Psychometric properties of the EQ-5D in a study of people with mild to moderate dementia

Assessing validity of the EQ-5D-5L proxy in children and adolescents with Duchenne muscular dystrophy or spinal muscular atrophy

OBJECTIVE

To assess the psychometric properties of the EuroQol-5-Dimension five-level instrument (EQ-5D-5L) proxy in caregivers of children and adolescents with Duchenne muscular dystrophy (DMD) or spinal muscular atrophy (SMA).

METHOD

Data were collected using the EQ-5D-5L proxy for individuals with DMD or SMA, as reported by their caregivers. Ceiling and floor effects, reliability (Cronbach's alpha), convergent and divergent validity (Spearman's correlation coefficient and Bland-Altman plot) and known-group validity (analysis of variance) was used to assess the instrument's psychometric properties.

RESULTS

Totally, 855 caregivers completed the questionnaire. Significant floor effects were observed for most dimensions of the EQ-5D-5L in both SMA and DMD samples. The EQ-5D-5L was strongly correlated with the hypothesized subscales of the SF-12, which confirmed satisfactory convergent and divergent validity. The EQ-5D-5L can significantly differentiate between impaired functional groups for individuals, demonstrating satisfactory discriminative ability. The agreement between the EQ-5D-5L utility and EQ-VAS scores was poor.

CONCLUSIONS

Based on the measurement properties assessed in this study, the EQ-5D-5L proxy is a valid and reliable tool for measuring the health-related quality of life of individuals with DMD or SMA rated by caregivers. Further studies should examine the content validity of the EQ-5D as well as the performance of its young version in these two patient groups.

Feasibility of a community-adapted multi-domain intervention for dementia prevention among older adults: a research protocol

BACKGROUND

Multi-domain interventions effectively prevent dementia in clinical settings; however, their efficacy within local communities is unclear. This study assesses the feasibility of an adapted multi-domain intervention for dementia prevention in community-dwelling older adults.

METHODS

The single-arm trial enrolls 60 participants from two Obu City communities, Japan.

PRIMARY OUTCOME

participant retention in the adapted multi-domain intervention; secondary outcomes: health and implementation outcomes. Over 12 months, a team of researchers and public health nurse oversees the study in the first half, gradually shifting the management to public health nurses in the second half. Using the Framework for Reporting Adaptations and Modifications-Enhanced, the clinical programme is adjusted for the local community. It includes a 60-minute exercise and 30-minute group sessions, targeting lifestyle, diet, and social participation.

DISCUSSION

This pioneer study evaluates the feasibility of an adapted intervention programme for dementia prevention in a community setting. Challenges in disseminating dementia prevention programmes warrant further investigation into effective implementation as well as strategies and methods to appeal to the target population. Upon confirming this programme's feasibility, future studies can further evaluate its broader effectiveness.

TRIAL REGISTRATION

The protocol is registered with the Clinical Trials Registry (UMIN-CTR) of the University Hospital's Medical Information Network, under registration number UMIN000050581.

Online Singing Groups for People With Dementia: Adaptation and Resilience in the Face of the COVID-19 Pandemic

INTRODUCTION

At the start of the COVID-19 pandemic, people with dementia living in the community experienced the sudden loss of their usual activities, and videoconferencing was widely adopted by music groups whilst face-to-face sessions were not possible. This paper reports the findings of a proof-of-concept study of online singing for people living with dementia and their carers, focusing on the experiences of the participants.

METHOD

People with dementia and their care partners were invited to take part in 10 weeks of online singing sessions. Each session lasted 1 hour, and comprised time for talking, warming up and singing familiar songs. Participants completed standardised outcome measures at baseline and after 10 weeks. Dyads were invited to take part in a semi-structured interview.

RESULTS

In total, 16 pairs were recruited. The response to the online singing group was mostly positive. Participants were able to use the technology to join the sessions, and reported few technical problems. Despite the limitations of online singing, the experience was frequently reported to be enjoyable. Some participants described longer-term benefits, such as improved mood and better relationship between care partners. Some felt online sessions had advantages over face-to-face ones; for example, they were more accessible. However, participants who had previously been attending face-to-face sessions felt that the online singing was a "better than nothing" substitute.

CONCLUSIONS

Online singing cannot recreate the experience of group singing face-to-face, and it requires some technical knowledge, but it provides a worthwhile alternative in a time of need for some people with dementia and their carers. Furthermore, for some people online singing may be preferable due to its accessibility. Given the potential for online singing to include people who cannot go out for any reason and its relatively low cost, providers may wish to consider hybrid online/in-person singing groups in future.

Measurement properties of the EQ-5D in populations with a mean age of ≥ 75 years: a systematic review

PURPOSE

Healthcare interventions for middle-old and oldest-old individuals are often (economically) evaluated using the EQ-5D to measure health-related quality of life (HrQoL). This requires sufficient measurement properties of the EQ-5D. Therefore, the current study aimed to systematically review studies assessing the measurement properties of the EQ-5D in this population.

METHODS

The databases PubMed, Cochrane library, Web of Science, Embase, and EconLit were searched for studies providing empirical evidence of reliability, validity, and/or responsiveness of the EQ-5D-3L and EQ-5D-5L in samples with a mean age ≥ 75 years. Studies were selected by two independent reviewers, and the methodological quality was assessed using the COSMIN Risk of Bias checklist. Results were rated against updated criteria for good measurement properties (sufficient, insufficient, inconsistent, indeterminate). The evidence was summarized, and the quality of evidence was graded using a modified GRADE approach.

RESULTS

For both EQ-5D versions, high-quality evidence for sufficient convergent validity was found. Known-groups validity was sufficient for the EQ-5D-5L (high-quality evidence), whereas the results were inconsistent for the EQ-5D-3L. Results regarding the reliability were inconsistent (EQ-5D-3L) or entirely lacking (EQ-5D-5L). Responsiveness based on correlations of change scores with instruments measuring related/similar constructs was insufficient for the EQ-5D-3L (high-quality evidence). For the EQ-5D-5L, the available evidence on responsiveness to change in (Hr)QoL instruments was limited.

CONCLUSION

Since the responsiveness of the EQ-5D in a population of middle-old and oldest-old individuals was questionable, either using additional instruments or considering the use of an alternative, more comprehensive instrument of (Hr)QoL might be advisable, especially for economic evaluations.

The Japan-Multimodal Intervention Trial for Prevention of Dementia PRIME Tamba (J-MINT PRIME Tamba): Study protocol of a randomised controlled multi-domain intervention trial

The Japan-Multimodal Intervention Trial for Prevention of Dementia PRIME Tamba (J-MINT PRIME Tamba) is a randomised controlled trial to prevent cognitive decline in community-dwelling cognitively ordinary older people at risk of dementia. Participants are aged 65-85 years living in a rural area in Japan, aware of very mild decline in cognitive function or abilities of activities of daily living, have at least one vascular risk (e.g. hypertension or diabetes), and have a Mini-Mental State Examination score of 24 or higher. Approximately 200 participants are randomly divided into two groups, with the intervention group receiving a multi-modal intervention, including lifestyle-related disease management, physical exercise, cognitive training, and nutritional counselling, over 18 months. The primary outcome is change in the composite score of seven neuropsychological tests, including the Free and Cued Selective Reminding Test, Logical Memory I and II subsets of the Wechsler Memory Scale-Revised, and Digit Symbol Substitution Test of the Wechsler Adult Intelligence Scale. In addition, changes in a wide range of other parameters such as physical function, blood test results, sleep, and frailty are also analysed as secondary outcomes. We believe that this study's results will contribute significantly to the development of dementia prevention measures in Japan. Clinical trial registration number: UMIN000041938.

Convergent validity of EQ-5D with core outcomes in dementia: a systematic review

Objectives

To explore through a systematic review, the convergent validity of EQ-5D (EQ-5D-3L and EQ-5D-5L (total score and dimensions)) with core outcomes in dementia and investigate how this may be impacted by rater-type; with the aim of informing researchers when choosing measures to use in dementia trials.

Methods

To identify articles relevant to the convergent validity of EQ-5D with core dementia outcomes, three databases were electronically searched to September 2022. Studies were considered eligible for inclusion within the review if they included individual level data from people with dementia of any type, collected self and/or proxy reported EQ-5D and collected at least one core dementia outcome measure. Relevant data such as study sample size, stage of dementia and administration of EQ-5D was extracted, and a narrative synthesis was adopted.

Results

The search strategy retrieved 271 unique records, of which 30 met the inclusion criteria for the review. Twelve different core outcome measures were used to capture dementia outcomes: cognition, function, and behaviour/mood across the studies. Most studies used EQ-5D-3L (n = 27). Evidence related to the relationship between EQ-5D and measures of function and behaviour/mood was the most robust, with unanimous directions of associations, and more statistically significant findings. EQ-5D dimensions exhibited associations with corresponding clinical outcomes, whereby relationships were stronger with proxy-EQ-5D (than self-report).

Conclusion

Measuring health-rated quality of life in dementia populations is a complex issue, particularly when considering balancing the challenges associated with both self and proxy report. Published evidence indicates that EQ-5D shows evidence of convergent validity with the key dementia outcomes, therefore capturing these relevant dementia outcomes. The degree of associations with clinical measures was stronger when considering proxy-reported EQ-5D and differed by EQ-5D dimension type. This review has revealed that, despite the limited targeted psychometric evidence pool and reliance on clinical and observational studies, EQ-5D exhibits convergent validity with other dementia outcome measures.

The Validity of Health-Related Quality of Life Instruments in Patients With Late-Stage Parkinson's Disease

OBJECTIVE

To examine the validity of health-related quality of life (Hr-QoL) measures in patients with late-stage Parkinson's disease (PD).

METHODS

We analysed data from patients with late-stage PD and their carers who were assessed with a range of clinical measures and the EQ-5D-3 L. The DEMQOL-Proxy was completed for 157 patients with a diagnosis of dementia and the PDQ-8 by 401 patients without dementia. Convergent validity was assessed using correlations with measures of Parkinson's severity, independence and cognitive function, and construct validity using correlations with patients' own EQ-5D-3 L scores. In addition, we assessed divergent validity using correlations with carers' own EQ-5D index, EQ-VAS and Zarit caregiver burden scores.

