Dr Magda Jordao

Objective: Dementia diagnosis relies on assessing functional decline, yet widely used assessment tools are often developed in Euro-American contexts, limiting their cross-cultural validity. This commentary highlights key challenges in functional assessment across cultures and proposes a framework for enhancing their applicability and equity. Method: We critically examine methodological limitations in current functional assessment tools, including poor cultural adaptability, inadequate validation processes, and limited stakeholder engagement. Drawing on existing literature, we propose a multidimensional framework integrating cultural perceptions, robust adaptation strategies, and participatory approaches to improve assessment relevance. Conclusions: Functional assessments must balance cultural specificity with broad applicability to ensure accurate dementia detection across diverse populations. Identifying transcultural markers of functional decline, engaging local communities, and systematically adapting tools through rigorous validation will enhance their diagnostic utility. A culturally inclusive approach to functional assessment can reduce disparities in dementia diagnosis and care worldwide.

Background People from minoritised ethnic groups are more likely to be impacted by dementia. In the general population, dementia may be prevented or delayed by up to 40% by reducing risk in 12 modifiable risk factors (MRF). However, minoritised ethnic groups are not systematically included. Objectives We conducted a scoping review following Joanna Briggs Institute guidance to map: (1) which minoritised ethnic groups have been included in UK research on dementia MRF, (2) for which MRF and (3) using which research methods. Eligibility criteria Eligible studies analysed one or more of the 12 MRFs among minoritised ethnic groups. Evidence sources Medline, Embase Classic+Embase, PsycInfo, Web of Science, CINAHL and grey literature were searched. Charting methods Patient and public involvement with minoritised ethnic groups and professionals informed the data extraction tool. We use frequencies and graphs in data description. Results We screened 7748 records, assessed 122 full text records and included 14 studies, which mostly used broad ethnic groups. Hypertension, diabetes and depression were studied as predictors of dementia in 10, eight and six studies, respectively, compared with low social contact and air pollution in just two each. Measures of MRF lacked consistency, and data per ethnic group were not reported in several studies. Research examining interactions in combinations of MRFs was lacking. Conclusions More research is needed with specific ethnic groups, consistent measures and focusing on discrimination and MRF interaction and severity. This will be key to personalised risk reduction with diverse communities.

Background Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement. Objectives To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect. Review design Systematic review and network meta-analysis. Eligibility criteria Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention. Main outcomes Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year. Data sources We searched MEDLINE (1946–), Embase (1947–), CINAHL (1972–), PsycINFO (1806–), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists. Review methods Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis). Results We included 129 studies (74,946 participants). Nineteen intervention components, including ‘multifactorial-action’ (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: - multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) - multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) - cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and - activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval −0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive. Limitations High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts. Conclusions Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence. Future work Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further. Study registration This study is registered as PROSPERO CRD42019162195. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Introduction Community-based services to sustain independence for older people have varying configurations. A typology of these interventions would improve service provision and research by providing conceptual clarity and enabling the identification of effective configurations. We aimed to produce such a typology. Method We developed our typology by qualitatively synthesising community-based complex interventions to sustain independence in older people, evaluated in randomised controlled trials (RCTs), in four stages: (i) systematically identifying relevant RCTs; (ii) extracting descriptions of interventions (including control) using the Template for Intervention Description and Replication; (iii) generating categories of key intervention features and (iv) grouping the interventions based on these categories. PROSPERO registration: CRD42019162195. Results Our search identified 129 RCTs involving 266 intervention arms. The Community-based complex Interventions to sustain Independence in Older People (CII-OP) typology comprises 14 action components and 5 tailoring components. Action components include procedures for treating patients or otherwise intended to directly improve their outcomes; regular examples include formal homecare; physical exercise; health education; activities of daily living training; providing aids and adaptations and nutritional support. Tailoring components involve a process that may result in care planning, with multiple action components being planned, recommended or prescribed. Multifactorial action from care planning was the most common tailoring component. It involves individualised, multidomain assessment and management, as in comprehensive geriatric assessment. Sixty-three different intervention types (combinations) were identified. Conclusions Our typology provides an empirical basis for service planning and evidence synthesis. We recommend better reporting about organisational aspects of interventions and usual care.

