Quality of life of community-residing persons with dementia based on self-rated and caregiver-rated measures

The Role of Neighborhood Socioeconomic Status in Institutionalization of Home Health Care Patients With and Without Alzheimer's Disease and Related Dementias

OBJECTIVES

To assess whether neighborhood socioeconomic status (SES) moderates the association between Alzheimer's disease and related dementias (ADRD) and successful discharge to the community. In addition, to explore whether the role of neighborhood SES on successful discharge for patients with ADRD varies by the severity of ADRD.

DESIGN

This is a retrospective cohort study.

SETTING AND PARTICIPANTS

Medicare Fee-for-service beneficiaries, aged 65 or older, who received home health care in 2019.

METHODS

We used linear probability regression models with successful discharge to the community as the main outcome, and neighborhood SES and ADRD as independent variables. Also, we modified the Functional Assessment Staging Tool (FAST) to measure ADRD severity.

RESULTS

Our study results show ADRD and residing in neighborhoods with lower socioeconomic conditions were independently associated with lower probabilities of successful discharge to the community. We also found that the differences in probabilities of remaining at home between patients with and without ADRD were larger among those in neighborhoods with lower SES (ADRD∗less disadvantaged neighborhood, coeff: -0.01, P < .001; ADRD∗more disadvantaged neighborhood, coeff: -0.02, P < .001; ADRD∗most disadvantaged neighborhood, coeff: 0.032, P < .001). Among patients with ADRD, patients with the most advanced ADRD were less likely to remain in their homes and community when living in neighborhoods with lower SES.

CONCLUSIONS AND IMPLICATIONS

Our study results show that when patients with ADRD receiving home health care live in neighborhoods with lower SES, they face further challenges to remaining in their homes and community. Public health officials and community planners should consider using area-level interventions to improve care and health outcomes for patients with ADRD. Also, further research aimed at identifying the specific factors and resources influencing lower care quality and poorer health outcomes in socioeconomically disadvantaged neighborhoods, particularly for patients with ADRD, can provide valuable insights for the development and implementation of targeted interventions.

Multiple Roads to Success: A Latent Class Analysis on Successful Ageing Among Hong Kong Near-Centenarians and Centenarians (NCC)

Notwithstanding the oldest-old cohort being the fastest-growing population in most ageing societies, characterizing successful ageing in adults of advanced age, such as nonagenarians and centenarians, remains challenging. This study investigated the successful ageing subphenotypes using the data from Hong Kong Centenarian Study 2. Between April 2021 and September 2022, 146 family caregivers of community-dwelling older adults aged 95 or above were interviewed by phone. Latent class analysis identified three classes-Overall Frail (46.6%) with poor mobility, cognitive and functional health, Nonambulant (37.0%) but good functional health, and Robust (16.4%) with overall good health-from 11 indicators based on caregivers' reports. Although we found a low prevalence of fulfillment of all indicators of successful ageing, our findings will help care professionals appreciate the heterogeneity underlying partial successful ageing in this vulnerable cohort for segmented and targeted healthy longevity interventions.

Healthcare Needs Patterns and Pattern-Predicting Factors in Dementia: Results of the Comprehensive, Computerized Unmet Needs Assessment from the Randomized, Controlled Interventional Trial InDePendent

Background

Determining unmet need patterns and associated factors in primary care can potentially specify assessment batteries and tailor interventions in dementia more efficiently.

Objective

To identify latent unmet healthcare need patterns and associated sociodemographic and clinical factors.

Methods

This Latent Class Analysis (LCA) includes n = 417 community-dwelling people living with dementia. Subjects completed a comprehensive, computer-assisted face-to-face interview to identify unmet needs. One-hundred-fifteen predefined unmet medical, medication, nursing, psychosocial, and social care needs were available. LCA and multivariate logistic regressions were performed to identify unmet needs patterns and patient characteristics belonging to a specific pattern, respectively.

Results

Four profiles were identified: [1] "few needs without any psychosocial need" (n = 44 (11%); mean: 7.4 needs), [2] "some medical and nursing care needs only" (n = 135 (32%); 9.7 needs), [3] "some needs in all areas" (n = 139 (33%); 14.3 needs), and [4] "many medical and nursing needs" (n = 99 (24%); 19.1 needs). Whereas the first class with the lowest number of needs comprised younger, less cognitively impaired patients without depressive symptoms, the fourth class had the highest number of unmet needs, containing patients with lower health status, less social support and higher comorbidity and depressive symptoms. Better access to social care services and higher social support reduced unmet needs, distinguishing the second from the third class (9.7 versus 14.3 needs).

Conclusions

Access to the social care system, social support and depressive symptoms should be assessed, and the patient's health status and comorbidities monitored to more comprehensively identify unmet needs patterns and more efficiently guide tailored interventions.

Suitability of memory aids and strategies for people with posterior cortical atrophy: protocol for a scoping review

Background

Posterior cortical atrophy (PCA) is a neurodegenerative syndrome characterised by progressive visuospatial and visuoperceptual impairment. Recent research shows that memory impairment can also occur as an early symptom of the condition and that the impairment can be ameliorated by providing support in the memory recall phase, for example, by presenting a related cue. In Alzheimer’s disease (AD), which is defined by an amnestic syndrome, memory aids and strategies have been used to help support everyday memory, which in turn can have a positive impact on patient and carer outcomes. Similar support for PCA could be achieved by using memory aids and strategies which help to encode and/or retrieve information, yet there are currently no guidelines for memory strategies that may be suitable in PCA. Due to the central visual disorder that defines PCA, careful consideration is needed when making recommendations.

Methods

A scoping review will be conducted of published studies that have assessed memory aids and strategies in people with AD and related dementias where memory is considered a core or supplementary feature, with the aim of distinguishing those that may be suitable or adaptable for PCA. The systematic search will include the electronic databases MEDLINE, PsycINFO and CINAHL, using search terms for dementia and memory aids and strategies identified in pilot searches. Findings will be mapped and described based on methods used, population, clinical data and memory aids and strategies identified.

Discussion

The scoping review will give an overview of the memory aids and strategies used in people with AD and related dementias and identify characteristics, modality and pragmatics to evaluate their suitability and adaptability for a PCA population. Tailored memory support strategies for people living with PCA could improve memory performance, with knock-on positive effects on patient and carer outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-023-02187-4.

A Systematic Review and Meta-Analysis of Dyadic Psychological Interventions for BPSD, Quality of Life and/or Caregiver Burden in Dementia or MCI

Objectives: This systematic review and meta-analysis assesses the effectiveness of psychological interventions that involve people with dementia or mild cognitive impairment (MCI) and their informal caregivers, and target improvements in the management of the behavioral and psychological symptoms of dementia (BPSD); quality of life; and/or burden reduction for people with either dementia or MCI and their informal caregivers.Methods: Studies were identified through database searches (Cochrane Library, CENTRAL, CINAHL, EMBASE, MEDLINE and PsychINFO) and clinical trials registers (ClinicalTrials.gov and http://apps.who.int/trialsearch/). Data were pooled for meta-analysis.Results: Database and reference list searches identified 1,878 references, of which fourteen studies were included. Positive effects were found on the anxiety symptoms of people with dementia on the RAID scale; on the quality of life of people with dementia on the self-rated QoL-AD scale; and on informal caregiver burden on the Zarit Burden Interview.Conclusions: Psychological interventions involving whole dyads have some promise for both people with dementia and informal caregivers, but are still far from uniformly effective across BPSD, quality of life, and caregiver burden. Further research directions are discussed.Clinical Implications: The results suggest that clinicians should routinely involve both halves of the dyad when delivering psychological interventions targeting anxiety or quality of life for people with dementia, or burden for informal caregivers.

Patient cognitive impairment associated with higher home health care delivery costs

OBJECTIVE

To assess whether home health agencies incur significantly higher care delivery costs for patients with cognitive impairment across three timeframes relevant to home health payment policy.

DATA SOURCES

Linked Medicare home health claims and patient assessments, National Health and Aging Trends Study (NHATS), and home health agency cost reports for a nationally representative sample of Medicare beneficiaries receiving home health between 2011 and 2016.

STUDY DESIGN

We modeled care delivery costs incurred by the home health agency as a function of patient cognitive impairment using multivariable, propensity score-adjusted, generalized linear models.

DATA COLLECTION/EXTRACTION METHODS

We identified NHATS participants who experienced an index home health episode between 2011 and 2016 (n = 1214; weighted n = 5,856,333) and linked their NHATS survey data to standardized patient assessment and claims data for the episode, as well as cost report data for the home health agency that provided care.

