The prevalence of Dementia and Cognitive Impairment in Dublin area

Nursing Homes: The need for On-Going

Assessment

Dr Suzanne Cahill & Ms Ana Diaz

25th November 2009

Acknowledgements

Cathal Walsh: Senior Lecturer Statistician

Robert Coen: Senior Neuro-Psychologist

Andrea Bobersky: PhD student

Introduction

It is suspected that like in the UK, dementia may be the core business in Irish nursing homes.

Numerous calls for a dementia audit of Irish nursing homes (Action Plan for Dementia 1999 and HSE report on Dementia 2007).

Yet absence of up to date information remains

Literature (I)

Internationally (USA and Europe), different estimated prevalence rates for dementia in NHs ranging from 48% to 50%, to 62%, to 68%. (Magaziner et al, 2000; Feldman et al, 2006; Matthews & Dening, 2002; MacDonald & Cooper, 2006)

Estimated prevalence of cognitive impairment in people in nursing homes also show different results from 48% to 61% to 80%. (Yap et al, 2003; Godlove Mozley, et al, 2000; Snowdon et al, 1996).

Earlier Irish studies have shown cognitive impairment prevalence rates at 58% in NH and similar rates for those in hospitals specializing in continuing care of the aged. (O’Neill et al, 1990 ; Hickey et al, 1997)

In 2007, Falconer and O’Neil estimated that there were some 14,764 people aged 65 + living in Irish NHs of whom 85% experienced a disability. Their data also suggest that large numbers may have had a CI since 58% of these residents were reported to have difficulties learning, remembering and concentrating. (Census Data 2002)

Literature (II)

Whilst researchers have uncovered large numbers of people with dementia living in non-specialist nursing homes, in practice, undetected dementia may also be a reality. In the context of dementia, diagnosis is critical to drug treatments and to other service interventions.

In residential care, diagnosis and staffs’ assessment of residents’ cognitive status, is the first stage in care planning and is essential for providing optimal treatments for residents with and without dementia.

The absence of knowledge about who has a memory and cognitive problem in long stay care may also seriously compromise care services delivered and quality of life.

Literature (III)

The literature suggests that mild and moderate forms of dementia are more frequently overlooked than severe dementia

Low expectations of cognitive functioning and the absence of challenging behaviours, often hinder staff from recognising dementia

In one UK study, only 34% of the residents that the researchers classified as cognitively impaired were acknowledged by senior nursing staff as having dementia. In the case of residents with a severe impairment, a higher number (46.4%) was recognised

In a Danish study, staff correctly identified some 74% of the residents that had a dementia or other brain disorder. In this study, information was collected from the key carer staff

Summarizing:

In conclusion, international research has shown that several PwD or with CI live in non-specialist NHs, of those a good number may have no clinical diagnosis

Staff members in NHs do not easily recognise CI and dementia amongst their residents

Lack of knowledge may compromise the quality of care and QoL of PwD or CI

In Ireland, several calls for a dementia audit of NHs, however there is not up to date data available

Research Questions

What proportion of residents in Dublin based nursing homes have a clinical diagnosis of dementia?

Was dementia a primary reason for NH admission?

What is the prevalence of cognitive impairment amongst residents in the Dublin nursing homes surveyed?

What are DoNs perceptions of residents’ level of cognitive impairment ?

Are there differences between DoNs’ perceptions of residents’ cognitive status and impairment levels found using the MMSE?