Objective To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people. Design Systematic review and network meta-analysis. Data sources Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies. Eligibility criteria Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks’ follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators. Main outcomes Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months. Data synthesis Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane’s revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment. Results The review included 129 studies (74 946 participants). Nineteen intervention components, including “multifactorial action from individualised care planning” (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine review with medication review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, −0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Conclusions The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts.

In the past 15 years, the study of spontaneous thoughts (i.e., thoughts coming to mind without intention and effort) has received increased attention. Spontaneous future thoughts (SFTs) are particularly important (e.g., in planning), yet difficult to study with regard to age differences. Two main problems arise: (1) lab tasks including word-cues induce more past than future thoughts; (2) younger adults report more spontaneous thoughts than older adults. To improve the elicitation of SFTs, we developed a future-oriented goal-related priming procedure and analyzed the extension of the goal-related priming effect in SFTs to older adults, to examine whether age-related changes in personal goals compromise the elicitation of SFTs. We also controlled for methodological factors that could influence age groups differently (including demand, retrospection, meta-awareness and instruction bias). Twenty-seven younger and 27 older adults performed a low-demand vigilance task including word-cues and were periodically stopped to describe their thoughts. The vigilance task was divided into two parts and, between them, participants performed a future-oriented goal-related priming task. An additional group of 27 younger participants performed the same procedure with a control task based on word counting. We found a significant increase in SFTs after priming in both age groups, but not in the control group, indicating that the priming manipulation was effective. This result suggests that age-related changes in personal goals do not disrupt the relation between personal goals and SFT frequency. The similar pattern of overall spontaneous thought in both age groups is also discussed considering methodological factors.

Objectives To report our experience using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). Study Design and Setting Two reviewers independently applied RoB 2 to results of interest in a large systematic review of complex interventions and reached consensus. We recorded the time taken, and noted and discussed our difficulties using the tool, and the resolutions we adopted. We explored the time taken with regression analysis and summarized our experience of implementing the tool. Results We assessed risk of bias in 860 results of interest in 113 studies. Staff resource averaged 358 minutes per study (SD 183). Number of results (β = 22) and reports (β = 14) per study and experience of the team (β = −6) significantly affected assessment time. To implement the tool consistently, we developed cut points for missingness and considerations of balance regarding missingness, assumed some concerns with intervention deviations unless otherwise prevented or investigated, some concerns with measurements from unblinded self-reporting participants, and judged low risk of selection for certain dichotomous outcomes despite the absence of an analysis plan. Conclusion The RoB 2 tool and guidance are useful but resource-intensive and challenging to implement. Critical appraisal tools and reporting guidelines should detail risk of bias implementation. Improved guidance focusing on implementation could assist reviewers.

Our attention frequently shifts from ongoing tasks to internal content such that we find ourselves mind wandering (MW). Recent research has revealed that increasing age in adulthood is associated with a decrease in the frequency of MW, but the factors that contribute to this age-related effect are unclear. Thus, in the present study we conducted a meta-analysis of age differences in MW that aimed to analyze (a) the size and consistency of the age-related decrease in MW frequency, and (b) the moderating impact of methodological and sociodemographic factors. We analyzed studies comparing MW frequency in healthy younger and older groups and found a large effect in older adults. The age-related decrease in MW was more pronounced for probe compared to self-caught procedures, when task-related interfering thoughts were measured separately, when visual masks were presented, as the proportion of targets increased, and as older participants and fewer women were included in older adult groups. In discussing the theoretical and practical implications of these findings, we highlight the role of motivation and response options and provide recommendations for future research. These included emphasizing the need for open-ended methods in order to avoid bias due to MW instructions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

When voluntarily describing their past or future, older adults typically show a reduction in episodic specificity (e.g., including fewer details reflecting a specific event, time and/or place). However, aging has less impact on other types of tasks that place minimal demands on strategic retrieval such as spontaneous thoughts. In the current study, we investigated age-related differences in the episodic specificity of spontaneous thoughts using experimenter-based coding of thought descriptions. Additionally, we tested whether an episodic specificity induction, which increases episodic detail during deliberate retrieval of events in young and older adults, has the same effect under spontaneous retrieval. Twenty-four younger and 24 healthy older adults performed two counterbalanced sessions including a video, the episodic specificity or control induction, and a vigilance task. In the episodic specificity induction, participants recalled the details of the video while in the control they solved math exercises. The impact of this manipulation on the episodic specificity of spontaneous thoughts was assessed in the subsequent vigilance task, in which participants were randomly stopped to describe their thoughts and classify them as deliberate/spontaneous. We found no differences in episodic specificity between age groups in spontaneous thoughts, supporting the prediction that automatic retrieval attenuates the episodic specificity decrease in aging. The lack of age differences was present regardless of the induction, showing no interactions. For the induction, we also found no main effect, indicating that automatic retrieval bypasses event construction and accesses pre-stored events. Overall, our evidence suggests that spontaneous retrieval is a promising strategy to support episodic specificity in aging.