PRINCIPAL FINDINGS

Across the first 30, 60, and 120 days of caring for a patient with cognitive impairment, we estimate additional costs of care to the home health agency of $186.19 (p = 0.02), $282.46 (p = 0.01), and $740.91 (p = 0.04), respectively.

CONCLUSIONS

Home health agencies incur significantly higher costs when caring for a patient with cognitive impairment. As patient cognitive function is not considered in the most recent Medicare home health reimbursement model, agencies may be disincentivized from providing care to those with cognitive impairment. Policy makers and researchers should carefully monitor home health access among Medicare beneficiaries with cognitive impairment and further investigate the inclusion of patient cognitive function in future risk adjustment models.

Risk Adjustment in Home and Community Based Services Outcome Measurement

The purpose of this study was to review and evaluate existing research that used risk adjusters in disability research. Risk adjustment controls for individual characteristics of persons when examining outcomes. We have conducted a systematic review and an evaluation of existing studies that included risk adjusters for outcomes of people with disabilities receiving services (home or community based). The process included coding each study according to the type(s) of risk adjusters employed and their relation to the specific population and outcomes within a framework. Panels were utilized to prioritize the risk adjusters. Findings indicate that four risk adjusters can be tentatively recommended as potential candidate risk adjusters: chronic conditions, functional disability, mental health status, and cognitive functioning. Holistic Health and Functioning far outweighed other outcomes studied to date. Further, there is a need for testing recommended risk adjusters across multiple outcomes and different populations of people with disabilities.

Everyday wishes of older people living with dementia in care planning: a qualitative study

BACKGROUND

The dementia care policy in Japan emphasizes the views of people living with dementia in care planning. An exploration of the everyday wishes of older people living with dementia can help clarify their priorities and assist in improving dementia care. This study aimed to explore the everyday wishes of older people living with dementia in Japan.

METHODS

This qualitative study was conducted in Aichi prefecture in Japan. Older people with mild to moderate dementia were considered for inclusion. Participants were recruited from a dementia outpatient clinic. In-depth interviews were conducted with 36 participants in the same dementia outpatient clinic from January to October 2019. Audio-recorded interviews were transcribed verbatim. Inductive content analysis was carried out to analyze the data.

FINDINGS

Participants expressed their everyday wishes within five themes (desire of being connected, freedom to decide, involvement in activities, status quo, and self-reliance). Older people living with dementia loved the connection with their family and wanted to have an enjoyable life by engaging in several activities without others' interference. They desired to maintain the status quo and not be a burden to others.

CONCLUSIONS

This study provides evidence on the everyday wishes of people living with dementia. Identified wishes are mostly on emotional aspects of their daily lives. The findings of our study might help provide care for the people living with dementia considering their wishes. Further exploration, including people with severe dementia, is needed.

Perceived Unmet Need and Need-Related Distress of People Living With Dementia

The unmet needs of people living with dementia have been shown to be multidimensional and impact well-being. However, there are a lack of studies examining variability of unmet needs and need-related distress from the person living with dementia's perspective. The current study (n = 12) examined the self-reported unmet needs and need-related distress of people with mild to moderate dementia. Seventy-five percent of participants (n = 9) identified at least one unmet need and 50% (n = 6) reported 10 or more unmet needs. "Finding and Arranging Services" and "Health Information" subscales had the highest reported average unmet needs. The most frequently reported unmet need-item was "getting information about your memory problems?" Participants reported variability in distress for both unmet and met needs. Continued research can provide beneficial information on the relationship between unmet needs, need-related distress, and outcomes of well-being for future interventions.

Association of Dementia Severity and Caregiver Support With Early Discharge From Home Health

INTRODUCTION

The objective of this study was to examine the relationship between dementia severity and early discharge from home health.

METHODS

This was a retrospective study of 100% national Medicare home health da ta files (2016-2017). Multilevel logistic regression was used to study the relationship of dementia severity, caregiver support, and medication assistance with early discharge from home health.

RESULTS

The final cohort consisted of 91 302 Medicare beneficiaries with an ADRD diagnosis. A pattern of early discharge rates across dementia severity levels was not demonstrated. The relative risk for early discharge was lower for individuals who needed assistance with medication and for those with unmet caregiver needs.

DISCUSSION

The findings of this study do not support the hypothesis that dementia severity contributes to early discharge from home health. Further research is needed to fully understand key factors contributing to early discharge from home health.

Depression and Functional Mobility Decline in Long Term Care Home Residents with Dementia: a Prospective Cohort Study

Objective

Assess the association between depression among new long-term care residents (<3 months stay) with dementia and functional mobility decline.

Methods

A multi-site prospective cohort study was carried out among 26 participants diagnosed with dementia. Functional mobility was measured by Timed-Up-and-Go (TUG) and 2-Minute walk test (2MWT) at baseline, and 60-day post-baseline while participants received usual care. Linear mixed models were applied to examine the association between depression and functional mobility decline.

Results

Residents experienced a statistically significant decline in functional mobility in as soon as 60 days. Each additional year of age was associated with a 2% increase in TUG. The interaction between depression and time spent in LTC was statistically significant. Age and time living in LTC were significantly associated with functional mobility decline in new residents with dementia.

Discussion

Further work determining why residents with dementia experience decline in functional mobility at an accelerated rate is needed.

Quality of Life Assessment in Older Adults with Dementia: A Systematic Review

INTRODUCTION

In the absence of a cure, dementia is often managed by minimizing risk factors contributing to quality of life (QOL). Attitudes to dementia in older adults may differ from those in relatively younger adults. The aim was to conduct a systematic review of the literature to determine how QOL was assessed in adults, 65 years and older with dementia, and identify factors that influence the reported scores.

METHODS

A systematic review of full-text articles addressing QOL in older adults with dementia, published in English from January 1995 to September 2020, was conducted using PubMed and PsycINFO. We included studies that assessed QOL and involved participants 65 years and older. Studies were evaluated for inclusion by 2 independent pairs of reviewers. We assessed the quality of the studies using the Joanna Briggs Institute's Critical Appraisal Checklist. Study characteristics and findings were summarized. Analysis was by narrative synthesis. We identified social and clinical factors influencing QOL scores.

RESULTS

Of the 1,010 articles identified, 19 met the inclusion criteria. These 19 studies involved 6,279 persons with dementia, with sample sizes from 32 to 1,366. Mean age of participants ranged from 77.1 to 86.6 years. Five measurement tools were identified; Quality of Life in Alzheimer Disease (QOL-AD), Alzheimer Disease-Related Quality of Life (ADRQL), Quality of Life in Late-Stage Dementia (QUALID), QUALIDEM (a dementia-specific QOL tool), and DEMQOL (health-related QOL for people with dementia). Self-ratings of QOL were higher than proxy ratings. Factors commonly influencing self-ratings of QOL included depression, functional impairment, and polypharmacy. Common factors that influenced proxy ratings included functional impairment, presence of neuropsychiatric symptoms, cognitive impairment, and caregiver burden.

CONCLUSION

In evaluating QOL in dementia, self- and proxy reports may complement each other to ensure that all perspectives are addressed.

Persons with dementia and informal caregivers prioritizing care: A mixed-methods study

INTRODUCTION

More persons with dementia are residing in the community as many countries shift from residential care to home and community care. Although there are many forms of care and support available to avoid crisis situations and prolong community living, it remains unclear how these are valued by community-dwelling persons with dementia and their informal caregivers. Understanding perspectives of persons with dementia and informal caregivers on care characteristics is a vital step in valuing care services. This study aims to prioritize care characteristics for community-dwelling persons with dementia and informal caregivers with the use of an innovative mixed-methods approach.

METHODS

Six mixed focus groups were conducted in The Netherlands with persons with dementia (n = 23) and informal caregivers (n = 20), including a quantitative ranking exercise that prioritized seven care and support characteristics from "most important" to "least important," followed by a group discussion about the prioritization. Audio recordings were transcribed and analyzed using thematic analysis.

RESULTS

The ranking exercise and discussion showed that persons with dementia favored in-home care, help with daily activities, and social activities, whereas informal caregivers favored social activities, information about dementia, navigating the health care system, and emotional support.

DISCUSSION

Persons with dementia prioritized day-to-day activities, whereas informal caregivers preferred assistance with organizing care and coping with caregiving. This study created a method to capture the care preferences of persons with dementia and informal caregivers.

