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Depressivität und kognitive Beeinträchtigungen bei Altenpflegeheim-Bewohnern.

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Leave for a week. Additionally, there are no studies that compare the accuracy of this instrument depending on if the instrument is administered by physicians versus other health personnel. The DSS is a 7-item scale that assesses both memory and orientation at the time of assessment [ 69 ]. The instrument was originally developed in the German language, tested in nursing home residents, and administered by nurses [ 69 ].

Because the scale is fast and easy to administer, this approach can be considered to be feasible in health services research, even though its validity must be critically discussed. The scientific literature concordantly states that the assessment of single domains of cognition, especially a single cognitive test, cannot accurately diagnose dementia and should not be used to substitute systematic evaluations, examinations and laboratory tests [ ].

Hence, the DSS will misclassify residents who have acute cognitive deficits that are due to infection or dehydration. The same misclassification can occur in residents who have chronic cognitive impairments due to other diseases. In our review, the MMSE was the instrument that was most often chosen to define the inclusion criteria. The rationale for using the MMSE in the studies was primarily its degree of popularity and widespread utilization. A meta-analysis on the accuracy of the MMSE confirms this choice: The notable shortcomings of the MMSE in the context of nursing home research were rarely discussed in the studies, although those shortcomings threatened the internal validity of the study results.

The MMSE shows a floor effect in very severe score ranges, people with little formal education, and people with severe language problems. We found a variety of MMSE thresholds for staging dementia in the reviewed studies - a result that was also reported in other reviews [ 12 , 20 ]. This result may be a consequence of missing normative data for the age group of the oldest-old and standardized age-adjusted cutoff values. The authors of a meta-analysis on dementia screening and case-finding tool validation studies suggest alternatives to the MMSE such as the Mini-Cog [ ].

However, the suitability of these screening tools for nursing home research needs to be investigated. In this respect, an associated question must be discussed in health services research in nursing homes: If the aim of the study is to prove the benefit of an intervention that should be provided exclusively to residents with dementia, a valid diagnosis is essential to prove the benefit for this population.

If the aim of the study is to prove a benefit for residents with cognitive and functional impairments independent of their etiology, a dementia diagnosis is dispensable. The same question must be considered by clinicians because in the absence of disease-modifying treatments, the primary advantage of a diagnosis for the oldest-old population has to be determined to justify resource-intensive diagnostics [ 20 ].

The need to perform diagnostics in the nursing home population must also be ethically justified because psychological tests can be significantly burdensome to people with CIs. We also found 4 articles that aimed to investigate residents who had CI but did not explicitly have dementia.

To us, it was unclear why some studies focused on the population of people with CI but not on people with dementia because the authors did not elaborate on the question whether the etiology of CI played a role with respect to their research focus.

If the authors did not explain why they defined their population based on a disease or a symptom and later failed to distinguish between the 2 conditions, one may ask whether the question was sufficiently addressed.

With each decade of dementia studies in German nursing home research, the diagnostic procedures were refined and reflect methodological innovations. Therefore, the definition and assessment of dementia and CI must be considered against the respective state of knowledge at the time a particular study was conducted. The problem of inconsistent management of methodological challenges in dementia research has already been recognized and has led to an initiative on how to improve the reporting of these challenges in clinical studies [ ].

However, studies of the outlined problem of inconsistent case ascertainment strategies in nursing home research have been lacking to date. We consider this as a prerequisite for improving dementia research in the nursing home sector and outline this as the major strength of this study. The generalizability of the displayed results is constrained to one country Germany. However, we assume that the outlined problem can also be demonstrated in other countries, but this must be proven in a later review.

Perhaps in countries in which physicians are employed in nursing homes and adherence to diagnostic standards can be guaranteed, the reliance on a recorded diagnosis can be received less critically. As discussed, the reporting of diagnostic procedures was partially insufficient; in particular, different publications from a single study provided varied information about their case ascertainment.

In some studies, it was not clear whether the assessments were used exclusively for study purposes, for diagnosis, or both. In particular, the scope of assessments with respect to behavior and function was not described clearly, making it unclear whether these instruments were also used for diagnostic procedures.

In an effort to rule out this lack of clarity, we unsuccessfully attempted to contact the authors. The short reporting made it also impossible to assess the quality of diagnostic procedures or the associated risk of bias. Because of the descriptive objective of the review, it has not been registered in a review register. Considering the findings of our review, we suggest the following principles to improve the validity and comparability of study results on dementia in nursing homes.