Research Methods

Survey Research

Random Sample of Nursing Homes

Random Sample of Residents

Sample

Final sample 100 participants

42 residents did not partipacipate

18 refusals 10 no reply 7 feeling unwell 7 others

142 residents were randomly selected

All private and voluntary NHs in the East Coast Area (Dublin-Mid Leinster) -HSE- 10 LHO

subdivisions

Sampling frame: three LHO which represent the Eastern Regional Health Authority (Dun Laogaire,

Dublin South East and Wicklow) 53 NHs

Four NHs ramdomly selected. Chances of being sampled proportional to NH's size

Total capacity of the 4 selected NHs 187 beds, of those 174 were occupied

Data Collection Instruments (I)

Mini Mental State Examination (MMSE)

Montreal Cognitive Assessment Scale (MoCA)

Dementia Screening Scale (DSS)

Quality of Life Interview Schedule

Semi-Structured Questionnaire with DoNs (demographic data & subjective assessment of CI and QoL)

Data Collection Instruments (II)

Mini Mental State Examination (MMSE)

• The MMSE is a widely used screening test for cognitive impairment in older adults. Gold Standard test for measuring CI

• Scores 0 -30• Different cut off points depending on purpose• For this study:

• 30-27 Intact• 26-20 Mild• 19-11 Moderate• 10-0 Severe

Data Collection Instruments (III)MMSE Orientation (10 points)

What is the (year) (season) (date) (day) (month)? Where are we: (country) (county) (town\ city) (building\ place) (floor)? Registration (3 points) Name three common objects (eg.: apple, table, penny) Take one second to say each. Then ask the patient to repeat all 3 after you have said them. Give one point for each correct answer. Then repeat them until he learns all three. Attention and calculation (5 points) Subtract 7 from 100 and keep subtracting 7 from what’s left. Score 1 point for each correct. Stop after five answers. (93__ 86__ 79__ 72__ 66__ ). Alternatively Spell 'world' backwards. The score is the number of letters in the correct order (D __ L__ R __ O __ W __ ) Recall (3 points) Ask for the three objects repeated above. Give one point for each correct answer Language (9 points) Name a pencil and a watch (two points). Repeat the following: 'No ifs, ands or buts' (one point). Follow a three-stage command: 'Take a paper in your right hand, fold it in half and put it on the floor' (three points). Read and obey the following: Close your eyes (one point). Write a sentence (one point). Copy a design (one point).

Total score 30 ( )

Data Collection Instruments (IV)

MoCa

The MoCA was designed as a screening instrument for the detection of mild cognitive impairment. It was developed in response to the poor sensitivity of the MMSE in distinguishing clients with mild cognitive impairment from normal elderly clients (Nasreddine et al., 2005).

The MoCA is intended for patients who score within the normal range on the MMSE.

MoCA scores 0 - 30. A total score of 26 and above is considered normal. A total score below 26 is indicative of mild cognitive impairment.

Data Collection Instruments (V)MoCA

.

Data Collection Instruments (VI)

DSS The DSS was constructed as a dementia

screening scale for use by professionals (proxy).

Total score varies between 0 to 14.

The higher the score the more severe the CI.

1 to 3 minutes to be completed

Data Collection Instruments (VII)

DSS

.

Never Occasio

nally Always

1. Did she/ he recognise friends/ relatives / staff? (2) (1) (0)

2. Did she/ he know friends / relatives/ staff by name?

(2) (1) (0)

3. Could she / he remember what happened in the past few days?

(2) (1) (0)

4. Does she / he confuse people, and does he / she not know where he / she is?

(0) (1) (2)

5. Could she / he orient her / himself in her / his room?

(2) (1) (0)

6. Could she / he orient her / himself in the home / living area?

(2) (1) (0)

7. Could she / he orient her / himself in the neighbourhood of the home?

(2) (1) (0)

Data Collection Instruments (VIII)

DONs subjective perceptions of each resident

cognitive Status (Likert Scale)

- How would you rate his/her cognitive status?

Intact Mild Moderate Severe

Results (I)

Table 1: Socio-demographic profile of residents (N=100)

Gender N %Female 82 82%Male 18 18%

Marital Status Single 44 44%Widowed 42 42% Married 12 12% Separated 2 2%

Highest level of education Secondary 46 46%Tertiary 20 20%Primary 5 5%Don’t know 29 29%

Previous Work Status Formally employed 56 56% Homemakers 30 30%Don’t know 14 14%

Whilst no statistical relationship was found between age or length of stay in the nursing homes and level of cognitive impairment, residents with more severe cognitive impairment were more likely to be older and have spent longer periods in long term care.