RESULTS

In patients without dementia, both the PDQ-8 and EQ-5D-3 L correlated with measures of disease severity, dependence and carer burden scores, and PDQ-8 scores moderately with EQ-5D-3 L and EQ-5D-3 L VAS scores. In patients with dementia, EQ-5D-3 L scores correlated with disease severity, cognition and dependence scores, but DEMQOL-Proxy scores were moderately associated only with patients' dependence and carers' own EQ-5D-3 L scores but not patients' disease severity, EQ-5D-3 L or cognitive scores.

CONCLUSIONS

The PDQ-8 and EQ-5D-3 L have adequate validity in late stage PD without dementia, but in those with PD and dementia the EQ-5D-3 L may be preferable to the DEMQOL-Proxy.

Assessing the psychometric performance of EQ-5D-5L in dementia: a systematic review

BACKGROUND

EQ-5D is widely used for valuing changes in quality of life for economic evaluation of interventions for people with dementia. There are concerns about EQ-5D-3L in terms of content validity, poor inter-rater agreement and reliability in the presence of cognitive impairment, but there is also evidence to support its use with this population. An evidence gap remains regarding the psychometric properties of EQ-5D-5L.

OBJECTIVES

To report psychometric evidence around EQ-5D-5L in people with dementia.

METHODS

A systematic review identified primary studies reporting psychometric properties of EQ-5D-5L in people with dementia. Searches were completed up to November 2020. Study selection, data extraction and quality assessment were undertaken independently by at least 2 researchers.

RESULTS

Evidence was extracted from 20 articles from 14 unique studies covering a range of dementia severity. Evidence of known group validity from 5 of 7 studies indicated that EQ-5D-5L distinguishes severity of disease measured by cognitive impairment, depression, level of dependence and pain. Convergent validity (9 studies) showed statistically significant correlations of weak and moderate strengths, between EQ-5D-5L scores and scores on other key measures. Statistically significant change was observed in only one of 6 papers that allowed this property to be examined. All seven studies showed a lack of inter-rater reliability between self and proxy reports with the former reporting higher EQ-5D-5L scores than those provided by proxies. Five of ten studies found EQ-5D-5L to be acceptable, assessed by whether the measure could be completed by the PwD and/or by the amount of missing data. As dementia severity increased, the feasibility of self-completing EQ-5D-5L decreased. Three papers reported on ceiling effects, two found some evidence in support of ceiling effects, and one did not.

CONCLUSIONS

EQ-5D-5L seems to capture the health of people with dementia on the basis of known-group validity and convergent validity, but evidence is inconclusive regarding the responsiveness of EQ-5D-5L. As disease progresses, the ability to self-complete EQ-5D-5L is diminished.

Do we agree or disagree? A systematic review of the application of preference-based instruments in self and proxy reporting of quality of life in older people

PURPOSE

Quality of life is an important person-centred outcome in health and aged care settings. Due to an increasing prevalence of cognitive decline and dementia in ageing populations, a proportion of older people receiving health and aged care services may not be able to reliably assess their own quality of life, highlighting the need for proxy assessment. This systematic review sought to investigate the level of agreement between self and proxy-report of older people's quality of life using established preference-based instruments of quality of life suitable for economic evaluation.

METHODS

A systematic review was conducted following PRISMA guidelines. Eight databases were searched: Web of Science, Scopus, Medline, Econlit, PsychINFO, CINAHL, Ageline and Cochrane Library. Information was extracted on the instruments, population samples (including any cognitive thresholds applied), mean scores, type of proxy, and measures of inter-rater agreement.

RESULTS

A total of 50 studies using eight different preference-based quality of life instruments were identified. Most studies were cross-sectional (72%) with a wide variety of cognitive assessments and thresholds applied to define older participants with cognitive impairment. The most common proxies were family members, mostly spouses. The level of agreement between self and proxy-report was generally poor - irrespective of the instrument applied or type of proxy - with proxy-report generally indicating lower levels of quality of life than self-report. There was some evidence of stronger agreement on more observable quality of life domains e.g., physical health and mobility, relative to less observable domains e.g. emotional well-being. Few studies tracked self and/or proxy-report of quality of life longitudinally.

CONCLUSIONS

More research is needed to develop evidence to inform guidance on self-report versus proxy-report of quality of life for older people receiving health and aged care services. Until then, the collection of both self and proxy reports as complementary measures is indicated.

Feasibility properties of the EQ-5D-3L and 5L in the general population: evidence from the GP Patient Survey on the impact of age

BACKGROUND

There is evidence to suggest that the proportion of missing values is slightly higher in the older population resulting in lower completion rates of the EQ-5D. However, existing studies rarely provide a within-sample comparison of feasibility properties across age groups to quantify this difference. Hence, this study examines feasibility properties of the EQ-5D-3L and 5L in the general population and explores the impact of age on the completion of EQ-5D instruments.

METHODS

We pool five waves from the English GP Patient Survey, where respondents self-report their health in either EQ-5D-3L or 5L. Descriptive analysis was undertaken to analyse the distribution and proportion of missing values and completion rates stratified by age and EQ-5D version; logistic regression models were specified to quantify the impact of age, gender and potential long-term conditions on the completion of each of the EQ-5D instruments.

RESULTS

The total sample comprises ~ 4.36 million observations, of which 2.88 million respondents report their health in 5L and 1.47 million in 3L, respectively. Respondents over 64 years have slightly more missing values in each dimension than younger respondents. The highest share was observed for the oldest age group in the dimension anxiety/depression (3L 9.1% vs. 5L 7.6%), but was otherwise below 5%. Consequently, completion rates (observed and predicted) decreased with older age and at a higher rate after the age of 64; this was more pronounced for the 3L.

CONCLUSION

Evidence from our study suggests that both the EQ-5D-3L and 5L have good feasibility properties. In comparison to younger populations there appears to be a higher proportion of respondents with incomplete responses beyond the age of 64 years. Overall, the 5L version compares more favourably in terms of missing values, completion rates as well as with regard to the expected probability of an incomplete descriptive system.

Impact of Sarcopenia on Decline in Quality of Life in Older People with Mild Cognitive Impairment

Quality of life (QOL) was assessed using the EQ-5D twice in 1 year in 57 older community-dwelling people (age 79.1±5.9 years) with mild cognitive impairment in a memory clinic. Screening for sarcopenia at the initial assessment revealed 40.1% of participants (23/57) were sarcopenic. QOL declined in 33.3% of participants (19/57) after around 1 year. Multiple logistic regression analysis showed that sarcopenia was associated with a decline in QOL around 1 year after initial assessment. Sarcopenia may be a risk factor for decline in QOL in older people with mild cognitive impairment.

The Impact of COVID-19 Confinement on Cognition and Mental Health and Technology Use Among Socially Vulnerable Older People: Retrospective Cohort Study

Background

COVID-19 forced the implementation of restrictive measures in Spain, such as lockdown, home confinement, social distancing, and isolation. It is necessary to study whether limited access to basic services and decreased family and social support could have deleterious effects on cognition, quality of life, and mental health in vulnerable older people.

Objective

This study aims to explore the impact of the COVID-19 outbreak on cognition in older adults with mild cognitive impairment or dementia as the main outcome and the quality of life, perceived health status, and depression as secondary outcomes and to analyze the association of living alone and a change in living arrangements with those outcomes and other variables related with the use of technology and health services. Likewise, this study aims to analyze the association of high and low technophilia with those variables, to explore the access and use of health care and social support services, and, finally, to explore the informative-, cognitive-, entertainment-, and socialization-related uses of information and communications technologies (ICTs) during the COVID-19 outbreak.

Methods

This cohort study was conducted in Málaga (Spain). In total, 151 participants with mild cognitive impairment or mild dementia, from the SMART4MD (n=75, 49.7%) and TV-AssistDem (n=76, 50.3%) randomized clinical trials, were interviewed by telephone between May 11 and June 26, 2020. All participants had undergone 1-3 assessments (in 6-month intervals) on cognition, quality of life, and mood prior to the COVID-19 breakout.

Results

The outbreak did not significantly impact the cognition, quality of life, and mood of our study population when making comparisons with baseline assessments prior to the outbreak. Perceived stress was reported as moderate during the outbreak. After correction for multiple comparisons, living alone, a change in living arrangements, and technophilia were not associated with negative mental health outcomes. However, being alone was nominally associated with self-perceived fear and depression, and higher technophilia with better quality of life, less boredom, perceived stress and depression, and also less calmness. Overall, health care and social support service access and utilization were high. The most used ICTs during the COVID-19 outbreak were the television for informative, cognitive, and entertainment-related uses and the smartphone for socialization.

Conclusions

Our findings show that the first months of the outbreak did not significantly impact the cognition, quality of life, perceived health status, and depression of our study population when making comparisons with baseline assessments prior to the outbreak. Living alone and low technophilia require further research to establish whether they are risk factors of mental health problems during lockdowns in vulnerable populations. Moreover, although ICTs have proven to be useful for informative-, cognitive-, entertainment-, and socialization-related uses during the pandemic, more evidence is needed to support these interventions.

Trial Registration

ClinicalTrials.gov NCT04385797; https://clinicaltrials.gov/ct2/show/NCT04385797

International Registered Report Identifier (IRRID)

RR2-10.2196/26431

Psychological Resilience Among Older Japanese Adults With Mild Cognitive Impairment During the COVID-19 Pandemic

Psychological resilience refers to the ability to cope with adversities, and deficits in resilience might lead to mental illness. The COVID-19 pandemic has had impact on psychological resilience for older adults, but there are as yet no data on its impacts on the mental health of older adults who were living with mild cognitive impairment (MCI). Therefore, the aim of this study was to investigate the impact of the COVID-19 pandemic on psychological resilience in older adults with MCI and to explore associated physical and psychosocial factors. In this cross-sectional study of 268 older adults aged 65-85, we defined MCI as age- and education-adjusted cognitive decline with a standard deviation of 1.0 or more from the reference threshold. During December 2020 to April 2021, we carried out to all participants the 10-item version of the Connor-Davidson Resilience Scale (CD-RISC-10) to measure psychological resilience. We also conducted a comprehensive geriatric assessment including sleep quality and depressive symptoms (Pittsburgh Sleep Quality Index and 15-item Geriatric Depression Scale, respectively). To identify factors associated with CD-RISC-10 scores (mean: 23.3 ± 0.4), multiple regression analysis revealed that older age [coefficient = 0.23, 95% confidence interval (CI) = 0.06-0.39] was significantly correlated with higher scores, whereas poor sleep quality (coefficient = -2.06, 95% CI = -3.93 to -0.19) and depressive symptoms (coefficient = -2.95, 95% CI = -5.70 to -0.21) were significantly correlated with lower scores. In this study, older adults with MCI showed low psychological resilience during the COVID-19 pandemic, and people with low psychological resilience indicated poor sleep quality and depressive symptoms. Our findings suggest directions for devising interventions to maintain mental health and psychological resilience among the vulnerable population of older adults with MCI living under the socially isolated conditions of COVID-19 pandemic restrictions. Our recommendation includes continuous assessment of this population and appropriate care for poor sleep quality and depressive symptoms.