Investigators must clearly distinguish whether their research addresses residents with CIs or residents with dementia with an appropriate etiology. If residents with dementia are addressed, it should be in accordance with the study aim. Studies that address the population of nursing home residents with dementia should report in detail which method of case ascertainment was used and should discuss the limitations associated with each method.

In our opinion, a criterion-based diagnosis is essential when a study addresses explicitly residents with dementia. If residents are included in studies based on diagnoses that do not conform to established criteria, the results from different studies are not comparable. To ensure that a diagnosis conforms to criteria, clinicians who are members of the research team should evaluate a diagnosis during the research project. When financial or human capacities are constrained, one should consider alternative methods to a face-to-face consultation by a geriatric physician, psychologist or psychiatrist.

Several methods utilizing an expert panel are described for the diagnosis of dementia [ ]. The method by Magaziner et al.

Another promising approach is a nurse-administered diagnosis. Studies showed a high agreement between a nurse-administered diagnosis and a multidisciplinary team diagnosis in determining mild CI in primary care [ ]; in addition, there is agreement between a Memory Clinic diagnosis [ ] and a moderate agreement with the ICD diagnosis ibd.

To our knowledge, a nurse-administered diagnostic procedure for dementia in nursing home residents has not yet been developed and tested. Regardless of which method is used to evaluate a diagnosis of dementia within a study, reporting requires details regarding the domains that are tested, the rationale behind instrument use for each domain examined, the cutoff values set for each domain and the management of missing data.

Transparency in reporting missing data is needed because approaches for adequately managing these gaps can differ and produce varying effect estimates [ ]. If a dementia diagnosis is considered as dispensable or a criteria-based diagnostic procedure cannot be applied due to constrained resources, the study should not target the dementia population, but instead clearly state which population they are addressing.

All data are contained within the manuscript and its supplementary files. We would like to thank Prof. Stefan Teipel and Dr. Martin Berwig for their constructive feedback on the manuscript. The German Center for Neurodegenerative Diseases funded the study.

All authors contributed in the conceptualization of the article and revised the final version for intellectual content.

RP drafted the manuscript and is responsible for final compilation. MH supervised the whole process. All authors have read and approved the final version of the manuscript. National Center for Biotechnology Information , U.

Published online Apr 5. Schwab , Martin N. Dichter , Bernhard Holle , and Margareta Halek. Author information Article notes Copyright and License information Disclaimer. Received Sep 24; Accepted Mar This article has been cited by other articles in PMC.

Associated Data Data Availability Statement All data are contained within the manuscript and its supplementary files. Abstract Background There are various definitions and diagnostic criteria for dementia, leading to discrepancies in case ascertainment in both clinical practice and research.

Results We summarized case ascertainment methods from 64 studies. Conclusion Pragmatic considerations often determine the sampling strategy; they also may explain the variances we detected in the different studies. Electronic supplementary material The online version of this article doi: Dementia, Cognitive impairment, Diagnosis, Symptom assessment, Nursing home, Health services research.

Background Health care service research aims to evaluate care strategies by obtaining an understanding of the causal factors in improving dementia-related outcomes for individuals living in nursing homes [ 1 ]. The diagnostic criteria for NCD are as follows: Evidence of a significant cognitive decline from a previous level of performance in one or more cognitive domains complex attention, executive function, learning and memory, language, perceptual-motor or social cognition.

How is dementia defined and measured in health services research studies in German nursing homes? Methodology of the review Compared to systematic reviews that aim to answer questions about the effectiveness of clinical procedures, there are few well-defined tools and processes for methodological reviews; not all items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA guidelines are applicable see PRISMA checklist in the Additional file 1: Data extraction and method of analysis Two researchers RP, SJ read the included articles in full-text and extracted the data: Results The literature search yielded articles.

Open in a separate window. Table 1 Characteristics of included studies. Methods to identify the study population residents with dementia All 64 articles focused on the population of nursing home residents with CI. Nursing home residents with dementia were identified in one of the following ways: A study diagnosis that was evaluated during the study.

The diagnosis was newly assessed either in all residents or in residents with a diagnosis that had previously been documented. Table 2 Overview of studies that determine study participants with dementia based on a study diagnosis. Physician with experience in geriatric psychiatry [ 23 ] Diagnostics performed by physicians from the research team for every resident fulfilling one of the criteria: Experienced geriatric psychiatrist with formal training in the administration and scoring of the respective instruments.

