response to increasing ethnic diversity
Great variability confronting testing as many demographic variables have a differential impact on test scores
Validity critical to accurate assessment and diagnosis depends on use of tests in populations on which they have been normed
Cultural diversity and assessment of neurodegenerative disorders
What is the problem?Slide7
Performance on psychometric tests is affected by several variables, e.g.
sexageeducation
sociocultural backgroundIf the effect of these variables are not taken into account, there is a high risk of making interpretative errorsIt
increases the risk of false positives (i.e. considering as pathological a performance which is within normal limits)Why should standardised tests be preferred?Slide8
At least 3 reasons:
Ethical
Research should be representative
Inform Theory
Add to explanation of behaviour and function
Inform Clinical Practice
L
ead to more valid and accurate assessment, diagnosis and treatment
Why address multicultural
issues?Slide9
Three solutions to
culture
free assessment
1. Novel test construction
Creation of new tests specifically designed for use with cultural groups that take into consideration item selection and analysis, normative studies, reliability and validity analyses
2. Modification of existing tests
Tests are translated and adapted for different linguistic and socio-cultural groups
3. Development of norms
Taking into consideration age and education for different ethnic groupsSlide10
Study 1: Autobiographical Memory (ABM)
What is Autobiographical Memory?
Personal experiences and events (includes semantic and episodic elements) - represents who we are today based on who we were in the past and what we want to become in the future
‘SELF’ representations: it is often termed as ‘mental time travel’, (Tulving, 2002)
HOWEVER, ‘SELF’ representations differ:General difference between Independent vs. Interdependent culturesWhy is it important?
Autobiographical memory is affected early in patients with Alzheimer’s Disease and Amnestic Mild Cognitive Impairment and it also forms the basis to clinical interviews, person-centred care pathways, making it a good research starting point
(Wang, 2001;Wang &
Brockmeier
, 2002; Markus & Kitayama, 1991)Slide11
There are several ABM tests used in practice, however, they are based on western norms.
Ivanoiu
et al., 2006 ABM questionnaireChildhood (6-16 yrs)
SemanticEpisodic Early adulthood (17-39
yrs)SemanticEpisodic Late adulthood (40-55 yrs)Semantic
Episodic
Recent (last 5 yrs) SemanticEpisodic
Methodology: Autobiographical testsSlide12
Methodology: Novel ABM test
Total number: 84 (42 British, 42 Pakistani; 42F,42M)
Mean
Pakistani
British
P
value
Age
65.2 (3.8)65 (5.1)
NS
Years of Education
7.07 (2.08)
14.92 (4.04)
<0.001Slide13
*
*
*
L
ess use of ‘I’ in the Pakistani group and more use of ‘we’ when recalling their memories, supporting other research to suggest independent vs. interdependent differences (Wang et al., 2008).
Results: Autobiographical Memory
Fewer details
expressed in the Pakistani group from the 80’s onwardsSlide14
Study 2: Cognitive Assessment
We aimed to collect normative data on various tests of language, memory and attention in order to be able to provide a sufficient Neuropsychological assessment for a Pakistani patient.
They were translated and modified and administered in Urdu/Punjabi.
In total we collected data on 123 healthy participants
Age Group
Total
Male
Female
Age
Education
21-30
20
10
10
24.4 (1.93)
13.9 (3.16)
31-40
20
10
10
34 (1.97)
12.7 (2.96)
41-50
20
10
10
42.65 (3.73)
12.4 (2.66)
51-60
20
10
10
54.85
(
1.81
)
9.18 (1.94)
61-70
20
10
10
65.05 (2.42)
8.2 (3.58)
71-80
20
10
10
75.40
(
2.70)
4.67 (1.97)
80+
3
2
1
82.33 (1.53)
4 (0.00)Slide15
Mini-Mental State Examination
(Folstein et al.
1975)
10. Copying
آپ اس ڈرائنگ کی نقل کر سکتے ہیں
Animals/
جانور
Semantic Fluency
Stroop Task
Confrontation Naming
Mini-Mental State Examination
Method: MaterialsSlide16
Method: Demographic variables
Age
and education
are reported in literature as strong predictors on performance of cognitive assessments.
In order to see what effects of ethnicity might have, we used an acculturation score as a measure which would show us if more acculturated people may perform better or worse on cognitive tests. Slide17
1. Collect normative data: based on 123 healthy participants
2. Derive
formula to adjust scores based on significant
predictors: Age and Education influenced performance on the Urdu MMSE
3. Calculate
population based
cut-offs: 23.33, which is similar to the currently used British cut-off
4. Validate
adjusted scores
Adjusted MMSE score
= [Raw score - ((age - 50.195)*(-0.27)) - ((education - 9.553) *(0.370))]
75 year old
Pakistani
male
with
4
years of education
MMSE Raw score
=
18
= impaired
MMSE
Adj
score
=
27.5
= normal
Results: The Urdu MMSE
Capitani and Laiacona (
1997) Slide18
Results: Cognitive Assessment
The Pakistani cut-off scores are much lower than the British cut off scores which are currently used as norms in the UK for all individuals who are screened via Neuropsychological assessment.
Neuropsychological Test
Predictors
UMMSE
Age, Education
RMMSE
Age, EducationConfrontation Naming
EducationRey’s Complex Figure Copy
Education, Age, Acculturation
Rey’s Complex Figure
Delay
Education, Age, Acculturation
Category
Fluency
Education, Age
Letter
Fluency
Education
Digit
Span Forward/Backward
Age,
Education
Stroop Worse
Time
Age, EducationShort Cognitive Evaluation BatteryAge, Education
Digit CancellationEducation, Age, Acculturation
Visuoconstructive Apraxia Test
Education, Age
Logical Memory
Education, Age, Acculturation
Education
– Strongest predictor
Followed by
Age
and then
AcculturationSlide19
Neuropsychologist
: Extensive assessment – clinical history taking, memory, language, attention
Clinical Interview
: Autobiographical memory differences allow us to better understand cultural differences in recall. So fewer memories recalled do not necessarily warrant any major concerns but in fact the over general approach to their recall at this stage will be considered a normal approach to answering questions about their memories.
Clinical Assessment
: The lower cut off scores obtained will also be of use when assessing the cognitive status of a Pakistani patient. Prior to these cut off scores, many patients would be considered as severely demented. However with closer examination and correction of scores we are able to see that this is not the case.
Improvement
in assessing dementia: AccessibilitySlide20
شکریہ
Thank You
धन्यवाद