EQ-5D-5L in Schizophrenia: differences between patients and nurses' reports

Purpose

To examine the differences between patient-reports and proxy-reports by nurses of EQ-5D-5L responses among patients with schizophrenia.

Methods

This study was conducted in June–September 2019 in Duren Sawit Regional Public Hospital in Jakarta, Indonesia. The self-report data were obtained by interviewing the patients and the proxy-report data were obtained from the psychiatric nurses. The patients’ Positive and Negative Syndrome Scale (PANSS) scores were obtained from their medical records. The data were collected in two time points: (1) when the patients moved from the acute to the quiet rooms (first-test) and (2) when they were discharged from the hospital (second-test). The self and proxy report scores were analysed by the Wilcoxon matched-pairs signed-ranks test and their relationship with the PANSS scores using Spearman's rank correlation coefficient.

Results

There were 206 patients in the final sample. The majority are male (56.8%) with a mean age of 37.5 years (SD = 12.05). Significant differences between the two reports were found in three domains (i.e., self-care, usual activities, and pain/discomfort) in the first-test and two domains (i.e., usual activities and pain/discomfort) in the second-test. Concerning the relationship with the PANSS scores, only three significant correlations were found, all in the proxy-version and in the second-test: mobility (r = 0.139), anxiety/depression (r = 0.2523), and utility scores (r = − 0.176).

Conclusions

The poor-to-fair agreement between patients and nurses reports and the poor correlation with the PANSS scores suggested that it is difficult to decide which report best represents the patients’ health status.

Feasibility of the EQ-5D in the elderly population: a systematic review of the literature

Purpose

The EQ-5D-3L and 5L are widely used generic preference-based instruments, which are psychometrically sound with the general population, but little is known about the instruments’ feasibility in the elderly. Therefore, this systematic review summarises the available literature with regard to the feasibility properties of the instruments in the elderly population.

Methods

We conducted a systematic search in PubMed, PsycInfo and EuroQol databases using pre-specified vocabulary and inclusion/exclusion criteria to identify publications until November 2020. Study characteristics and outcomes referring to the feasibility of the EQ-5D-3L and 5L in the elderly were extracted, if all study participants were at least 65+ years.

Results

We identified 17 studies reporting feasibility outcomes based on four criteria: missing values, completion rates, completion time and broad qualitative statements referring to the completion. Missing values per dimension ranged from 0 to 10.7%, although being mostly below 7%. The completion rate was around 90% or better, whereas the EQ VAS rating was missing from 2.3 to 25.3% of the respondents. Only two of the included studies examined the EQ-5D-5L; 15 studies reported on the EQ-5D-3L.

Conclusion

Comparing our findings against the general population from published literature, we find that feasibility outcomes in older age groups are just below that of younger populations. Furthermore, older respondents have a higher propensity of requiring assistance or even an interviewer-based approach. Nonetheless, the reviewed literature indicates that the EQ-5D-3L still has good feasibility properties and, hence, is highly applicable in older respondents. However, further research is needed to explore feasibility properties of the EQ-5D-5L in this population.

The Japan-Multimodal Intervention Trial for Prevention of Dementia (J-MINT): The Study Protocol for an 18-Month, Multicenter, Randomized, Controlled Trial

Background/Objectives

The Japan-multimodal intervention trial for prevention of dementia (J-MINT) is intended to verify the effectiveness of multi-domain interventions and to clarify the mechanism of cognitive improvement and deterioration by carrying out assessment of dementia-related biomarkers, omics analysis and brain imaging analysis among older adults at high risk of dementia. Moreover, the J-MINT trial collaborates with partnering private enterprises in the implementation of relevant interventional measures. This manuscript describes the study protocol.

Design/Setting

Eighteen-month, multi-centered, randomized controlled trial.

Participants

We plan to recruit 500 older adults aged 65–85 years with mild cognitive impairment. Subjects will be centrally randomized into intervention and control groups at a 1:1 allocation ratio using the dynamic allocation method with all subjects stratified by age, sex, and cognition.

Intervention

The multi-domain intervention program includes: (1) management of vascular risk factors; (2) group-based physical exercise and self-monitoring of physical activity; (3) nutritional counseling; and (4) cognitive training. Health-related information will be provided to the control group every two months.

Measurements

The primary and secondary outcomes will be assessed at baseline, 6-, 12-, and 18-month follow-up. The primary outcome is the change from baseline to 18 months in a global composite score combining several neuropsychological domains. Secondary outcomes include: cognitive change in each neuropsychological test, incident dementia, changes in blood and dementia-related biomarkers, changes in geriatric assessment including activities of daily living, frailty status and neuroimaging, and number of medications taken.

Conclusions

This trial that enlist the support of private enterprises will lead to the creation of new services for dementia prevention as well as to verify the effectiveness of multi-domain interventions for dementia prevention.

Electronic Supplementary Material

Supplementary material is available for this article at 10.14283/jpad.2021.29 and is accessible for authorized users.

Strategies to enhance routine physical activity in care home residents: the REACH research programme including a cluster feasibility RCT

Background

Care home residents are mainly inactive, leading to increased dependency and low mood. Although exercise classes may increase activity, a more sustainable model is to engage staff and residents in increasing routine activity.

Objectives

The objectives were to develop and preliminarily test strategies to enhance the routine physical activity of care home residents to improve their physical, psychological and social well-being through five overlapping workstreams.

Design

This trial had a mixed-methods research design to develop and test the feasibility of undertaking an evaluative study consisting of gaining an understanding of the opportunities for and barriers to enhancing physical activity in care homes (workstream 1); testing physical activity assessment instruments (workstream 2); developing an intervention through a process of intervention mapping (workstream 3); refining the provisional intervention in the care home setting and clarifying outcome measurement (workstream 4); and undertaking a cluster randomised feasibility trial of the intervention [introduced via three facilitated workshops at baseline (with physiotherapist input), 2 weeks (with artist input) and 2 months], with embedded process and health economic evaluations (workstream 5).

Setting

The trial was set in 12 residential care homes differing in size, location, ownership and provision in Yorkshire, UK.

Participants

The participants were elderly residents, carers, managers and staff of care homes.

Intervention

The intervention was MoveMore, designed for the whole home, to encourage and support the movement of residents in their daily routines.

Main outcome measures

The main outcome measures related to the feasibility and acceptability of implementing a full-scale trial in terms of recruitment and retention of care homes and residents, intervention delivery, completion and reporting of baseline data and outcomes (including hours of accelerometer wear, hours of sedentary behaviour and hours and type of physical activity), and safety and cost data (workstream 5).

Results

Workstream 1 – through a detailed understanding of life in a care home, a needs assessment was produced, and barriers to and facilitators of activity were identified. Key factors included ethos of care; organisation, management and delivery of care; use of space; and the residents’ daily routines. Workstream 2 – 22 (73.3%) out of 30 residents who wore a hip accelerometer had valid data (≥ 8 hours on ≥ 4 days of the week). Workstream 3 – practical mechanisms for increasing physical activity were developed, informed by an advisory group of stakeholders and outputs from workstreams 1 and 2, framed by the process of intervention mapping. Workstream 4 – action groups were convened in four care homes to refine the intervention, leading to further development of implementation strategies. The intervention, MoveMore, is a whole-home intervention involving engagement with a stakeholder group to implement a cyclical process of change to encourage and support the movement of residents in their daily routines. Workstream 5 – 12 care homes and 153 residents were recruited to the cluster randomised feasibility trial. Recruitment in the care homes varied (40–89%). Five care homes were randomised to the intervention and seven were randomised to usual care. Predetermined progression criteria were recruitment of care homes and residents (green); intervention delivery (amber); and data collection and follow-up – 52% of residents provided usable accelerometer data at 9 months (red), > 75% of residents had reported outcomes at 9 months (green, but self-reported resident outcomes were red), 26% loss of residents to follow-up at 9 months [just missing green criterion (no greater than 25%)] and safety concerns (green).

Limitations

Observations of residents’ movements were not conducted in private spaces. Working with care home residents to identify appropriate outcome measures was challenging. Take-up of the intervention was suboptimal in some sites. It was not possible to make a reliably informed decision on the most appropriate physical activity end point(s) for future use in a definitive trial.

Conclusions

A whole-home intervention was developed that was owned and delivered by staff and was informed by residents and staff. The feasibility of conducting a cluster randomised controlled trial was successfully tested: the target numbers of care homes and residents were recruited, demonstrating that it is possible to recruit care home residents to a cluster randomised trial, although this process was time-consuming and resource heavy. A large data set was collected, which provided a comprehensive picture of the environment, residents and staff in care homes. Extensive quantitative and qualitative work comprehensively explored a neglected area of health and social care research. Completion of ethnographic work in a range of settings enabled the production of an in-depth picture of life in care homes that will be helpful for other researchers considering organisational change in this setting.

Future work

The content and delivery of the intervention requires optimisation and the outcome measurement requires further refinement prior to undertaking a full trial evaluation. Consideration could be given to a recommended, simplified, core outcome set, which would facilitate data collection in this population.

Trial registration

Current Controlled Trials ISRCTN16076575.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grant for Applied Research programme and will be published in full in Programme Grant for Applied Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

Evaluating the psychometric properties of the EQ-5D-5L and SF-6D among patients with haemophilia

OBJECTIVE

The aim of this study was to evaluate the psychometric properties of the EQ-5D-5L and SF-6D, and to compare their performance among patients living with haemophilia in China.