Unmet needs for assistance related to subjective cognitive decline among community-dwelling middle-aged and older adults in the US: prevalence and impact on health-related quality of life

OBJECTIVES

To estimate the prevalence of unmet needs for assistance among middle-aged and older adults with subjective cognitive decline (SCD) in the US and to evaluate whether unmet needs were associated with health-related quality of life (HRQOL).

DESIGN

Cross-sectional.

SETTING

US - 50 states, District of Columbia, and Puerto Rico.

PARTICIPANTS

Community-dwelling adults aged 45 years and older who completed the Cognitive Decline module on the 2015--2018 Behavioral Risk Factor Surveillance System reported experiencing SCD and always, usually, or sometimes needed assistance with day-to-day activities because of SCD (n = 6,568).

MEASUREMENTS

We defined SCD as confusion or memory loss that was happening more often or getting worse over the past 12 months. Respondents with SCD were considered to have an unmet need for assistance if they sometimes, rarely, or never got the help they needed with day-to-day activities. We measured three domains of HRQOL: (1) mental (frequent mental distress, ≥14 days of poor mental health in the past 30 days), (2) physical (frequent physical distress, ≥14 days of poor physical health in the past 30 days), and (3) social (SCD always, usually, or sometimes interfered with the ability to work, volunteer, or engage in social activities outside the home). We used log-binomial regression models to estimate prevalence ratios (PRs). All estimates were weighted.

RESULTS

In total, 40.2% of people who needed SCD-related assistance reported an unmet need. Among respondents without depression, an unmet need was associated with a higher prevalence of frequent mental distress (PR = 1.55, 95% CI: 1.12-2.13, p = 0.007). Frequent physical distress and social limitations did not differ between people with met and unmet needs.

CONCLUSIONS

Middle-aged and older adults with SCD-related needs for assistance frequently did not have those needs met, which could negatively impact their mental health. Interventions to identify and meet the unmet needs among people with SCD may improve HRQOL.

What should be measured to assess the quality of community-based palliative care? Results from a collaborative expert workshop

OBJECTIVES

The need for palliative care (PC) will continue to increase in Canada with population aging. Many older adults prefer to "age in place" and receive care in their own homes. Currently, there is a lack of standardized quality indicators (QIs) for PC delivered in the community in Canada.

METHODS

A one-day workshop collected expert opinions on what should be measured to capture quality PC. Three brainstorming sessions were focused on addressing the following questions: (1) what is important to measure to support quality PC, regardless of setting? (2) Of the identified measures, are any of special importance to care provided in the home? (3) What are the challenges, barriers, and opportunities for creating these measures? The National Consensus Project (NCP) for Quality Palliative Care framework was used as a guide to group together important comments into key themes.

RESULTS

The experts identified four themes that are important for measuring quality, regardless of care setting, including access to care in the community by a multidisciplinary team, care for the individual with PC needs, support for the informal caregiver (e.g., family, friends), and symptom management for individuals with PC needs. Two additional themes were of special importance to measuring quality PC in the home, including spiritual care for individuals with PC needs and home as the preferred place of death. The challenges, barriers, and potential opportunities to these quality issues were also discussed.

SIGNIFICANCE OF RESULTS

PC experts, through this collaborative process, made a substantial contribution to the creation of a standardized set of QIs for community-based PC. Having a standardized set of QIs will enable health care professionals and decision makers to target areas for improvement, implement interventions to improve the quality of care, and ultimately, optimize the health and well-being of individuals with a serious illness.

Physical Activity in Hospitalized Persons With Dementia: Feasibility and Validity of the MotionWatch 8

Persons with dementia are at high risk for hospital-acquired disability, associated with low physical activity during hospitalizations. To determine the effectiveness of efforts to increase physical activity, a valid and reliable measurement approach is required. Data from an ongoing cluster randomized clinical trial examined the feasibility and validity of the MotionWatch 8 (MW8) triaxial actigraphy device. The sample included 321 participants of which 259 (81%) were willing to wear the MW8 for 24 hr. Regression analysis revealed that time in low activity, β = 0.17, t(255) = 2.9, p = .004, and time in moderate activity, β = 0.14, t(255) = 2.4, p = .017, measured by the MW8, were associated with participants' physical function. Engagement in moderate physical activity was associated with return to baseline function at discharge (Wald χ2 = 4.10, df = 1, p = .043). The study provides preliminary support for the feasibility and validity of the MW8 in hospitalized persons with dementia.

Association of Progressive Supranuclear Palsy Rating Scale with Progressive Supranuclear Palsy Quality of Life Scale

INTRODUCTION

There is growing interest in using patient-reported outcomes as end points in clinical trials, such as the progressive supranuclear palsy quality of life (PSP-QoL) scale. However, this tool has not been widely validated and its correlation with validated motor scales has not been explored. To evaluate the potential utility of using PSP-QoL as an outcome, it is important to examine its relationship with a standard scale used to evaluate neurologic parameters, such as the PSP Rating Scale.

METHODS

PSP-QoL and PSP Rating Scale scores were gathered from 60 clinically diagnosed PSP patients, including patients with Richardson syndrome PSP (PSP-RS, n = 43) and those with non-RS PSP variants (n = 17). Linear regression analysis adjusted for age, sex, and disease duration was used to evaluate the cross-sectional relationship between the total and subscale scores of the 2 instruments.

RESULTS

Among 60 PSP patients, there was a significant correlation between total PSP-QoL and PSP Rating Scale scores. The physical and mentation subscales of each instrument also demonstrated significant correlations. Comparisons among PSP subtypes indicated that worsening PSP-QoL Total and Physical subscale scores correlated with worsening PSP Rating Scale gait subscale scores more strongly for the non-RS PSP variants than for PSP-RS.

DISCUSSION

There is a significant association between the total scores and many of the subscale scores of the PSP-QoL and the PSP Rating Scale. Additionally, the relationship between these measures may differ for PSP-RS and non-RS variants. These findings suggest that the PSP-QoL may be useful in clinical trials as a patient-reported outcome measure. Large prospective multicenter studies utilizing the PSP-QoL are necessary to examine its relationship to disease evolution and changes in the PSP Rating Scale.

Health-related physical indicators and self-rated quality of life in older adults with neurocognitive disorder

PURPOSE

This study aimed to identify the association between health-related physical indicators-sarcopenia-related factors, physical fitness, independence in activities of daily living (ADL) and habitual physical activity-and self-rated quality of life (QoL) in people with neurocognitive disorder (NCD).

METHODS

This cross-sectional study included 115 participants (78.22 ± 7.48 years; 74.8% female) clinically diagnosed with NCD. Self-rated QoL was evaluated using The Quality of Life-Alzheimer's Disease (QoL-AD). Dual energy X-ray Absorptiometry, handgrip strength, Short Physical Performance Battery, and the 6-m Walk test were used to assess sarcopenia-related factors. Senior Fitness Test and One Leg Balance test, Barthel Index, Baecke Modified Habitual Physical Activity Questionnaire were used to determine physical fitness, independence in ADL and physical activity, respectively. Regressions analyses were performed to examine associations between these variables and QoL-AD.

RESULTS

Data from univariable linear regression analysis revealed that self-rated QoL was associated with sarcopenia-related factors (lower body function, handgrip strength, gait speed, and appendicular skeletal muscle mass index-ASMI), physical fitness (upper-and-lower-body strength, agility/dynamic balance, cardiorespiratory fitness and body mass index), habitual physical activity and independence in ADL. Results from multivariable regression analysis showed that ASMI (B = 1.846, 95% CI 0.165-3.527, p = 0.032) and lower body function (B = 0.756, 95% CI 0.269-1.242, p = 0.003) were positively associated with self-rated QoL. These variables explained 20.1% of the variability seen in self-rated QoL, controlling for age, sex, marital status and education.

CONCLUSION

Sarcopenia-related factors, namely lower body function and ASMI, should be acknowledged in future research studies as critical health-related indicators associated with QoL in people with NCD.

TRIAL REGISTRATION

ClinicalTrials.gov-identifier number NCT04095962.

Racial/Ethnic Differences in Health-Related Quality of Life in Persons With and Without Dementia

BACKGROUND/OBJECTIVES

Given the lack of effective pharmacologic strategies to prevent, slow, or reverse dementia progression, maximizing quality of life (QOL) is a major priority for persons living with dementia. Despite well-documented racial/ethnic disparities in dementia incidence and prevalence, it is unknown whether there are racial/ethnic disparities in QOL among persons with dementia. The objective of this study was to determine if there are racial/ethnic differences in poor health-related quality of life (HRQOL) among persons with and without dementia in a nationally-representative cohort.