Study monitor with a medical education [ 69 ] Diagnostics in the study was performed for all nursing home residents. Trained clinical psychologist Screening DSS: Determined in multidisciplinary consensus conferences held by psychiatrists, clinical psychologists and health and nursing specialists. In the study by Graessel et al. In this study, the dementia diagnosis was an admission criterion for the care unit that participated in the study Dementia Special Care Unit. This study does not report whether the diagnosis was confirmed.

Table 3 Overview of studies that defined study participants with dementia based on a recorded diagnosis. Recorded medical diagnosis and screening. One study used a stepwise approach [ 48 — 51 ]: Table 4 Overview of studies that defined study participants with dementia based on a recorded diagnosis and additional cognitive screenings. Publications Method of sample determination Definition and criteria used for existing dementia diagnostics Screenings performed to define and describe dementia Qualification and training of professionals involved [ 48 ] Residents with dementia were identified using a mixed stepwise approach: Multiple combined inclusion criteria: Physician from the research team who was experienced in geriatric psychiatry Screening instruments: Specifically trained raters, including medical students with an advanced academic degree and physicians experienced in geriatric psychiatry [ 49 ] [ 50 ] a [ 51 ] [ 81 ] b [ 76 ] Residents with dementia were identified using two combined inclusion criteria: Psychology students in their final year who had received training [ 77 ] [ 78 ] [ 79 ] [ 80 ] Residents with dementia were identified using two combined inclusion criteria: Majic referred to DSM- IV, other publications to ICD b Reporting of methods and proceedings slightly deviates from that of the other publications originating from this project validation of recorded dementia diagnosis is not specified; MMSE cutoff 23; no exclusion criteria are reported.

In these studies, an existing diagnosis was recorded, but it was not used as the inclusion criterion. One article reported exclusion criteria that were used to differentiate dementia from other psychiatric disorders [ 53 ].

Table 5 Overview of studies that defined study participants with dementia based on cognitive screenings. Caregivers who were familiar with the resident were interviewed from a trained external research assistant registered nurses and students in health care study programs [ 52 ] Residents were included using 2 criteria: Table 6 Overview of studies that investigated study participants with cognitive impairment. Publications Method of sample determination Screenings performed to define and describe CI Qualification and training of professionals involved [ 37 ] Assessment of CI performed for a random sample of NH residents.

In 4 of these publications, all of the residents from a participating nursing home or living unit were included in the study and investigated with respect to various indicators for dementia dementia diagnosis in the records and results of cognitive screenings [ 24 , 54 — 56 ].

In these studies, the sample was described, but participants were not selected or assigned based on these indicators. One article is a study protocol; the method to define residents with dementia was not determined, only the measurements that were intended to assess dementia [ 57 ].

In 2 publications [ 58 , 59 ], the method to identify residents with dementia was not reported at all. Table 7 Overview of studies that did not clearly define participants with dementia.

Publications Method of sample determination Information about dementia diagnosis Screenings performed to define and describe dementia Qualification and training of professionals involved [ 24 ] Every resident on the living unit enclosed in the study and described with respect to dementia-related characteristics Medical diagnosis is derived from the medical records and coded according to ICD Presence of dementia diagnosis in the nursing records, DSS Screening instruments: Professional nursing staff that were familiar with the resident [ 57 ] Study protocol Every resident on the living unit included in the study and described with respect to dementia-related characteristics Medical diagnosis is derived from the nursing records.

Nurses who are familiar with the residents and received training or supervision by a trained study coordinator NH staff [ 58 ] Procedure to identify residents with dementia not reported Not specified Not specified Not specified [ 59 ]. Reporting about dementia diagnostics within the study Fifteen articles reporting on studies with a newly assessed diagnosis detailed diagnostic criteria and gave information on the diagnostic process or referred to related articles that described the diagnostic process [ 22 , 23 , 48 — 51 , 60 — 68 ].

Reporting about screening of cognitive impairment CI was measured in all studies, but with different instruments and cutoff values.

Table 8 MMSE cutoff values for dementia staging a. Discussion This review reveals a sampling challenge for dementia studies in German nursing homes in health services research: In our review, we found 4 sampling methods to identify residents with dementia: Table 9 Case ascertainment strategies in comparison summary. Strengths and limitations The problem of inconsistent management of methodological challenges in dementia research has already been recognized and has led to an initiative on how to improve the reporting of these challenges in clinical studies [ ].

Conclusions Considering the findings of our review, we suggest the following principles to improve the validity and comparability of study results on dementia in nursing homes. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials All data are contained within the manuscript and its supplementary files. Acknowledgement We would like to thank Prof.

Additional file Additional file 1: DOCX 63 kb Additional file 2: Footnotes Competing interests The authors declare that they have no competing interests.

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