METHODS

A total of 875 Chinese patients completed the EQ-5D-5L, SF-6D, and Haem-A-QoL questionnaires. Construct validity of the EQ-5D-5L and SF-6D dimensions and indices was assessed by testing hypotheses relating these measures to Haem-A-QoL and clinical measures. The Spearman correlation coefficient was used to assess convergent validity, and one-way analysis of variance (F statistic) was used to assess the known-groups validity (discriminatory power). The agreement between EQ-5D-5L and SF-6D indices was assessed using the intraclass correlation coefficient (ICC) and the Bland-Altman plot.

RESULTS

Both the EQ-5D-5L and SF-6D indices showed acceptable ceiling and floor effects. As hypothesised, both EQ-5D-5L and SF-6D were significantly correlated with Haem-A-QoL (both dimensions and overall score). EQ-5D-5L and SF-6D indices as well as EQ-VAS differentiated patients are known to differ in severity of haemophilia, bleeding status, disabling levels, and comorbidity. The F statistics in the known-groups comparisons suggested that the EQ-5D-5L was slightly more discriminative than the SF-6D. ICC (0.41) and Bland-Altman plot confirmed that the agreement between the EQ-5D-5L and SF-6D indices was poor.

CONCLUSION

Both EQ-5D-5L and SF-6D showed satisfactory construct validity in the measurement of the HRQoL among patients with haemophilia. However, the two instruments may not be used interchangeably in this patient population due to their poor agreement and differing discriminatory power.

Association Between Sarcopenia and Quality of Life in Patients with Early Dementia and Mild Cognitive Impairment

BACKGROUND

Cognitive impairment is linked to decreased quality of life (QOL), but few studies have investigated the impact of comorbid sarcopenia.

OBJECTIVE

The aim of this study was to elucidate the association of sarcopenia with QOL in patients with early dementia and mild cognitive impairment.

METHODS

Individuals with a Clinical Dementia Rating of 0.5 or 1 and a Mini-Mental State Examination score of 20-30 underwent a battery of neuropsychological assessments administered by a group of well-trained clinical psychologists. The EQ-5D was completed by both the patients and their main caregivers. EQ-5D utility and visual analog scale scores were measured. Sarcopenia was defined according to the criteria published in the 2019 consensus update by the Asian Working Group for Sarcopenia.

RESULTS

Patients with sarcopenia had significantly lower scores on the Digit Symbol Substitution Test and Trail Making Test Part A. There was a significant negative association between sarcopenia and both self- and proxy-rated EQ-5D utility scores independent of potential confounding factors. However, there was no association between QOL visual analog scale scores and sarcopenia.

CONCLUSION

Given that sarcopenia is often found in individuals with cognitive impairment, early detection by timely screening and effective intervention may help to maintain or improve QOL in this population. However, this study could not determine whether reduced QOL is a direct consequence of sarcopenia.

Construct Validity, Test-Retest Reliability, Sensitivity to Change, and Feasibility of the Patient-Specific Functional Scale in Acutely Hospitalized Older Patients With and Without Cognitive Impairment

BACKGROUND AND PURPOSE

The Patient-Specific Functional Scale (PSFS) as an individualized patient-reported outcome measure may allow to assess limitations and changes in self-determined functional activities most important to an older patient in the acute care setting. However, its clinimetric properties have not yet been evaluated in these patients. The study aimed to investigate the construct validity, test-retest reliability, sensitivity to change, and feasibility of the PSFS in acutely hospitalized older patients with and without cognitive impairment (CI).

METHODS

The clinimetric properties of the PSFS were investigated by secondary data analysis from a prospective observational cohort study examining physical activity and mobility in acutely hospitalized older patients. In this analysis, 120 older patients-83.0 (6.4) years-with (Mini-Mental State Examination [MMSE] 18-23, n = 52) and without CI (MMSE ≥24, n = 68) receiving early multidisciplinary geriatric rehabilitation in acute care were included. Construct validity was assessed by Spearman correlations (rs) with the Activity-specific Balance Confidence Scale (ABC-6), Short Falls Efficacy Scale-International (Short FES-I), EuroQoL-5 Dimensions (EQ-5D), Short Physical Performance Battery (SPPB), de Morton Mobility Index (DEMMI), and Barthel Index (BI); test-retest reliability within 24 hours by intraclass correlation coefficients (ICCs); sensitivity to change by standardized response means (SRMs) calculated for treatment effects, and feasibility by completion rates/times and floor/ceiling effects.

RESULTS

The PSFS showed fair to moderate correlations with all construct variables in patients with CI (rs = 0.31 to 0.53). In patients without CI, correlations were fair for the ABC-6, FES-I, EQ-5D, and BI (rs = |0.27 to 0.36|), but low for the SPPB and DEMMI (rs = -0.04 to 0.14). Test-retest reliability (both: ICC = 0.76) and sensitivity to change (CI: SRM = 1.10, non-CI: SRM = 0.89) were excellent in both subgroups. Excellent feasibility was documented by high completion rates (>94%), brief completion times (<8 min), and no floor/ceiling effects in both subgroups.

CONCLUSIONS

The PSFS has adequate clinimetric properties for assessing patient-specific functional limitations and changes in acutely hospitalized older patients with and without CI. It might be an appropriate complement to traditional functional scales to enhance patient-centeredness in clinical geriatric assessment.

Changes in Health-Related Quality of Life for Older Persons With Cognitive Impairment After Hip Fracture Surgery: A Systematic Review

BACKGROUND

Hip fractures in persons with cognitive impairments represent a major public health issue in older populations that often results in poor health-related quality of life (HRQoL).

PURPOSE

The aim of this systemic review was to examine the changes in HRQoL in older, cognitively impaired patients with hip fracture who had received surgical treatment.

METHODS

A literature search of PubMed, Scopus, MEDLINE, PsycINFO, and CINAHL (EBSCO) databases was conducted for studies published up to July 2018 that addressed the issue of HRQoL in cognitively impaired patients with hip fracture after surgery. Studies that met the following criteria were included: Patients with hip fracture were over 60 years old and had cognitive impairment or dementia, patients had undergone hip fracture repair surgery, HRQoL was determined using standardized questionnaires, a descriptive or interventional methodology was used, and the full-text article was available in English.

RESULTS

A primary search of databases yielded 1,528 studies, 621 duplicates were removed, and the remaining 907 abstracts were screened. Thirty-four full-text articles were deemed relevant for full review; of these, 10 articles met the criteria for inclusion in the review. Cognitive impairment was found to impact negatively on the patients' HRQoL after hip fracture surgery (n = 809). Severity of cognitive impairment was correlated with deterioration in HRQoL after hospital discharge. When compared with prefracture measures of HRQoL, the greatest deterioration in HRQoL postsurgery occurred during the first 4 months after discharge. Impacts on HRQoL for patients with cognitive impairment at later time points differed depending on type of hip fracture and type of surgical treatment. However, for most of the patients, HRQoL remained relatively unchanged at 6, 12, and 24 months postdischarge.

CONCLUSIONS

We recommend nursing care interventions for older persons with cognitive impairment be initiated immediately after surgery for hip fracture to prevent a significant decline in HRQoL. Further examination of interventions that are effective in maintaining HRQoL for these patients such as interdisciplinary care is necessary. In addition, the influences of hip fracture type and surgical approach on changes in HRQoL suggest a need for further investigations to determine what contributed to the observed inconsistencies in the outcomes.

Pilot Randomised Evaluation of Singing in Dementia (PRESIDE): protocol for a two-arm, parallel-group randomised controlled feasibility study with waiting-list control

Background

As the number of people living with dementia grows, so does the need to provide them with adequate psychosocial support. Many people with dementia live at home with family carers, who also require social and emotional support to cope with their role. Community group singing has received attention for its potential to support people with dementia and their carers. It is postulated that singing can improve cognitive function, strengthen the bonds between care partners and help to establish social support networks. However, there is a lack of rigorous evidence of singing’s benefits for this population. This study aims to test the feasibility of a randomised controlled trial of community singing in dementia, to pave the way for a larger, conclusive study.

Methods

The PRESIDE study is designed as a two-arm, parallel-group randomised trial with a waiting list control. Dyads consisting of a person with dementia (n = 80) and their carer (n = 80) will be recruited. Each dyad will be randomised either to attend 10 weeks of community group singing sessions straight away or to wait for 3 months before attending the sessions. The singing sessions will be led by experienced professional musicians and will last about 90 min, including time for socialising. The primary outcome of this study is the attainment of feasibility criteria around recruitment, retention and the acceptability of the waiting list control. Secondary outcomes include the quality of life, mood, cognition, and musical engagement of the person with dementia, and quality of life, mood, and experiences/challenges of the carer. These data will be collected during home visits at baseline, and 3 and 6 months post-baseline.

Discussion

Despite growing public interest in the positive effects of singing, and encouraging findings from qualitative and non-randomised quantitative studies, there is a lack of rigorous evidence. This is the first randomised controlled trial of community group singing for people with dementia in Europe, to our knowledge. If the results favour a full trial, conclusively demonstrating the effectiveness of group singing could positively affect the opportunities available to community-dwelling people with dementia and their carers.

Trial registration

Unique identification number in ISRCTN registry: ISRCTN10201482. Date registered: 12 May 2020

Potentially Inappropriate Medications and Polypharmacy: A Study of Older People with Mild Cognitive Impairment and Mild Dementia

BACKGROUND

With multimorbidity increasing among older people, polypharmacy and the use of potentially inappropriate medications (PIMs) are assuming a prominent role in the life of the geriatric population.

OBJECTIVE

To investigate the association of polypharmacy and PIM use with a wide range of factors in older people with mild cognitive impairment (MCI) to mild dementia.

METHODS

The study population comprised 160 outpatients with a Clinical Dementia Rating of 0.5-1 and a Mini-Mental State Examination score of 20-30. Patients were classified as receiving polypharmacy when they took ≥5 different medications at the same time. PIMs were identified using the STOPP-J criteria. Cognitive, neuropsychological, nutritional, and physical function tests were performed and body measurements taken. Quality of life (QOL) was assessed using both components of the EQ-5D scale, the index score and the visual analogue scale (QOL VAS). A comorbidity index was calculated for all participants.