DESIGN

Repeated measures cross-sectional analysis of a prospective cohort study.

SETTING

United States nationally-representative National Health and Aging Trends Study (2011-2018).

PARTICIPANTS

Non-nursing home-dwelling Black, Latino, and white adults age 65+ (n = 10,886).

MEASUREMENTS

We estimated racial/ethnic differences in five dichotomous indicators of poor HRQOL (depressive and anxiety symptoms, self-rated health, pain, and physical functional limitations), stratified by dementia status (probable, possible, none). We used generalized estimating equations to estimate prevalence ratios (PRs) and differences, and marginal standardization to estimate prevalence.

RESULTS

Generally, Blacks and Latinos reported higher prevalence of poor HRQOL compared with whites. The largest differences were observed for self-rated health, and Latino-white differences were slightly larger compared to Black-white differences. PRs were larger among those with no dementia. For example, the Black versus white PRs for poor self-rated health were 1.93 (95% confidence interval (CI) = 1.82-2.04) among the no dementia group and 1.21 (95% CI = 1.12-1.31) among the probable dementia group; Latino versus white PRs for these comparisons were 2.39 (2.21-2.59) and 1.48 (1.35-1.62), respectively. Prevalence differences also showed racial/ethnic differences, but these were similar across dementia statuses.

CONCLUSIONS

We observed racial/ethnic disparities in poor HRQOL, showing greater unmet clinical needs among Black and Latino versus white older adults. Relative disparities were smaller in those with dementia, but absolute magnitudes of disparities were similar by dementia status.

Profiles of Met and Unmet Needs in People with Dementia According to Caregivers' Perspective: Results from a European Multicenter Study

OBJECTIVES

This exploratory study aimed at investigating profiles of care needs in people with mild to moderate dementia and examined variables associated with these profiles.

DESIGN

A longitudinal international cohort study.

SETTING AND PARTICIPANTS

The baseline data of 447 community-dwelling dyads of people with dementia and their caregivers from the Access to Timely Formal Care (Actifcare) Study were included for analysis.

METHODS

A latent class analysis was applied to identify profiles of needs, measured with the Camberwell Assessment of Need for the Elderly as rated by the caregiver. We examined sociodemographic (eg, relative stress scale) and clinical characteristics (eg, neuropsychiatric inventory) associated with these profiles.

RESULTS

Four distinct need profiles were identified through latent class analysis. These comprised a "no need" profile (41% of the sample), a "met psychological needs" profile (25%), a "met social needs" profile (19%), and an "unmet social needs" profile (15%). A larger impact of caregiving on the caregiver's life as indicated by a higher relative stress scale score was associated with the "unmet social needs" profile.

CONCLUSIONS AND IMPLICATIONS

In this large European sample, there was a subgroup of persons with dementia with high "unmet social needs" whose caregivers simultaneously perceived high stress in their caregiving tasks. Identification of these profiles may help provision of appropriate support for these people.

A comparison of self and proxy quality of life ratings for people with dementia and their carers: a European prospective cohort study

Objectives: To identify correlates of self-rated and proxy-rated quality of life (QoL) in people with dementia on (i) a dementia-specific and (ii) a capability-wellbeing QoL measure at baseline and 12-month follow-up, and to consider such factors in the context of QoL intervention development.Method: Prospective clinical and demographic data were collected from 451 community-dwelling dyads (mild-moderate dementia) across eight European countries. QoL was measured using the QOL-AD and the ICECAP-O. Multivariate modelling identified correlates of self- and proxy-rated QoL at baseline and at 12-month follow-up.Results: Carer's proxy-ratings of QoL were significantly lower than self-ratings at all time-points for both measures. Proxy-ratings declined over time, but self-ratings remained stable. Baseline predictors of greater self-rated QoL were education, and greater functional ability and relationship quality. Greater proxy-rated QoL was associated with education and greater functional ability, relationship quality, carer social support and carer QoL, lower carer anxiety/depression and less severe neuropsychiatric symptoms in people with dementia. At follow-up, greater self-rated QoL was predicted by greater functional ability, relationship quality, carer social support and having a spousal carer. Greater proxy-rated QoL at follow-up was associated with the same factors as at baseline; however, the dyad living together was an additional predictive factor.Conclusion: Both proxy-ratings and self-ratings of QoL should be interpreted with caution and in the context of each individual caregiving relationship. Different functional, psychosocial, relational and contextual factors influence self- and proxy-ratings, and both sets of factors should be considered in the context of QoL intervention development for the dyad.

Unmet needs in community-living persons with dementia are common, often non-medical and related to patient and caregiver characteristics

OBJECTIVE

Understanding which characteristics of persons with dementia (PWD) and their caregivers are associated with unmet needs can inform strategies to address those needs. Our purpose was to determine the percentage of PWD having unmet needs and significant correlates of unmet needs in PWD.

DESIGN

Cross-sectional data were analyzed using bivariate and hierarchical multiple linear regression analyses.

SETTING

Participants lived in the greater Baltimore, Maryland and Washington DC suburban area.

PARTICIPANTS

A sample of 646 community-living PWD and their informal caregivers participated in an in-home assessment of dementia-related needs.

MEASUREMENTS

Unmet needs were identified using the Johns Hopkins Dementia Care Needs Assessment. Correlates of unmet needs were determined using demographic, socioeconomic, clinical, functional and quality of life characteristics of the PWD and their caregivers.

RESULTS

PWD had a mean of 10.6 (±4.8) unmet needs out of 43 items (24.8%). Unmet needs were most common in Home/Personal Safety (97.4%), General Health Care (83.1%), and Daily Activities (73.2%) domains. Higher unmet needs were significantly related to non-white race, lower education, higher cognitive function, more neuropsychiatric symptoms, lower quality of life in PWD, and having caregivers with lower education or who spent fewer hours/week with the PWD.

CONCLUSIONS

Unmet needs are common in community-living PWD, and most are non-medical. Home-based dementia care can identify and address PWD's unmet needs by focusing on care recipients and caregivers to enable PWD to remain safely at home.

Supporting self-care of long-term conditions in people with dementia: A systematic review

BACKGROUND

Long-term conditions are common in people living with dementia; their self-management is an important determinant of wellbeing. Family carers often support or substitute self-care activities, and act as proxies for self-management, as dementia progresses.

OBJECTIVES

To conduct the first systematic review of how management of long-term conditions in people with dementia is best enabled and supported, including factors that facilitate or inhibit self-management and management by a proxy.

DESIGN

Systematic review.

DATA SOURCES

We systematically searched MEDLINE, PsychINFO, Embase and Allied and Complementary Medicine databases up to November 2018.

REVIEW METHODS

We identified the long-term conditions most prevalent in people with dementia that require an element of self-management. We then developed our inclusion criteria to identify qualitative and quantitative studies describing the self-management (or self-management assisted by family carers) of long-term conditions in people with dementia. Two authors independently rated study validity using a standardised checklist. We synthesised qualitative and quantitative findings using a data driven convergent synthesis approach.

RESULTS

We included 12 articles meeting predetermined inclusion criteria: seven qualitative, two case studies, two quantitative and one mixed methods study. We identified four main themes across these studies: (1) dementia symptoms impeding treatment regimens (forgetfulness, decreased understanding, ability to communicate symptoms and behavioural and psychological symptoms); (2) adapting routines to be simpler, (using memory aids and accommodating physical limitations); (3) negotiating self-management support (carer availability and knowledge; balancing needs for safety and empowerment); and (4) interface with professionals, (Routine simplification, condition specific education, and acknowledging carer role).

CONCLUSIONS

People living with dementia can be supported to manage their own health for as long as possible, through simplifying routines and reminding, but where this can no longer be negotiated, carers take over responsibility for self-management, often due to safety concerns. Empowerment of people with dementia to remain involved in their care reduces the loss experienced by this transition. Communication and partnership between clinicians and carers is critical when supporting people living with a long-term condition and dementia. Care planning for people living with dementia and a long-term condition should include explicit discussion of how these partnerships will work and guidance on strategies carers can use to support people to self-manage long-term conditions.