Results (II)Table 2: Age, length of stay and Mean MMSE scores (N=100)

N Minimum Maximum Mean SD

Age (in years) 100 63 101 85.1 years 7.9

How long has he/she been a resident in the NH

100 1 month 12 years 3.3 years 2.8

MMSE score as per pilot study 100 0 30 13.84 8.7

MoCA Score (MMSE Cut Off Point 27) 11 19 28 23.36 3.9

DSS Score (MMSE Cut Off Point 10) 42 4 14 10.19 3.2

Figure 1: DoN’s perceptions of reasons for Nursing Home admission (N=100)

Figure 2: Has the resident ever been clinically diagnosed with Dementia (N=100)

No68%

Yes32%

Figure 3: Has resident ever had a MMSE done before (N= 100)

Figure 4: Rates of Cognitive Impairment amongst nursing home residents using the MMSE and Folstein’s recommended cut offs (N=100)

Figure 5: Rates of Cognitive Impairment in nursing home residents using both MMSE & MOCA (N=100)

Figure 6: Rates of Cognitive Impairment in nursing home residents according to DoNs (N=100)

Table 3: Differences between Matron’s perceptions of residents cognitive impairment & MMSE findings

(N=100) Intact

MatronsMild

MatronsModerate Matrons

Severe Matrons

34.80% 13.60% 0 0

8 3 0 0

34.80% 27.30% 23.80% 2.90%

8 6 5 1

21.70% 45.50% 38.10% 11.80%

5 10 8 4

8.70% 13.60% 38.10% 85.30%

2 3 8 29

34

Intact MMSE

Mild MMSE

Severe MMSE

Moderate MMSE

Total residents 23 22 21

Figure 7: Differences between Matrons’ perceptions of residents’ cognitive impairment, MMSE findings and clinical diagnosis

Discussion Almost all residents in the nursing homes surveyed had a cognitive impairment (MMSE 89%, MoCA 97%)But only 32% had a clinical diagnosis of dementia and 14% were admitted due to dementia Only one of the four surveyed NH used the MMSE on a regular basis to assess residents’ CI Directors of Nursing perceptions of residents CI were sometimes quite inaccurate. They tended to under-estimate the severity of cognitive impairment of residents in their care. Residents with a clinical diagnosis of dementia were more likely to be accurately identified & those without a clinical diagnosis were more likely to be mis-classified. It would appear that having a diagnosis helped DoNs better identify residents’ status

Conclusion

These results need careful consideration but raise concerns about the quality of care in Dublin area nursing homes

The misclassification as normal, of people with a mild to moderate cognitive impairment has serious implications including delayed or inappropriate treatments and compromised quality of care

The under-recognition of residents with severe cognitive

impairment also has profound implications in relation to residents’ well-being, the delivery of care and other resource allocation

Once admitted to long term care, there is a need for regular and on-going monitoring of residents’ physical and cognitive health care needs and when appropriate pursuing a differential diagnosis

Challenges of research

Access

Consent

Relying on others for sampling

Feedback. How to deal with findings which may be unattractive to key stakeholders.

Some of the positive outcomes

Testing tools and procedures

Forging good relationships with NHs

NHs have an up-to-date assessment of each participant and a report with results and comparative results

Awareness among their staff

Information and access to workshops and seminars

Acknowledgements

This research has been funded by a grant from The Atlantic Philanthropies

Cahill S, Diaz-Ponce A, Coen RF & Walsh C. The under-detection of cognitive impairment in Nursing Homes in the Dublin Area. The need for on-going cognitive assessment.

Age and Ageing. 38(1) Forthcoming 2010

Our thanks to all those residents in nursing homes who kindly agreed to participate in this research study

Thank you for listening