RESULTS

PIM use was significantly associated with lower scores on the verbal fluency (initial letters) test and QOL index. Participants receiving polypharmacy showed an increased likelihood of worse frailty status and lower QOL VAS score. The number of medications was significantly associated with a worse frailty status.

CONCLUSION

In a geriatric population with MCI to mild dementia, PIM use was associated with lower verbal fluency (initial letters) score and lower QOL, while the presence of polypharmacy was correlated with a worse frailty status and lower QOL. The number of medicines, instead, was correlated with a worse frailty status only.

Acceptability and Validity of the EQ-5D in Patients Living With Dementia

OBJECTIVES

To assess the acceptability and validity of the 3 levels of the EQ-5D (EQ-5D-3L) compared with the Quality of Life in Alzheimer's Diseases (QoL-AD) in patients living with dementia.

METHODS

The analysis was based on 560 dyads of persons with dementia and their caregivers of the multicenter observational study of dementia care networks in Germany (DemNet-D). Health-related quality of life was assessed by face-to-face interviews using the EQ-5D-3L (self-rating) and the QoL-AD (self- and proxy-rating). The number of missing values, the score ranges (observed vs possible range) and the floor and ceiling effects were used to assess the acceptability. We used one-way analyses of variance and multivariate linear regression models to evaluate the discriminative ability. The convergent validity was assessed using Spearman's correlation coefficient (r_s) and multivariate regression models.

RESULTS

The EQ-5D index had a higher response rate (89% vs 84%) and a comparable floor (>1%) but a higher ceiling effect (18% vs >1%) compared with the QoL-AD. Both measures can significantly differentiate between different stages of general health, instrumental activities of daily living, and depression. The EQ-5D index and the visual analog scale self-rating scores strongly correlated with the QoL-AD self-rating (r_s = 0.644 and 0.553, respectively) but not with the proxy-rating score (r_s = 0.314 and r_s = 0.170, respectively), which was confirmed by multivariate regression analyses.

CONCLUSION

The results satisfy acceptability, discriminative ability, and convergent validity for moderately cognitively and functionally impaired patients living with dementia. The EQ-5D-3L performed comparably with the QoL-AD, and could, therefore, be used in economic evaluations in dementia. The differences between self- and proxy-ratings should be evaluated and considered in the interpretation of health-related quality of life scores.

People with dementia attending farm-based day care in Norway - Individual and farm characteristics associated with participants' quality of life

Farm-based day care for people with dementia is supposed to improve the participants quality of life by using activities and resources of the farm environment to promote mental and physical health. In this paper, we describe the characteristics of those attending farm-based day care services in Norway and explore the association between individual and farm characteristics and the quality of life. A sample of 94 people with dementia who attended farm-based day care was recruited from 25 farms between January 2017 and January 2018. The data collection was performed using standardized instruments. Information about the farms was retrieved from a former study. The association between the participants' quality of life and their individual and/or farm characteristics was examined with a linear multilevel regression model. The participants had a mean age of 76 years, 62% were men, and 68% had additional education after primary school. Most of them had mild (54.3%) or questionable dementia (18.3%). A few participants used antipsychotics (3.7%), tranquilizers (9.9%) and painkillers (13.6%), while a higher number used antidepressants (30.9%). Quality of life was associated with the experience of having social support (p = .023), a low score on depressive symptoms (p < .001), and spending time outdoors at the farm (p < .001). The variation between the farm-based day care services in the participants' reported quality of life was related to time spent outdoors at the farm. In light of the present study, it seems as farm-based day care is addressing people with dementia in an early stage, dominated by men, with quite good physical and medical condition. The strong association between quality of life and spending time outdoors underscores that facilitation for outdoor activity should be prioritized in all types of dementia care.

Assessing the quality of life and well-being of older adults with physical and cognitive impairments in a German-speaking setting: A systematic review of validity and utility of assessments / Die Erfassung von Lebensqualität und Wohlbefinden älterer Menschen mit psychischen und kognitiven Einschränkungen: ein systematisches Literaturreview zur Validität und Praktikabilität deutschsprachiger Assessments

Background

For health professionals working with older adults with physical and cognitive impairments, improving or maintaining clients’ quality of life and well-being is of crucial importance. The aim of this study was to evaluate validity and utility of assessments of quality of life and well-being in German suitable for this group of clients.

Methods

In an initial literature search, we identified potentially viable assessments based on existing systematic reviews. We then conducted a systematic literature search in the databases Medline, CINAHL, and PsycINFO using keywords related to validity, utility, client group, and German. Assessments for which sufficient evidence was found were evaluated regarding their validity and utility when used with older adults with physical and cognitive impairments.

Results

For 14 of 27 initially identified assessments, sufficient evidence was found to evaluate validity and utility with this client group. WHOQOL-BREF, WHOQOL-OLD, WHO-5, EUROHIS-QOL 8, SF-36, SF-12, EQ-5D, NHP, SEIQOL-DW, SWLS, PANAS, DQOL, QOL-AD, and QUALIDEM were evaluated based on 82 studies. Of these, WHOQOL-BREF, WHO-5, SF-36, SF-12, EQ-5D, NHP, QUALIDEM, QOL-AD and DQOL are presented here.

Conclusion

Assessments differed widely in the way they operationalized quality of life/well-being, use of self-evaluation or evaluation-by-proxy, and amount of available evidence for their validity and utility. On the basis of our results in regard to the assessments’ validity, utility, and appropriateness of operationalization of quality of life/well-being to the client group, three assessments were recommended for use: WHOQOL-BREF for self-evaluation, QUALIDEM for evaluation-by-proxy in case of severe dementia, and EQ-5D for cost-utility analyses.

How Should We Capture Health State Utility in Dementia? Comparisons of DEMQOL-Proxy-U and of Self- and Proxy-Completed EQ-5D-5L

BACKGROUND

Dementia-specific and proxy-completed preference-based measures have been proposed for use in intervention studies involving people living in residential care, in instances where generic, self-reported preference-based measures have been deemed inappropriate.

OBJECTIVE

This study was conducted to investigate the construct validity, criterion validity, and responsiveness of DEMQOL-Proxy-U and of self- and proxy-completed EQ-5D-5L.

METHODS

The analysis used a 3-wave, individual-level data set of 1004 people living with dementia in residential care that included self-completed EQ-5D-5L and formal-carer and informal-carer proxy-completed EQ-5D-5L and DEMQOL-Proxy-U utility values, in addition to other nonutility cognitive measures (Functional Assessment Staging [FAST], Clinical Dementia Rating [CDR], Cohen-Mansfield Agitation Inventory [CMAI]) and health-related quality of life (HRQOL) measures (nursing home version of the Quality of Life with Alzheimer's disease scale [QOL-AD-NH], Quality of Life in Late-Stage Dementia [QUALID] scale). Construct validity, criterion validity, and responsiveness were assessed using correlation, Bland-Altman plots, and panel data regression models.

RESULTS

Self-completed EQ-5D-5L failed to reflect clinically important differences and changes in FAST, CDR, and CMAI but did capture the resident's own view of HRQOL (QOL-AD-NH). As dementia severity increased, collection of EQ-5D-5L-proxy and DEMQOL-Proxy-U data was more feasible than collection of self-completed EQ-5D-5L. These formal-carer and informal-carer proxy measures also better reflected changes in FAST, CDR, and CMAI but did not capture the resident's own view of HRQOL (QOL-AD-NH), despite adequately capturing the proxy's own view of the resident's HRQOL (QUALID). This indicates discrepancies between a proxy's view and resident's view of the impact that tangible declines in health, cognition, or functional abilities have on HRQOL. The EQ-5D-5L-proxy and DEMQOL-Proxy-U were generally poor substitutes. Regardless of which proxy completed it, the EQ-5D-5L-proxy was typically more responsive than the DEMQOL-Proxy-U to changes in CDR, FAST, and CMAI, indicating that use of the DEMQOL-Proxy-U is not always justified.

CONCLUSION

Disparities in the measurement properties of different utility measures mean that choices about how to measure utility in trials could affect economic evaluation outcomes and hence how resources are allocated for dementia care.

HOMESIDE: home-based family caregiver-delivered music and reading interventions for people living with dementia: protocol of a randomised controlled trial

INTRODUCTION

Pharmacological interventions to address behavioural and psychological symptoms of dementia (BPSD) can have undesirable side effects, therefore non-pharmacological approaches to managing symptoms may be preferable. Past studies show that music therapy can reduce BPSD, and other studies have explored how formal caregivers use music in their caring roles. However, no randomised study has examined the effects on BPSD of music interventions delivered by informal caregivers (CGs) in the home setting. Our project aims to address the need for improved informal care by training cohabiting family CGs to implement music interventions that target BPSD, and the quality of life (QoL) and well-being of people with dementia (PwD) and CGs.

METHODS AND ANALYSIS

A large international three-arm parallel-group randomised controlled trial will recruit a sample of 495 dyads from Australia, Germany, UK, Poland and Norway. Dyads will be randomised equally to standard care (SC), a home-based music programme plus SC, or a home-based reading programme plus SC for 12 weeks. The primary outcome is BPSD of PwD (measured using the Neuropsychiatric Inventory-Questionnaire). Secondary outcomes will examine relationship quality between CG and PwD, depression, resilience, competence, QoL for CG and QoL for PwD. Outcomes will be collected at baseline, at the end of the 12-week intervention and at 6 months post randomisation. Resource Utilisation in Dementia will be used to collect economic data across the life of the intervention and at 6-month follow-up. We hypothesise that the music programme plus SC will generate better results than SC alone (primary comparison) and the reading programme plus SC (secondary comparison).

ETHICS AND DISSEMINATION

Ethical approval has been obtained for all countries. Results will be presented at national and international conferences and published in scientific journals and disseminated to consumer and caregiver representatives and the community.

TRIAL REGISTRATION NUMBERS

ACTRN12618001799246p; NCT03907748.

Quality of life in cognitively impaired older adults

AIM

Quality of life (QOL) in older adults can be affected by many factors, such as dementia, sarcopenia and frailty. This study sought to identify factors that can lead to global deterioration in QOL among older outpatients, including factors stated in caregiver reports. This study also evaluated the discrepancy between QOL ratings reported by the patients and those by their family or professional caregivers.