Before Hospice: Symptom Burden, Dementia, and Social Participation in the Last Year of Life

Background: Little is known about clinical symptom burden, dementia, and social isolation in the last year of life among older adults. Objective: To describe and contrast the type and severity of symptom burden for older decedents with and without dementia, and whether specific symptoms and presence of dementia are associated with limitations in social participation in the last year of life. Design: Cross-sectional logistic regression analysis of a population-based study. Setting/Subjects: A total of 1270 community-dwelling adults of age ≥65 years in the United States participated in the 2011 National Health and Aging Trends Study and died by 2015. Measurements: Dementia status, 13 clinical symptoms, and limitations in 6 social activities were drawn from the interview preceding death. Severity of sensory, physical, and psychiatric symptom burden was examined in tertiles. Results: Decedents with dementia (37.3%) had higher prevalence of all symptoms (p's < 0.05), except insomnia and breathing problems. Dementia was associated with greater likelihood of high versus low burden of sensory (odds ratio [OR] 4.52 [95% confidence interval {CI} 3.08-6.63]), physical (OR 3.49 [95% CI 2.48-4.91]), and psychiatric (OR 2.80 [95% CI 1.98-3.95]) symptoms. Dementia and physical symptoms (problems with speaking, leg strength/movement, and balance) were independently associated with limitations in at least three social activities (p's < 0.05 for adjusted ORs). Conclusion: Symptom burden is higher in patients with dementia. Dementia and physical symptoms are associated with social activity limitations. Older patients with dementia or physical symptoms may benefit from earlier emphasis on palliative care and quality of life.

The evidence for services to avoid or delay residential aged care admission: a systematic review

BACKGROUND

Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care.

METHOD

Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia).

RESULTS

Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults' ability to remain living at home (risk difference - 0.02; 95% CI -0.03, - 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001).

CONCLUSIONS

Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes.

TRIAL REGISTRATION

PROSPERO Registration CRD42016050086 .

The relationship between perceived functional difficulties and the ability to live well with mild-to-moderate dementia: Findings from the IDEAL programme

OBJECTIVES

The objectives of the study are to investigate how different levels of functional ability relate to quality of life, well-being, and satisfaction with life, conceptualised as reflecting capability to "live well" in people with dementia.

METHODS/DESIGN

Participants were 1496 people with mild-to-moderate dementia and 1188 informants who completed baseline assessments in the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study. Total self-rated and informant-rated scores on the Functional Activities Questionnaire were split into six ability levels to monitor how poorer functioning impacts the ability to live well. We also investigated the potential influence of sociodemographic and diagnostic variables, depression, cognition, and carer stress.

RESULTS

Multivariate multiple regression models found that people with dementia who had the greatest functional impairment according to self-ratings and informant ratings had poorer living well scores than those with the least functional impairment. Sociodemographic and diagnostic factors and cognition had little impact on effect sizes. For self-ratings, depression attenuated the relationship between functional ability and living well, whereas carer stress attenuated informant ratings.

CONCLUSIONS

People with dementia with the least functional impairments had greater capability to live well than those with the most functional impairment. Even subtle perceived difficulties in functional ability had a detrimental effect on the ability of people with dementia to live well. Depression in people with dementia and carer stress in informants influenced these associations, and therefore, these factors should be routinely included in future research studies and clinical assessments.

Quality of Life with Late-Stage Dementia: Exploring Opportunities to Intervene

BACKGROUND/OBJECTIVES

In late-stage dementia, families often prioritize quality of life (QoL) and comfort, yet little research examines factors impacting QoL. We sought to (1) describe temporal trends in QoL in late-stage dementia, and (2) explore associations between patient characteristics, care interventions, and QoL.

DESIGN

Secondary analysis of data from the Goals of Care clinical trial.

SETTING

Twenty-two nursing homes (NHs) in North Carolina.

PARTICIPANTS

Family decision makers for residents with late-stage dementia.

MEASUREMENTS

Family-reported QoL at baseline and at 9 months using the Alzheimer's Disease-Related Quality of Life Instrument (ADRQL) with five subscales scored 0 to 100 (higher scores indicate better quality). Families reported demographics, primary goal of care, and described their perceptions of residents' QoL. Chart reviews provided data on hospital transfers, treatment plans, and hospice enrollment. We ran mixed effects models of hypothesized variables and change in ADRQL over time.

RESULTS

The study sample was 241 dyads of residents with late-stage dementia and family decision makers. Family-reported ADRQL scores reflected moderately good QoL at baseline and at 9 months (69.1 vs 66.9; p = .106). Subscales for Awareness of Self (62.8; Global Deterioration Scale [GDS] = 5; 30.5; GDS = 7; p > .01) and Enjoyment of Activities (53.4; GDS = 5; 39.4; GDS = 7; p > .01) were lower in later stage disease. Qualitatively, family members associated better QoL for dementia with (1) activities, (2) opportunities to leave NH, (3) NH-structured activities, (4) attentiveness in NH, and (5) passive interaction. ADRQL at 9 months was associated with later dementia stage and referral to hospice (p < .01). Age (p = .004) and hospice enrollment were significantly associated with a larger decrease in ADRQL over 9 months (p = .019). A primary goal of comfort was associated with a larger increase in ADRQL (p = .022).

CONCLUSION

Families judge QoL to be moderately good in late-stage dementia. They perceive activities, opportunities to leave the NH, and quality of interpersonal care as ways to improve dementia-specific QoL.

Synthesis of the Literature: Variables Influencing Caregiver Use or Nonuse of Supportive Services

Two out of three caregivers (CGs) of persons with dementia (PWD) living in the community do not use supportive services or resources, and three out of four underutilize available support. These findings are troubling because CGs report many unmet needs in providing support to PWD. What predisposing, enabling, and need variables influence CGs to use or not use support services are poorly understood. This article reviews the literature on CG of PWD to find characteristic variables that are related to CG's decisions to use or not use support services. Instruments used in research studies were named to determine recommendations for future studies. The article organizes the variables following Anderson's model of predisposing, enabling, and need characteristics. It also supports future research to examine CG use or nonuse of resources that could inform practice, funding of programs, and policy.

Apolipoprotein E and affective symptoms in mild cognitive impairment and Alzheimer's disease dementia: A systematic review and meta-analysis

OBJECTIVE

APOE status has been associated to affective symptoms in cognitively impaired subjects, with conflicting results.

METHODS

Databases CINAHL, Embase, PsychINFO and PubMed were searched for studies evaluating APOE genotype with affective symptoms in MCI and AD dementia. Symptoms were meta-analyzed separately and possible sources of heterogeneity were examined.

RESULTS

Fifty-three abstracts fulfilled the eligibility criteria. No association was found between the individual symptoms and APOE ε4 carriership or zygosity. For depression and anxiety, only pooled unadjusted estimates showed positive associations with between-study heterogeneity, which could be explained by variation in study design, setting and way of symptom assessment.

CONCLUSIONS

There is no evidence that APOE ε4 carriership or zygosity is associated with the presence of depression, anxiety, apathy, agitation, irritability or sleep disturbances in cognitively impaired subjects. Future research should shift its focus from this single polymorphism to a more integrated view of other biological factors.

Antidepressants for treating depression in dementia

BACKGROUND

The use of antidepressants in dementia accompanied by depressive symptoms is widespread, but their clinical efficacy is uncertain. This review updates an earlier version, first published in 2002.

OBJECTIVES

To determine the efficacy and safety of any type of antidepressant for patients who have been diagnosed as having dementia of any type and depression as defined by recognised criteria.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 16 August 2017. ALOIS contains information on trials retrieved from databases and from a number of trial registers and grey literature sources.

SELECTION CRITERIA

We included all relevant double-blind, randomised trials comparing any antidepressant drug with placebo, for patients diagnosed as having dementia and depression.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies for inclusion and extracted data independently. We assessed risk of bias in the included studies using the Cochrane 'Risk of bias' tool. Where clinically appropriate, we pooled data for treatment periods up to three months and from three to nine months. We used GRADE methods to assess the overall quality of the evidence.