Research has the potential to inform and enhance the care and experiences of people living and working in care homes. While there is a growing interest in research relevant for care homes, there is also a need to ensure that staff, residents and their families and friends are supported when considering taking part in research; particularly in a type of research called a ‘trial’. Trials are a type of research study that can help guide decisions about the best treatment, care and support for both residents (and their families and friends) and care home staff. While potentially important, trials are demanding for both care homes and trial research teams. Before agreeing to support a trial, there are questions a care home manager, staff, residents and their families and friends can consider. These questions are outlined in this article, and the answers to these will help a care home to determine whether they have the capacity, readiness and relationships to support a trial. By taking the time to ‘pause’ and ask ‘are we ready?’, care teams can support both care and science.

Introduction Provision of community-based health services to support independence of older people, and further research in this area, would be improved by a typology of these complex interventions - thereby enabling evidence synthesis and the identification of effective intervention components. We aimed to produce such a typology in preparation for a systematic review and network meta-analysis. Methods The typology was developed based upon the descriptions of these interventions in published reports. This involved four stages: (1) systematic identification of relevant RCTs and related publications; (2) the extraction of descriptions of the interventions (including control/comparison) using the Template for Intervention Description and Replication (TIDieR); (3) a qualitative synthesis generating categories of key intervention features and (4) grouping the interventions based on the categories. Results Our search identified 496 reports of 129 studies, involving 266 intervention arms. 19 intervention components were identified: Formal homecare; Physical exercise; Health education; ADL training; Providing aids and adaptations; Nutritional support; Psychological therapy; Technology for communication and engagement; Cognitive training; Engagement in meaningful activities; Care voucher provision; Alternative medicine; Social skills training; Welfare rights advice; Medication review; Monitoring; Routine risk screening; Multifactorial-action from care planning; and Routine review following multifactorial-action from care planning. Multifactorial-action from care planning refers to a process of individualised, multidomain assessment and management resulting in a tailored selection of action components, as in comprehensive geriatric assessment. 63 different intervention types (combinations of these components) were identified. Conclusions The typology provides an empirical basis for service planning and evidence synthesis. Target populations are not explicitly integrated and should be considered separately. The components, being broad actions, are likely to endure; further components may be identified. However, the huge potential number of intervention types constitutes a challenge to typical approaches to effectiveness research. We recommend better reporting about organisational aspects of interventions and usual care.

The distinction between a semantic memory system, encompassing conceptual knowledge, and an episodic memory system, characterized by specific episodes, is one of the most important theoretical proposals in cognitive science. However, the distinction between systems has rarely been discussed in relation to spontaneous thought that comes to mind with reduced cognitive effort and intentionality. In this review, we propose that the growing research on spontaneous thought can contribute to current discussions on the interaction between the episodic and semantic systems. Firstly, we review research that shows that, as in deliberate retrieval, spontaneous thoughts are influenced by both episodic and semantic memory, as reflected by the mix of semantic and episodic elements in descriptions of spontaneous thoughts, as well as semantic priming effects in spontaneous thoughts. We integrate the current evidence based on the interplay between cues and semantic activation. Namely, we suggest that cues are key to access episodic memory and modulate the frequency of spontaneous thought, while semantic activation modulates the content of spontaneous thought. Secondly, we propose that spontaneous retrieval is a privileged area to explore the question of functional independence between systems, because it provides direct access to the episodic system. We review the evidence for spontaneous thought in semantic dementia, which suggests that episodic and semantic systems are functionally independent. We acknowledge the scarcity of evidence and suggest that future studies examine the contents of spontaneous thought descriptions and their neural correlates to test the functional relationship and inform the interaction between episodic and semantic systems.