METHODS

The sample comprised 141 patients with a Mini-Mental State Examination score ≥20 and a Clinical Dementia Rating of 0.5-1, indicating mild cognitive impairment to mild dementia. QOL was assessed using both components of the EQ-5D scale, namely, the index score and visual analog scale. In addition, cognitive, neuropsychological, nutritional and physical function tests were carried out, and body measurements were taken.

RESULTS

Patients' self-reported QOL was significantly associated with basic activities of daily living, Mini Nutritional Assessment score and Geriatric Depression Scale-15. QOL rated by caregivers was significantly associated with basic activities of daily living. EQ-5D index scores reported by caregivers were lower than those reported by patients. Furthermore, patients achieved a better score for self-care, usual activities, pain/discomfort and anxiety/depression than those assigned by caregivers.

CONCLUSIONS

As far as the patient's ratings are concerned, the presence of depressive symptoms and a worse nutritional status were indicative of lower QOL, whereas a better functional status was associated with a higher QOL. For caregivers, however, the most relevant factor negatively affecting QOL was basic activities of daily living. Geriatr Gerontol Int 2019; 19: 999-1005.

Farm-based day care services - a prospective study protocol on health benefits for people with dementia and next of kin

Introduction

The increasing number of people with dementia will place a considerable challenge on the health care system and will necessitate innovation and new solutions. Day care services aim to provide meaningful activities and coping experiences for the target group. The aim of the present study is to explore the experience and potential health benefits for people with dementia attending farm-based day care services in Norway and their next of kin.

Methods and design

The present study is a prospective study organized into several qualitative and quantitative sub-studies. Study period will last from 2016-2020. We use a multi-method approach and both an empirical and a constructivist view on knowledge to explore this multi-facetted phenomenon.

Discussion

Several challenges are expected, for instance, the ability to include participants with dementia and keep them within the study for the whole study period. The functioning level of participants regarding language and understanding could challenge their ability to answer. Despite having several limitations, we believe that this study with its different approaches and methods will add important knowledge to the field. Knowledge from our study could be essential for creating day care services of good quality for people with dementia and such services could reduce the burden of care for their next of kin.

Exploring the views of being a proxy from the perspective of unpaid carers and paid carers: developing a proxy version of the Adult Social Care Outcomes Toolkit (ASCOT)

Background

Outcomes-based policy and administration of public services present a compelling argument for the value of outcomes data. However, there are a number of challenges inherent in collecting these data from people who are unable to complete a paper-based survey or interview due to cognitive or communication impairments. In this paper, we explore the views of being a proxy from the perspective of unpaid carers and paid carers who may be asked to act as a proxy on behalf of the person(s) they care for. We consider the key issues that need to be addressed when adapting an instrument designed to measure social care outcomes, the Adult Social Care Outcomes Tool (ASCOT), into a proxy-report tool.

Methods

Participants took part in either a focus group (35 paid carers in eight focus groups), or a one-to-one interview (eight unpaid carers). All participants were recruited via carer organisations and care providers. Transcripts, field notes and audio data collected during focus groups and interviews were analysed using a thematic framework approach.

Results

Participants agreed that any person acting as a proxy would need to be very familiar with the care recipient, as well as their needs and care provision. A number of provisions for proxy respondents were proposed to improve face validity and acceptability of completing a questionnaire by proxy, and to ensure that any potential bias is reduced in the design of the questionnaire. These included: providing two sets of response options for each proxy perspective (the proxy themselves and the proxy view of how they think the care recipient would respond); a comments box to help people explain why they have selected a given response option (especially where these indicate unmet need); and providing clear guidance for the proxy respondent on how they should complete the questionnaire.

Conclusions

This study has shown some of the challenges involved in assessing outcomes by proxy and explored some potential ways these can be mitigated. The findings highlight the benefits of developing and testing proxy measures in a robust way to widen participation in social care research.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4025-1) contains supplementary material, which is available to authorized users.

Health-related quality of life in people with advanced dementia: a comparison of EQ-5D-5L and QUALID instruments

BACKGROUND

Assessing health-related quality of life (HRQOL) in people with advanced dementia is challenging but important for informed decision-making. Proxy measurement of this construct is difficult and is often rated lower than self-report. Accurate proxy rating of quality of life in dementia is related to identification of concepts important to the person themselves, as well as the sensitivity of the measures used. The main aim of this study was to compare the performance of two instruments-QUALID and EQ-5D-5L-on measuring HRQOL in people with advanced dementia.

METHODS

In a sub-study nested within a cluster-RCT we collected proxy(nurse)-completed EQ-5D-5L and QUALID measures at baseline, 3, 6, 9 and 12 months' follow-up for people with advanced dementia, residing in 20 nursing homes across Australia. Spearman's rank correlations, partial correlations and linear regressions were used to assess the relationship between the HRQOL instrument scores and their changes over time.

RESULTS

The mean weight from 284 people for the EQ-5D-5L and QUALID at baseline were 0.004 (95% CI - 0.026, 0.033) and 24.98 (95% CI 24.13, 25.82), respectively. At 12 months' follow-up, 115 participants remained alive. EQ-5D-5L weights and QUALID scores at baseline and at follow-up were moderately correlated (r = - 0.437; p < 0.001 at 12 months). Changes within QUALID and EQ-5D-5L across the same follow-up periods were also correlated (r = - 0.266; p = 0.005). The regression analyses support these findings.

CONCLUSION

Whilst these quality of life instruments demonstrated moderate correlation, the EQ-5D-5L does not appear to capture all aspects of quality of life that are relevant to people with advanced dementia and we cannot recommend the use of this instrument for use within this population. The QUALID appears to be a more suitable instrument for measuring HRQOL in people with severe dementia, but is not preference-based, which limits its application in economic evaluations of dementia care.

Evaluating the effect of Brainfood groups for people with mild cognitive impairment and mild dementia: preliminary mixed-methodology study

BACKGROUND

Brainfood is a 5-week group intervention for people with mild cognitive impairment and mild dementia, promoting cognitive health through a Mediterranean-style diet, exercise, mindfulness and health self-management.

AIMS

To evaluate Brainfood acceptability and the feasibility of conducting a randomised controlled trial; in a single group study in two National Health Service (NHS) memory services.

METHOD

Participants self-completed quantitative and semi-structured questionnaires. Recruitment, attendance and outcome completion were the primary outcomes.

RESULTS

In total, 30 of 59 people invited to Brainfood attended; of the 26 (87%) who completed baseline measures: 25 (96%) completed post-intervention quantitative measures, 16 (67%) qualitative questions and 21 (81%) attended ≥3/5 sessions. Compared with baseline, participants reported significantly higher quality of life, Mediterranean diet adherence and exercising more, up to 2 months after the groups. Participants valued the groups and felt enabled to improve their well-being.

CONCLUSIONS

Brainfood was acceptable and feasible to implement in an NHS setting.

DECLARATION OF INTEREST

A.B. and C.C. developed Brainfood - they hold a creative commons license for the manual and make it available to use for free to all. The manual evolves iteratively, but the manual used in this research study is provided in an online supplement.

Quality of life of the Indonesian general population: Test-retest reliability and population norms of the EQ-5D-5L and WHOQOL-BREF

Objectives

The objective of this study is to obtain population norms and to assess test-retest reliability of EQ-5D-5L and WHOQOL-BREF for the Indonesian population.

Methods

A representative sample of 1056 people aged 17–75 years was recruited from the Indonesian general population. We used a multistage stratified quota sampling method with respect to residence, gender, age, education level, religion and ethnicity. Respondents completed EQ-5D-5L and WHOQOL-BREF with help from an interviewer. Norms data for both instruments were reported. For the test-retest evaluations, a sub-sample of 206 respondents completed both instruments twice.

Results

The total sample and test-retest sub-sample were representative of the Indonesian general population. The EQ-5D-5L shows almost perfect agreement between the two tests (Gwet’s AC: 0.85–0.99 and percentage agreement: 90–99%) regarding the five dimensions. However, the agreement of EQ-VAS and index scores can be considered as poor (ICC: 0.45 and 0.37 respectively). For the WHOQOL-BREF, ICCs of the four domains were between 0.70 and 0.79, which indicates moderate to good agreement. For EQ-5D-5L, it was shown that female and older respondents had lower EQ-index scores, whilst rural, younger and higher-educated respondents had higher EQ-VAS scores. For WHOQOL-BREF: male, younger, higher-educated, high-income respondents had the highest scores in most of the domains, overall quality of life, and health satisfaction.

Conclusions

This study provides representative estimates of self-reported health status and quality of life for the general Indonesian population as assessed by the EQ-5D-5L and WHOQOL-BREF instruments. The descriptive system of the EQ-5D-5L and the WHOQOL-BREF have high test-retest reliability while the EQ-VAS and the index score of EQ-5D-5L show poor agreement between the two tests. Our results can be useful to researchers and clinicians who can compare their findings with respect to these concepts with those of the Indonesian general population.

An empirical comparison of the measurement properties of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U for older people in residential care

PURPOSE

This study aimed to empirically compare the measurement properties of self-reported and proxy-reported (in cases of severe cognitive impairment) generic (EQ-5D-5L) and condition-specific (DEMQOL-U and DEMQOL-Proxy-U) preference-based HRQoL instruments in residential care, where the population is characterised by older people with high rates of cognitive impairment, dementia and disability.

METHODS

Participants were recruited from seventeen residential care facilities across four Australian states. One hundred and forty-three participants self-completed the EQ-5D-5L and the DEMQOL-U while three hundred and eight-seven proxy completed (due to the presence of severe dementia) the EQ-5D-5L and DEMQOL-Proxy-U. The convergent validity of the outcome measures and known group validity relative to a series of clinical outcome measures were assessed.

RESULTS

Results satisfy convergent validity among the outcome measures. EQ-5D-5L and DEMQOL-U utilities were found to be significantly correlated with each other (p < 0.01) as were EQ-5D-5L and DEMQOL-Proxy-U utilities (p < 0.01). Both self-reported and proxy-reported EQ-5D-5L utilities demonstrated strong known group validity in relation to clinically recognised thresholds of cognition and physical functioning, while in contrast neither DEMQOL-U nor DEMQOL-Proxy-U demonstrated this association.