MAIN RESULTS

We included ten studies with a total of 1592 patients. Eight included studies reported sufficiently detailed results to enter into analyses related to antidepressant efficacy. We split one study which included two different antidepressants and therefore had nine groups of patients treated with antidepressants compared with nine groups receiving placebo treatment. Information needed to make 'Risk of bias' judgements was often missing.We found high-quality evidence of little or no difference in scores on depression symptom rating scales between the antidepressant and placebo treated groups after 6 to 13 weeks (standardised mean difference (SMD) -0.10, 95% confidence interval (CI) -0.26 to 0.06; 614 participants; 8 studies). There was probably also little or no difference between groups after six to nine months (mean difference (MD) 0.59 point, 95% CI -1.12 to 2.3, 357 participants; 2 studies; moderate-quality evidence). The evidence on response rates at 12 weeks was of low quality, and imprecision in the result meant we were uncertain of any effect of antidepressants (antidepressant: 49.1%, placebo: 37.7%; odds ratio (OR) 1.71, 95% CI 0.80 to 3.67; 116 participants; 3 studies). However, the remission rate was probably higher in the antidepressant group than the placebo group (antidepressant: 40%, placebo: 21.7%; OR 2.57, 95% CI 1.44 to 4.59; 240 participants; 4 studies; moderate-quality evidence). The largest of these studies continued for another 12 weeks, but because of imprecision of the result we could not be sure of any effect of antidepressants on remission rates after 24 weeks. There was evidence of no effect of antidepressants on performance of activities of daily living at weeks 6 to 13 (SMD -0.05, 95% CI -0.36 to 0.25; 173 participants; 4 studies; high-quality evidence) and probably also little or no effect on cognition (MD 0.33 point on the Mini-Mental State Examination, 95% CI -1.31 to 1.96; 194 participants; 6 studies; moderate-quality evidence).Participants on antidepressants were probably more likely to drop out of treatment than those on placebo over 6 to 13 weeks (OR 1.51, 95% CI 1.07 to 2.14; 836 participants; 9 studies). The meta-analysis of the number of participants suffering at least one adverse event showed a significant difference in favour of placebo (antidepressant: 49.2%, placebo: 38.4%; OR 1.55, 95% CI 1.21 to 1.98, 1073 participants; 3 studies), as did the analyses for participants suffering one event of dry mouth (antidepressant: 19.6%, placebo: 13.3%; OR 1.80, 95% CI 1.23 to 2.63, 1044 participants; 5 studies), and one event of dizziness (antidepressant: 19.2%, placebo: 12.5%; OR 2.00, 95% CI 1.34 to 2.98, 1044 participants; 5 studies). Heterogeneity in the way adverse events were reported in studies presented a major difficulty for meta-analysis, but there was some evidence that antidepressant treatment causes more adverse effects than placebo treatment does.

AUTHORS' CONCLUSIONS

The available evidence is of variable quality and does not provide strong support for the efficacy of antidepressants for treating depression in dementia, especially beyond 12 weeks. On the only measure of efficacy for which we had high-quality evidence (depression rating scale scores), antidepressants showed little or no effect. The evidence on remission rates favoured antidepressants but was of moderate quality, so future research may find a different result. There was insufficient evidence to draw conclusions about individual antidepressant drugs or about subtypes of dementia or depression. There is some evidence that antidepressant treatment may cause adverse events.

MIND at Home-Streamlined: Study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers

BACKGROUND

Dementia is associated with high health care costs, premature long-term care (LTC) placement, medical complications, reduced quality of life, and caregiver burden. Most health care providers and systems are not yet organized or equipped to provide comprehensive long-term care management for dementia, although a range of effective symptoms and supportive care approaches exist. The Maximizing Independence at Home-Streamlined (MIND-S) is a promising model of home-based dementia care coordination designed to efficiently improve person-centered outcomes, while reducing care costs. This report describes the rationale and design of an NIA-funded randomized controlled trial to test the impact of MIND-S on time to LTC placement, person with dementia outcomes (unmet needs, behavior, quality of life), family caregiver outcomes (unmet needs, burden), and cost offset at 18 (primary end point) and 24 months, compared to an augmented usual care group.

METHODS

This is a 24-month, parallel group, randomized trial evaluating MIND-S in a cohort of 304 community-living persons with dementia and their family caregivers in Maryland. MIND-S dyads receive 18 months of care coordination by an interdisciplinary team comprised of trained non-clinical community workers (e.g. Memory Care Coordinators), a registered nurse, and a geriatric psychiatrist. Intervention components include in-home dementia-related needs assessments; individualized care planning; implementation of standardized evidence-based care strategy protocols; and ongoing monitoring and reassessment. Outcomes are assessed by blinded evaluators at baseline, 4.5, 9, 13.5, 18, and 24 months.

DISCUSSION

Trial results will provide rigorous data to inform innovations in effective system-level approaches to dementia care.

Quality of life in small-scaled homelike nursing homes: an 8-month controlled trial

Background

Quality of life is a clinical highly relevant outcome for residents with dementia. The question arises whether small scaled homelike facilities are associated with better quality of life than regular larger scale nursing homes do.

Methods

A sample of 145 residents living in a large scale care facility were followed over 8 months. Half of the sample (N = 77) subsequently moved to a small scaled facility. Quality of life aspects were measured with the QUALIDEM and GIP before and after relocation.

Results

We found a significant Group x Time interaction on measures of anxiety meaning that residents who moved to small scale units became less anxious than residents who stayed on the regular care large-scale units. No significant differences were found on other aspects of quality of life.

Conclusions

This study demonstrates that residents who move from a large scale facility to a small scale environment can improve an aspect of quality of life by showing a reduction in anxiety.

Trial registration

Current Controlled Trials ISRCTN11151241. registration date: 21–06-2017. Retrospectively registered.

A Computer-Assisted Personal Interview App in Research Electronic Data Capture for Administering Time Trade-off Surveys (REDCap): Development and Pretest

Background

The time trade-off (TTO) task is a method of eliciting health utility scores, which range from 0 (equivalent to death) to 1 (equivalent to perfect health). These scores numerically represent a person’s health-related quality of life. Software apps exist to administer the TTO task; however, most of these apps are poorly documented and unavailable to researchers.

Objective

To fill the void, we developed an online app to administer the TTO task for a research study that is examining general public proxy health-related quality of life estimates for persons with Alzheimer’s disease. This manuscript describes the development and pretest of the app.

Methods

We used Research Electronic Data Capture (REDCap) to build the TTO app. The app’s modular structure and REDCap’s object-oriented environment facilitated development. After the TTO app was built, we recruited a purposive sample of 11 members of the general public to pretest its functionality and ease of use.

Results

Feedback from the pretest group was positive. Minor modifications included clarity enhancements, such as rearranging some paragraph text into bullet points, labeling the app to delineate different question sections, and revising or deleting text. We also added a research question to enable the identification of respondents who know someone with Alzheimer’s disease.

Conclusions

We developed an online app to administer the TTO task. Other researchers may access and customize the app for their own research purposes.

Quality of Life in relation to neuropsychiatric symptoms in Alzheimer's disease: 5-year prospective ALSOVA cohort study

OBJECTIVE

To examine the association between neuropsychiatric symptoms (NPS) with self- and caregiver-rated Quality of Life (QoL) for patients with Alzheimer's disease (AD) during a 5-year follow-up.

METHODS

The ALSOVA 5-year follow-up study included, at baseline, 236 patients with either very mild (Clinical Dementia Rating Scale (CDR) 0.5), or mild (CDR 1) AD, together with their caregivers from three Finnish hospital districts. QoL was evaluated using patient self-reported, and caregiver-rated, QoL in AD (QoL-AD) scores. NPS were assessed using the Neuropsychiatric Inventory (NPI), and AD severity was evaluated using the CDR, with cognition tested by the mini-mental state examination. The performance of daily activities was assessed using the Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory.

RESULTS

Over the 5-year follow-up period, patient self-reported QoL-AD scores did not change significantly (p = 0.245), despite increases in their NPS. However, caregiver-rated patient QoL-AD scores declined significantly (p ≤ 0.001), as total NPI scores increased during follow-up. No NPS at baseline, and only apathy at follow-up, correlated significantly (p = 0.007) with patient self-rated QoL-AD scores. Caregiver-rated patient QoL-AD scores correlated significantly with most NPS, especially (p ≤ 0.001) apathy, agitation, anxiety, irritability, depression, and delusions at baseline, and delusions, hallucinations, apathy, appetite disturbances, and anxiety during follow-up.

CONCLUSIONS

Patient rated QoL-AD scores are an unreliable tool with which to evaluate the success of therapy for NPS. Instead, caregiver-rated scores for patients correlated well with NPI scores, and health care professionals in the clinic should preferentially use these. Copyright © 2017 John Wiley & Sons, Ltd.

Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol

INTRODUCTION

Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology.

METHODS

This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group.

DISCUSSION

The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.

How to explore the needs of informal caregivers of individuals with cognitive impairment in Alzheimer's disease or related diseases? A systematic review of quantitative and qualitative studies

BACKGROUND

This study aims to review the methodologies used to identify the needs, the existing needs assessment instruments and the main topics of needs explored among caregivers of patients with mild cognitive impairment to dementia.