CONCLUSIONS

The findings suggest that the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U capture distinct aspects of HRQoL for this population. The measurement and valuation of HRQoL form an essential component of economic evaluation in residential care. However, high levels of cognitive impairment may preclude self-completion for a majority. Further research is needed to determine cognition thresholds beyond which an individual is unable to reliably self-report their own health-related quality of life.

Costs and quality of life in community-dwelling patients with Alzheimer's disease in Spain: results from the GERAS II observational study

BACKGROUND

Country-specific data on resource use and costs associated with Alzheimer's disease (AD) help inform governments about the increasing need for medical and financial support as the disease increases in prevalence.

METHODS

GERAS II, a prospective observational study, assessed resource use, costs, and health-related quality of life (HRQoL) among patients with AD and their caregivers in Spain. Community-dwelling patients aged ≥55 years with probable AD, and their primary caregivers, were recruited by study investigators during routine clinical practice and assessed as having mild, moderate, or moderately severe/severe (MS/S) AD dementia based on patient Mini-Mental State Examination scores. Costs of AD were calculated by applying costs to resource-use data obtained in caregiver interviews using the Resource Utilization in Dementia instrument. Total societal costs included patients' health and social care costs and caregiver informal care costs. Baseline results are presented.

RESULTS

Total mean monthly societal costs/patient (2013 values) were €1514 for mild (n = 116), €2082 for moderate (n = 118), and €2818 for MS/S AD dementia (n = 146) (p value <0.001 between groups). Caregiver informal care costs comprised most of the total societal costs and differed significantly between groups (€1050, €1239, €1580, respectively; p value = 0.013), whereas patient healthcare costs did not. Across AD dementia severity groups, patient HRQoL (measured by proxy) decreased significantly (p value <0.001), caregiver subjective burden significantly increased (p value <0.001) and caregiver HRQoL was similar.

CONCLUSIONS

Societal costs associated with AD in Spain were largely attributable to caregiver informal care costs and increased with increasing AD dementia severity.

Podiatry intervention versus usual care to prevent falls in care homes: pilot randomised controlled trial (the PIRFECT study)

Background

Common foot problems are independent risk factors for falls in older people. There is evidence that podiatry can prevent falls in community-dwelling populations. The feasibility of implementing a podiatry intervention and trial in the care home population is unknown. To inform a potential future definitive trial, we performed a pilot randomised controlled trial to assess: (i) the feasibility of a trial of a podiatry intervention to reduce care home falls, and (ii) the potential direction and magnitude of the effect of the intervention in terms of number of falls in care home residents.

Methods

Informed by Medical Research Council guidance on developing and evaluating complex interventions, we conducted a single blind, pilot randomised controlled trial in six care homes in the East of Scotland. Participants were randomised to either: (i) a three month podiatry intervention comprising core podiatry care, foot and ankle exercises, orthoses and footwear provision or (ii) usual care. Falls-related outcomes (number of falls, time to first fall) and feasibility-related outcomes (recruitment, retention, adherence, data collection rates) were collected. Secondary outcomes included: generic health status, balance, mobility, falls efficacy, and ankle joint strength.

Results

474 care home residents were screened. 43 (9.1%) participants were recruited: 23 to the intervention, 20 to control. Nine (21%) participants were lost to follow-up due to declining health or death. It was feasible to deliver the trial elements in the care home setting. 35% of participants completed the exercise programme. 48% reported using the orthoses ‘all or most of the time’. Completion rates of the outcome measures were between 93% and 100%. No adverse events were reported. At the nine month follow-up period, the intervention group per-person fall rate was 0.77 falls vs. 0.83 falls in the control group.

Conclusions

A podiatry intervention to reduce falls can be delivered to care home residents within a pilot randomised controlled trial of the intervention. Although not powered to determine effectiveness, these preliminary data provide justification for a larger trial, incorporating a full process evaluation, to determine whether this intervention can significantly reduce falls in this high-risk population.

Trial registration

ClinicalTrials.gov identifier: NCT02178527; Date of registration: 17 June 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0541-1) contains supplementary material, which is available to authorized users.

Cost-effectiveness of a randomised trial of physical activity in Alzheimer's disease: a secondary analysis exploring patient and proxy-reported health-related quality of life measures in Denmark

OBJECTIVES

To explore the cost-effectiveness of a supervised moderate-to-high intensity aerobic exercise programme in people diagnosed with Alzheimer's disease (AD) and estimate incremental cost-effectiveness ratios (ICER) using participant-reported and proxy-reported measures of health-related quality of life (HRQoL) DESIGN: A cost-effectiveness analysis of economic and HRQoL data from a randomised trial delivered over 16 weeks.

SETTING

Memory clinics in Denmark.

PARTICIPANTS

200 individuals with mild AD aged 50-90 years gave informed consent to participate in the study. Participants were randomised to control or intervention group.

INTERVENTIONS

Control group received treatment as usual. The intervention group performed 1 hour of supervised moderate-to-high intensity aerobic exercise three times weekly for 16 weeks.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Different physical, functional and health measures were obtained at inclusion (baseline) and 4 and 16 weeks after. HRQoL (EuroQol-5 Dimensions-5 Levels/EQ-Visual Analogue Scale) was reported by the participants and the primary caregivers as proxy respondents. Differences in HRQOL as reported by the participant and caregiver were explored as were different values of caregiver time with respite from care tasks.

RESULTS

The intervention cost was estimated at €608 and €496 per participant, with and without transport cost, respectively. Participants and caregivers in the intervention group reported a small, positive non-significant improvement in EQ-5D-5L and EQ-VAS after 16 weeks. The ICER was estimated at €72 000/quality-adjusted life year using participant-reported outcomes and €87000 using caregiver-reported outcomes.

CONCLUSIONS

The findings suggest that the exercise intervention is unlikely to be cost-effective within the commonly applied threshold values. The cost of the intervention might be offset by potential savings from reduction in use of health and social care.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ct2/show/NCT01681602.

Developing a proxy version of the Adult social care outcome toolkit (ASCOT)

BACKGROUND

Social care-related quality of life is a key outcome indicator used in the evaluation of social care interventions and policy. It is not, however, always possible to collect quality of life data by self-report even with adaptations for people with cognitive or communication impairments. A new proxy-report version of the Adult Social Care Outcomes Toolkit (ASCOT) measure of social care-related quality of life was developed to address the issues of wider inclusion of people with cognitive or communication difficulties who may otherwise be systematically excluded. The development of the proxy-report ASCOT questionnaire was informed by literature review and earlier work that identified the key issues and challenges associated with proxy-reported outcomes.

METHODS

To evaluate the acceptability and content validity of the ASCOT-Proxy, qualitative cognitive interviews were conducted with unpaid carers or care workers of people with cognitive or communication impairments. The proxy respondents were invited to 'think aloud' while completing the questionnaire. Follow-up probes were asked to elicit further detail of the respondent's comprehension of the format, layout and content of each item and also how they weighed up the options to formulate a response.

RESULTS

A total of 25 unpaid carers and care workers participated in three iterative rounds of cognitive interviews. The findings indicate that the items were well-understood and the concepts were consistent with the item definitions for the standard self-completion version of ASCOT with minor modifications to the draft ASCOT-Proxy. The ASCOT-Proxy allows respondents to rate the proxy-proxy and proxy-patient perspectives, which improved the acceptability of proxy report.

CONCLUSIONS

A new proxy-report version of ASCOT was developed with evidence of its qualitative content validity and acceptability. The ASCOT-Proxy is ready for empirical testing of its suitability for data collection as a self-completion and/or interview questionnaire, and also evaluation of its psychometric properties.

A Path Analysis of Dependence and Quality of Life in Alzheimer's Disease

OBJECTIVE

To determine the direct and indirect relationships of cognitive, functional, and behavioral factors and other medical comorbidities with the quality of life (QoL) of patients with Alzheimer's disease (AD) according to the theoretical model of dependence.

METHODS

Observational and cross-sectional study. Cognitive and functional status, behavior, dependence, medical comorbidities, and QoL were assessed by using standardized instruments. A path analysis was used to model the direct and indirect relationships among clinical indicators according to the theoretically based model of dependence.

RESULTS

The sample consisted of 343 patients with AD (32.1% mild, 36.7% moderate, and 31.2% severe). Medical comorbidities, disease severity, and dependence level had a direct relationship with QoL. The functional disability and the behavior disturbances were indirectly related to QoL via dependence level, and the cognitive impairment was indirectly related to QoL via severity level.

CONCLUSION

Direct and indirect effects exist between clinical indicators, dependence, and QoL.

Comparison of the HUI3 and the EQ-5D-3L in a nursing home setting

BACKGROUND

Accurately assessing changes in the quality of life of older people living permanently in nursing homes is important. The multi-attribute utility instrument most commonly used and recommended to assess health-related quality of life in the nursing home population is the three-level EuroQol EQ-5D-3L. To date, there have been no studies using the Health Utilities Index Mark III (HUI3). The purpose of this study was to compare the level of agreement and sensitivity to change of the EQ-5D-3L and HUI3 in a nursing home population.

METHODS

EQ-5D-3L and HUI3 scores were measured as part of a cluster randomised controlled trial of nurse led care coordination in a nursing home population in Perth, Western Australia at baseline and 6-month follow up.

RESULTS

Both measures were completed for 199 residents at baseline and 177 at 6-month follow-up. Mean baseline utility scores for EQ-5D-3L (0.45; 95% CI 0.41-0.49) and HUI3 (0.15; 95% CI 0.10-0.20) were significantly different (Wilcoxon signed rank test, p<0.01) and agreement was poor to moderate between absolute scores from each instrument (intra-class correlation coefficient = 0.63). The EQ-5D-3L appeared more sensitive to change over the 6-month period.

CONCLUSION

Our findings show that the EQ-5D-3L and HUI3 estimate different utility scores among nursing home residents. These differences should be taken into account, particularly when considering the implications of the cost-effectiveness of particular interventions and we conclude that the HUI3 is no better suited to measuring health-related quality of life in a nursing home population when compared to the EQ-5D-3L.

Health-Related Quality of Life in Patients with Alzheimer's Disease in Different German Health Care Settings

The purpose of this study is to evaluate the health-related quality of life (HrQoL) of patients with Alzheimer's disease (AD) in different care settings (institutionalized versus community-dwelling) across all severity stages of dementia. Patients were consecutively recruited with their primary caregivers (123 inpatients and 272 outpatients), and the impact of patient-related parameters such as behavioral and psychological symptoms of dementia (BPSD) (Geriatric Depression Scale [GDS] and Neuropsychiatric Inventory [NPI]) and functional capacity (Alzheimer's Disease Cooperative Study-Activities of Daily Living [ADCS-ADL]) on HrQoL was analyzed. Patients' HrQoL was assessed using self-reported and caregiver-rated generic (EuroQoL Instrument) and dementia-specific (Quality of Life-Alzheimer's Disease [Qol-AD]) scales. Patients reported a considerably higher HrQoL than their caregivers on the QoL-AD, EQ-5D, and EQ VAS (p <  0.001). Different dementia severity groups showed significantly worse results in HrQoL for patients with lower MMSE scores. The mean self-reported QoL-AD decreased from 32.3±5.7 in the group with the highest MMSE scores to 27.1±5.5 in patients with the lowest MMSE scores (p <  0.001). A considerably lower HrQoL was shown for institutionalized patients versus participants in outpatient settings (proxy-rated QoL-AD 19.7±4.6 versus 26.0±7.1, p <  0.001). Depressive symptoms (GDS), BPSD (NPI), and reduced functional capacity (ADCS-ADL) were evaluated for their impact on patients' HrQoL. Multivariate models explained between 22% and 54% of the variance in patients' HrQoL. To analyze the causative direction of the reported associations, further longitudinal studies should be conducted.

The PaArticular Scales - A new outcome measure to quantify the impact of joint contractures on activities and participation in individuals in geriatric care: Development and Rasch analysis

BACKGROUND

Joint contractures are frequent conditions in individuals in geriatric care settings and are associated with activity limitations and participation restrictions. As such, relevant intervention programs should address these aspects, and the effectiveness of such programs should be determined by assessing improvement in activities and participation. However, no patient-centred and psychometrically sound outcome measures for this purpose are available so far.

OBJECTIVES

The objectives of this study were to develop and to validate a new outcome measure, the PaArticular Scales, to quantify activities and participation in older individuals with joint contractures. Specific aims were (A) to operationalize the content of an International Classification of Functioning, Disability and Health-based standard set towards meaningful questions and to combine them to a questionnaire and (B) to assess the psychometric properties of the developed questionnaire, in detail to evaluate test-retest reliability, objectivity, internal consistency reliability and criterion validity.

DESIGN

Operationalization was reached by an expert consensus conference and a subsequent expert Delphi survey. Psychometric properties were assessed in a cross-sectional study.

SETTINGS

Nursing homes, geriatric rehabilitation facilities.

PARTICIPANTS

23 experts (nurses, physicians, physical and occupational therapists) participated in the consensus conference and the Delphi survey. A total of 191 individuals with joint contractures (as confirmed by physician, nurse or physical therapist) between 65 and 102 years, living in nursing homes or as patients in geriatric rehabilitation were enrolled in the cross-sectional study.

METHODS

Rasch Partial Credit Modelling.

RESULTS

The consensus conference and Delphi survey resulted in a questionnaire with 86 items of the International Classification of Functioning, Disability and Health. Test-retest-reliability among those was acceptable (Cohen's weighted kappa: 0.779). The Rasch analysis revealed two independent interval-scaled scales with 24 items for the Activities scale and 11 items for the Participation scale with high internal consistency reliability. Cronbach's alpha was 0.96 for the Activities scale and 0.92 for the Participation scale. Criterion validity was -0.40 and -0.30 for the Activities scale and for the Participation scale, respectively.

CONCLUSIONS

The PaArticular Scales, a new patient-centred and psychometric sound outcome measures to comprehensively assess the impact of joint contractures in geriatric care, are available now. These developed scales will serve as primary outcomes in a scheduled evaluation of a complex intervention to improve participation and quality of life in nursing home residents with joint contractures.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Can The EQ-5D Detect Meaningful Change? A Systematic Review

BACKGROUND

The EQ-5D is one of the most frequently used, generic, preference-based instruments for measuring the health utilities of patients in economic evaluations. It is recommended for health technology assessment by the National Institute for Health and Clinical Excellence. Because the EQ-5D plays such an important role in economic evaluations, useful information on its responsiveness to detect meaningful change in health status is required.

OBJECTIVE

This study systematically reviewed and synthesized evidence on the responsiveness of the EQ-5D to detect meaningful change in health status for clinical research and economic evaluations.

METHODS

We searched the EuroQol website, PubMed, PsychINFO, and EconLit databases to identify studies published in English from the inception of the EQ-5D until August 15, 2014 using keywords that were related to responsiveness. Studies that used only the EQ-VAS were excluded from the final analysis. Narrative synthesis was conducted to summarize evidence on the responsiveness of the EQ-5D by conditions or physiological functions.

RESULTS

Of 1401 studies, 145 were included in the narrative synthesis and categorized into 19 categories for 56 conditions. The EQ-5D was found to be responsive in 25 conditions (45 %) with the magnitude of responsiveness varying from small to large depending on the condition. There was mixed evidence of responsiveness in 27 conditions (48 %). Only four conditions (7 %) (i.e., alcohol dependency, schizophrenia, limb reconstruction, and hearing impairment) were identified where the EQ-5D was not responsive.

CONCLUSION

The EQ-5D is an appropriate measure for economic evaluation and health technology assessment in conditions where it has demonstrated evidence of responsiveness. In conditions with mixed evidence of responsiveness, researchers should consider using the EQ-5D with other condition-specific measures to ensure appropriate estimates of effectiveness. These conditions should be a main focus for future research using the new EQ-5D version with five response levels.

How does the EQ-5D perform when measuring quality of life in dementia against two other dementia-specific outcome measures?

PURPOSE

This study aimed to assess and compare the psychometric performance of the EQ-5D in relation to other dementia-specific measures, the QoL-AD and DEMQoL, within a psychosocial intervention study.

METHODS

Two hundred and seventy-two people with dementia completed the EQ-5D, DEMQoL and QoL-AD. Convergent and discriminant validity of the measures were assessed, and inter-rater reliability was tested by comparing the self-reported and proxy scores of the measures. Internal consistency was tested using Cronbach's alpha.

RESULTS

Results satisfy convergent validity amongst the three outcome measures. EQ-5D, DEMQoL and QoL-AD total scores were shown to be significantly correlated with each other (p < 0.001) in both participants with dementia and proxy reports. Results also satisfied discriminant validity for participant EQ-5D, DEMQoL and QoL-AD total scores. In relation to reliability between self and proxy scores, the EQ-5D showed higher reliability scores between participant and proxy total scores for mild and moderate level of cognitive impairment and performed better than the dementia-specific measures. Reliability assessed through Cronbach's alpha was satisfactory, indicating adequate internal consistency of all three measures.

CONCLUSIONS

The results suggest that the EQ-5D might have advantages over other dementia-specific measures, and it could be used routinely and as a stand-alone measure of quality of life in dementia research.

Responsiveness of the EQ-5D to clinical change: is the patient experience adequately represented?

OBJECTIVES

In many economic evaluations and reimbursement decisions, quality-adjusted life-years (QALYs) are used as a measure of benefit to assess effectiveness of novel therapies, often based on the EQ-5D 3-level questionnaire. As only five dimensions of physical and mental well-being are reflected in this tool, significant aspects of the patient experience may be missed. We evaluate the use of the EQ-5D as a measurement of clinical change across a wide range of disorders from dermatological (acne) to life-threatening (metastatic cancers).

METHODS

We analyze published studies on the psychometric properties of the EQ-5D 3-level questionnaire, extracting information on the Visual Analogue Scale versus Index score, Standardized Response Mean, and Effect Size. These are compared with ranges generally accepted to represent good responsiveness in the psychometric literature.

RESULTS

We find that only approximately one in five study populations report subjective health state valuation of patients within 5 percent of the score attributed by the EQ-5D index, and more than 40 percent of studies report unacceptable ceiling effects. In the majority of studies, responsiveness of the EQ-5D index was found to be poor to moderate, based on Effect Size (63 percent poor–moderate) and Standardized Response Mean (72 percent poor–moderate).

CONCLUSIONS

We conclude that the EQ-5D index does not adequately reflect patient health status across a range of conditions, and it is likely that a significant proportion of the subjective patient experience is not accounted for by the index. This has implications for economic evaluations of novel drugs based on evidence generated with the EQ-5D.

The relationship between changes in quality of life outcomes and progression of Alzheimer's disease: results from the dependence in AD in England 2 longitudinal study

OBJECTIVE

The relationship between conventional indicators of Alzheimer's disease (AD) progression and quality of life (QoL) outcomes is unclear. Dependence on others has been recommended as a unifying construct in defining AD severity. This study examined the relationship between indicators of disease severity (including dependence) and changes in QoL and utility over 18 months.

METHODS

A multi-centre, cohort study was conducted across 18 UK sites. One hundred and forty-five patients with possible/probable AD and their caregivers completed assessments of disease severity (Dependence Scale, Mini-mental state examination, Neuropsychiatric Inventory, Disability Assessment for Dementia), dementia-specific QoL (DEMQOL, DEMQOL-Proxy) and generic health-related utility (EQ-5D) at both time points.

RESULTS

There was evidence of individual change in QoL over 18 months, with over 50% of patients reporting either maintenance or improvement of life quality. The EQ-5D proxy suggested a mean decline in QoL, whereas the DEMQOL-Proxy indicated overall improvement. In the subsample of people who self-reported QoL and utility, no mean change was evident. Changes in dependence did not explain changes on any QoL or utility outcome. There was a weak association between the EQ-5D proxy and changes in cognition, whereas changes on the DEMQOL-Proxy were partly explained by changes in behavioural disturbance.

CONCLUSIONS

The natural progression of AD over 18 months does not lead to inevitable decline in QoL or utility. There are no clear or consistent direct relationships between changes in disease severity and QoL outcomes. The impact of increasing dependence and worsening disease severity is likely buffered by a combination of psychological, social and environmental factors.