METHODS

MEDLINE, PsycINFO, The Cochrane Library and Web of science were searched from January 1980 to January 2017. Research studies in English or French were eligible for inclusion if they fulfilled the following criteria: quantitative, qualitative and mixed method studies that used instrument, focus group or semi-structured interviews to assess the informal caregiver's needs in terms of information, coping skills, support and service.

RESULTS

Seventy studies (n = 39 quantitative studies, n = 25 qualitative studies and n = 6 mixed method studies) met the inclusion criteria and were included. Thirty-six quantitative instruments were identified but only one has been validated for the needs assessment of dementia caregivers: the Carer's Needs Assessment for Dementia (CNA-D). The main areas of needs explored in these instruments were: information, psychosocial, social, psychoeducational and other needs.

CONCLUSIONS

No instrument has been developed and validated to assess the needs of informal caregivers of patients with cognitive impairment, whatever the stage and the etiology of the disease. As the perceived needs of caregivers may evolve with the progression of the disease and the dementia transition, their needs should be regularly assessed.

Caregiving-related needs of family caregivers of older Singaporeans

OBJECTIVE

To describe the extent and correlates of caregiving-related needs among family caregivers of Singaporeans aged 75+ with ≥1 activity of daily living limitations (care-recipients).

METHODS

National survey data of 1181 care-recipient/caregiver dyads were used. Caregiver's report (yes/no) of 16 needs was assessed. Care-recipient and caregiver correlates of each need were determined through logistic regression analysis.

RESULTS

Caregiving-related needs were expressed by 42.3% caregivers. The most commonly reported need was keeping care-recipient safe at home (24.5%). Needs concerned with caring for care-recipients were more frequent than those concerned with the caregiver's own needs. The most frequent correlate was care-recipient's extent of mood impairment (associated with 13 needs).

CONCLUSION

Caregivers should not neglect themselves when engaging in care provision. Families and service providers should explore whether reported lack of needs reflects limited awareness and/or under-reporting.

Determinants of quality of life in young onset dementia - results from a European multicenter assessment

BACKGROUND

Promoting adaptation, improving well-being and maintaining an optimal quality of life (QOL) is an important aspect in dementia care. The purpose of this study was to identify determinants of QOL in young onset dementia, and to assess differences in QoL domains between people with Alzheimer's disease (AD) and frontotemporal dementia (FTD).

METHODS

In total 135 persons with AD and 58 persons with FTD were included from two prospective cohort studies. QOL was assessed with the proxy reported quality of life in Alzheimer's disease questionnaire (QoL-AD). Possible determinants were explored using multiple linear regression and included sociodemographic variables, diagnosis, dementia severity, disease awareness, neuropsychiatric symptoms, met and unmet needs and hours of personal and instrumental care. Differences between QOL domains in people with AD and FTD were calculated using Mann-Whitney U tests.

RESULTS

Lower QOL was associated with more depressive symptoms, lower disease awareness, and a higher amount of needs, both met and unmet. People with AD scored lower on the memory and higher on the friends' subscale. No differences were found for the other items.

CONCLUSION

This study demonstrates a unique set of determinants of QOL in AD and FTD. Interventions directed towards these specific factors may improve QOL.

Quality-of-life assessment in dementia: the use of DEMQOL and DEMQOL-Proxy total scores

PURPOSE

There is a need to determine whether health-related quality-of-life (HRQL) assessments in dementia capture what is important, to form a coherent basis for guiding research and clinical and policy decisions. This study investigated structural validity of HRQL assessments made using the DEMQOL system, with particular interest in studying domains that might be central to HRQL, and the external validity of these HRQL measurements.

METHODS

HRQL of people with dementia was evaluated by 868 self-reports (DEMQOL) and 909 proxy reports (DEMQOL-Proxy) at a community memory service. Exploratory and confirmatory factor analyses (EFA and CFA) were conducted using bifactor models to investigate domains that might be central to general HRQL. Reliability of the general and specific factors measured by the bifactor models was examined using omega (ω) and omega hierarchical (ω h) coefficients. Multiple-indicators multiple-causes models were used to explore the external validity of these HRQL measurements in terms of their associations with other clinical assessments.

RESULTS

Bifactor models showed adequate goodness of fit, supporting HRQL in dementia as a general construct that underlies a diverse range of health indicators. At the same time, additional factors were necessary to explain residual covariation of items within specific health domains identified from the literature. Based on these models, DEMQOL and DEMQOL-Proxy overall total scores showed excellent reliability (ω h > 0.8). After accounting for common variance due to a general factor, subscale scores were less reliable (ω h < 0.7) for informing on individual differences in specific HRQL domains. Depression was more strongly associated with general HRQL based on DEMQOL than on DEMQOL-Proxy (-0.55 vs -0.22). Cognitive impairment had no reliable association with general HRQL based on DEMQOL or DEMQOL-Proxy.

CONCLUSIONS

The tenability of a bifactor model of HRQL in dementia suggests that it is possible to retain theoretical focus on the assessment of a general phenomenon, while exploring variation in specific HRQL domains for insights on what may lie at the 'heart' of HRQL for people with dementia. These data suggest that DEMQOL and DEMQOL-Proxy total scores are likely to be accurate measures of individual differences in HRQL, but that subscale scores should not be used. No specific domain was solely responsible for general HRQL at dementia diagnosis. Better HRQL was moderately associated with less depressive symptoms, but this was less apparent based on informant reports. HRQL was not associated with severity of cognitive impairment.

Impact of neurocognitive deficits on patient-proxy agreement regarding health-related quality of life in low-grade glioma patients

PURPOSE

Clinical trials in glioma patients with neurocognitive deficits face challenges due to lacking or unreliable patient self-reports on their health-related quality of life (HRQOL). Patient-proxy data could help solve this issue. We determined whether patient-proxy concordance levels were affected by patients' neurocognitive functioning.

METHODS

Patient and patient-by-proxy HRQOL ratings were assessed via SF-36 and EORTC QLQ-BN20, respectively, in 246 patients. Data on neurocognitive functioning were collected on a subgroup of 195 patients. Patient-proxy agreement was measured using the Bland-Altman limit of agreement, the mean difference, the concordance correlation coefficient (CCC), and the percentage difference (PD, ±0, 5, or 10 points). We defined patients to be cognitively impaired (n = 66) or cognitively intact (n = 129) based on their neurocognitive performance.

RESULTS

Patients rated their physical function and general health to be better than their proxies did, while at the same time, patients reported more visual disorders, communication deficits, itchy skin, and problems with bladder control. The cognitively impaired subgroup reported poorer physical functioning, more visual disorders, headaches, itchy skin, and issues with bladder control. In the cognitively intact group, no statistical significant differences were observed between patients and proxies. Not surprisingly, Bland-Altman plots revealed a high agreement between the patient and patient-by-proxy rating in all HRQOL domains ranging from 95 to 99 %. The CCC was fairly high in all HRQOL domains (0.37-0.80), and the percentage of perfect agreement (PD ± 0) ranged from 8.5 to 76.8 %. In the cognitively impaired patients, the mean difference between patients and proxies was overall larger, and accordingly, agreement based on Bland-Altman plots was lower.

CONCLUSIONS

The level of agreement between patient and patient-by-proxy ratings of low-grade glioma patients' HRQOL is generally high. However, patient-proxy agreement is lower in patients with neurocognitive deficits than in patients without neurocognitive deficits.

Development of Clinical Vignettes to Describe Alzheimer's Disease Health States: A Qualitative Study

Aims

To develop clinical descriptions (vignettes) of life with Alzheimer’s disease (AD), we conducted focus groups of persons with AD (n = 14), family caregivers of persons with AD (n = 20), and clinicians who see persons with AD in their practices (n = 5).

Methods

Group participants read existing descriptions of AD and commented on the realism and comprehensibility of the descriptions. We used thematic framework analysis to code the comments into themes and develop three new vignettes to describe mild, moderate, and severe AD.

Results

Themes included the types of symptoms to mention in the new vignettes, plus the manner in which the vignettes should be written. Since the vignette descriptions were based on focus group participants’ first-hand knowledge of AD, the descriptions can be said to demonstrate content validity.

Conclusion

Members of the general public can read the vignettes and estimate their health-related quality-of-life (HRQoL) as if they had AD based on the vignette descriptions. This is especially important for economic evaluations of new AD medications, which require HRQoL to be assessed in a manner that persons with AD often find difficult to undertake. The vignettes will allow the general public to serve as a proxy and provide HRQoL estimates in place of persons with AD.

Dementia-specific quality of life instruments: a conceptual analysis

BACKGROUND

Over the past 20 years, many researchers have worked in developing various methods for measuring quality of life (QoL) of people with dementia. The aim of this review is to develop the conceptual frameworks of the dementia-specific QoL instruments, to identify their evolution over time and to provide elements of reflection on the QoL concept in dementia and its evaluation.

METHODS

An electronic search was conducted on PsycINFO and MEDLINE databases, from January 1985 to June 2015 using a combination of key words that include QoL, dementia, and review.

RESULTS

The analysis of the conceptual frameworks of the 18 selected dementia-specific QoL tools shows a great diversity in: (1) the QoL definitions (e.g. health-related QoL definitions, QoL definitions based on Lawton's work, or similar to this latter); (2) the theoretical QoL models (e.g. Lawton' work and modified Lawton, adaptation, personhood); (3) the domains and dimensions; (4) the way to construct the instrument (e.g. development based on literature, opinion of the experts), and (5) the items' formulation (e.g. use of criterion of intensity or frequency).

CONCLUSIONS

There are different conceptual frameworks in the dementia-specific QoL measures with improvements over time (e.g. inclusion of interesting concepts such as adaptation, taking into account the views of patients themselves). Each of the conceptual parameters (definitions, models, domains, and dimensions) is discussed to identify the scales that are conceptually the strongest. Through their review, recommendations for future instrument refinement and development are discussed and a new QoL definition is proposed.

Latent Classes of Neuropsychiatric Symptoms in NACC Controls and Conversion to Mild Cognitive Impairment or Dementia

BACKGROUND

A number of studies have linked neuropsychiatric symptoms to increase risk of dementia.

OBJECTIVE

To determine if risk of conversion to mild cognitive impairment or dementia among healthy controls varied as a function of their pattern of neuropsychiatric symptoms.

METHOD

We studied individuals in the National Alzheimer Coordinating Center dataset collected from 34 Alzheimer Disease Centers between 2005 and 2013. The analysis included 4,517 volunteers who were ≥60 years old, cognitively normal, and had complete Neuropsychiatric Inventory data at their baseline visit, and had at least one follow-up. We used latent class analysis to identify four classes based on patterns of NPI symptoms. We used a Cox proportional hazards model to determine if time to MCI or dementia varied by baseline latent class membership.

RESULTS

We identified four latent classes of neuropsychiatric symptoms: irritable, depressed, complex (depression, apathy, irritability, and nighttime behaviors) and asymptomatic. 873 participants converted to MCI or dementia. Hazard ratios for conversion by class were 1.76 (95% CI: 1.34, 2.33) for the irritable class, 3.20 (95% CI: 2.24, 4.58) for the complex class, and 1.90 (95% CI: 1.49, 2.43) for the depressed class, with the asymptomatic class as the reference.

CONCLUSIONS

Membership in all three symptomatic classes was associated with greater risk of conversion to MCI or dementia; the complex class had the greatest risk. Different patterns of neuropsychiatric symptoms may represent different underlying neuropathological pathways to dementia. Further work imaging and pathology research is necessary to determine if this is the case.

Factors influencing quality of life of elderly people with dementia and care implications: A systematic review

BACKGROUND

Identifying factors associated with Quality of Life (QoL) of elderly people with dementia could contribute to finding pathways to improve QoL for elderly people in dementia.

AIM

This paper systematically reviews all possible factors that influence QoL of elderly people with dementia, identifies how these factors are different by different stages of dementia and living settings, and explores how the influencing factors could be perceive differently by elderly people with dementia, family members, and caregivers.

METHOD

PubMed, PsycINFO, Web of Science and DelphiS searches from 2000 to 2015 and hand searches of publication lists, reference lists and citations were used to identify primary studies on 'quality of life' and 'dementia' elderly people.

RESULTS

The results suggest that there are a complex variety of factors influencing QoL of elderly people with dementia, and the factors cover demographic, physical, psychological, social, and religious aspects. And the factors influencing QoL of elderly people with dementia are different in different living settings (care institutions and communities) as well as different people's perspectives (elderly people with dementia, family members and care staff). Environmental factors and quality of care are important for elderly people in care institutions; while religious seem to only affect QoL of those living in communities. However, this review fails to comprehensively identify unique or common factors associated QoL in dementia across three stages. Further study should pay more attention to comparing factors associated with QoL in dementia across three stages of dementia.

Oral health-related quality of life in mild Alzheimer: patient versus caregiver perceptions

PURPOSE

To compare perceptions on oral health-related quality of life (OHRQoL) between Alzheimer disease (AD) patients and their caregivers by using the Geriatric Oral Health Assessment Index (GOHAI). Correlation between GOHAI and prostheses quality was also performed.

METHODS

GOHAI was applied to 16 AD elders and their caregivers. GOHAI index was compared to objective measures of AD patients' prostheses quality, rated by a researcher. Data were submitted to Wilcoxon signed rank and McNemar tests (α = 5%). Kappa correlations verified the concordance for GOHAI scores between AD patients and caregivers. Spearman's correlation was used to explore concordance between GOHAI scores and prostheses quality indices.

RESULTS

Total GOHAI scores from AD patients and caregivers were similar (P = 0.262). Overall Kappa was good (0.62). There were no correlations between GOHAI scores and prostheses quality.

CONCLUSION

AD patients assess and self-report their OHRQoL similarly to their main caregiver.

Can the general public use vignettes to discriminate between Alzheimer's disease health states?

BACKGROUND

Valid estimates of health-related quality-of-life (HRQoL) are often difficult to obtain from persons with Alzheimer's disease (AD) and family caregiver proxies. To help assess whether the general public can serve as an alternate source of proxy HRQoL estimates in AD, we examined whether the general public can use vignettes to discriminate between AD health states.

METHODS

We administered a telephone survey to randomly recruited participants from the general public who were aged 18 years or older. Interviewers read vignettes describing the mild, moderate, and severe AD health states to the participants, who answered the EQ-5D-5L and Quality of Life-Alzheimer's Disease (QoL-AD) scales as if they had AD based on the vignette descriptions. Participants also answered the EQ-5D-5L for their current health states. We converted EQ-5D-5L responses into health utility scores using Canadian preference weights. We employed the Wilcoxon signed rank test to examine whether mean health utility scores and mean QoL-AD scores differed between health states. We used Pearson's r to assess correlations between health utility and QoL-AD scores.

RESULTS

Forty-eight participants (median age = 53 years; 25 female) completed the telephone interview; health utility and QoL-AD scores decreased as AD severity increased (p <0.0001). Mean health utility scores were 0.65 (mild), 0.51 (moderate), and 0.25 (severe). Mean QoL-AD scores were 26.7 (mild), 23.0 (moderate), and 17.4 (severe). The correlations between health utility and QoL-AD scores were moderate to strong (r ≥ 0.62).

CONCLUSIONS

Using the vignettes, the general public provided HRQoL estimates that discriminated between the three AD health states. This finding suggests the general public may be a promising source of proxy HRQoL estimates in place of persons with AD.

Self-Rated and Caregiver-Rated Quality of Life in Alzheimer Disease with a Focus on Evolving Patient Ability to Respond to Questionnaires: 5-Year Prospective ALSOVA Cohort Study

OBJECTIVE

To examine and compare self-rated and caregiver-rated measures of quality of life (QoL) in relation to disease progression in patients with very mild or mild Alzheimer disease (AD) and at what disease stage patient's ability to respond to QoL questionnaires with or without assistance begins to diminish.

METHODS

236 patients with very mild or mild AD and their family caregivers from three Finnish hospital districts participated in this prospective, longitudinal study with 5 years of follow-up. Three patient-reported instruments were used to assess QoL (the generic 15D, the Quality of Life in Alzheimer Disease [QoL-AD] questionnaire, and a visual analogue scale) as well as one caregiver-rated assessment of patient QoL (QoL-AD). AD severity was evaluated with the Clinical Dementia Rating Scale - Sum of Boxes (CDR-SOB).

RESULTS

All self- and caregiver-rated QoL estimates correlated with AD severity. The self- and caregiver-rated QoL scores began to diverge even with very mild cognitive impairment after CDR-SOB reached 4, the value that corresponds with a Mini-Mental State Examination (MMSE) score of 25-30. Patients also began to need assistance in responding to questionnaires at very early stages of AD (CDR-SOB score: 4-6). Furthermore, their ability to respond to QoL questionnaires with or without assistance declined after CDR-SOB reached 11 points, a value that correlates with an early moderate stage of AD and MMSE score of 11-20.

CONCLUSIONS

AD patients' self-rated QoL ratings are much more insensitive to disease progression than caregiver ratings.