[Quality of life in mild cognitive impairment, patients with different stages of Alzheimer disease and healthy control subjects]

Toward the optimized assessment of clinical outcomes in studies of novel treatments for Alzheimer's disease

INTRODUCTION

Alzheimer's disease (AD) is characterized by a progressive decline in cognition and daily function, leading to a greater need for caregiver support. Clinical disease is segmented into a preclinical stage, mild cognitive impairment, and mild, moderate, and severe stages of Alzheimer's dementia. Although AD trials enroll participants at various stages of illness, treatment efficacy is often assessed using endpoints based on measures of outcomes that are held fixed across disease stages. We hypothesize that matching the primary outcomes measured in the endpoint hierarchy to the stage of disease targeted by the trial will increase the likelihood of detecting true treatment benefits.

AREAS COVERED

We discuss current approaches to assessing clinical outcomes in AD trials, followed by a consideration of how effect detection can be improved by linking the stage of AD to the endpoints that most likely reflect stage-specific disease progression.

EXPERT OPINION

Failing to account for stage-specific relevance and sensitivity of clinical outcomes may be one factor that contributes to trial failures in AD. Given the history of failure, experts have begun to scrutinize the relevance and sensitivity of outcomes as a potentially modifiable barrier to successful trials. To this end, we present a framework for refining trial endpoint selection and evaluation.

Association Between Cognition, Health Related Quality of Life, and Costs in a Population at Risk for Cognitive Decline

Background:

The association between health-related quality of life (HRQoL) and care costs in people at risk for cognitive decline is not well understood. Studying this association could reveal the potential benefits of increasing HRQoL and reducing care costs by improving cognition.

Objective:

In this exploratory data analysis we investigated the association between cognition, HRQoL utilities and costs in a well-functioning population at risk for cognitive decline.

Methods:

An exploratory data analysis was conducted using longitudinal 2-year data from the FINGER study (n = 1,120). A change score analysis was applied using HRQoL utilities and total medical care costs as outcome. HRQoL utilities were derived from the Short Form Health Survey-36 (SF-36). Total care costs comprised visits to a general practitioner, medical specialist, nurse, and days at hospital. Analyses were adjusted for activities of daily living (ADL) and depressive symptoms.

Results:

Although univariable analysis showed an association between cognition and HRQoL utilities, multivariable analysis showed no association between cognition, HRQoL utilities and total care costs. A one-unit increase in ADL limitations was associated with a -0.006 (p < 0.001) decrease in HRQoL utilities and a one-unit increase in depressive symptoms was associated with a -0.004 (p < 0.001) decrease in HRQoL utilities.

Conclusion:

The level of cognition in people at-risk for cognitive decline does not seem to be associated with HRQoL utilities. Future research should examine the level at which cognitive decline starts to affect HRQoL and care costs. Ideally, this would be done by means of cross-validation in populations with various stages of cognitive functioning and decline.

Determinants of Cross-Sectional and Longitudinal Health-Related Quality of Life in Memory Clinic Patients Without Dementia

OBJECTIVE

To identify determinants within 3 different domains (ie, somatic comorbidities, cognitive functioning, and neuropsychiatric symptoms [NPS]) of health-related quality of life (HRQoL) over time in memory clinic patients without dementia.

METHODS

This longitudinal multicenter cohort study with a 3-year observation period recruited 315 individuals (age: 69.8 ± 8.6, 64.4% males, Mini-Mental State Examination score 26.9 ± 2.6). A multivariable explanatory model was built using linear mixed effects models (forward selection per domain) to select determinants for self-perceived HRQoL over time, as measured by the EuroQoL-5D visual analogue scale (EQ VAS).

RESULTS

Mean HRQoL at study entry was 69.4 ± 15.6. The presence of agitation, appetite and eating abnormalities, and eyes/ears/nose (ie, sensory impairment) comorbidities were associated with a change in HRQoL over time. Agitation was most strongly associated with HRQoL over time.

CONCLUSIONS

The association of somatic comorbidities and NPS in memory clinic patients with course of HRQoL shows that these should receive more awareness, detection, and monitoring by clinicians.

Mild cognitive impairment and quality of life in the oldest old: a closer look

PURPOSE

Mild cognitive impairment (MCI) is a widespread phenomenon, especially affecting older individuals. We will analyze in how far MCI affects different facets of quality of life (QOL).

METHODS

We used a sample of 903 participants (110 with MCI) from the fifth follow-up of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe), a prospective longitudinal study, to analyze the effects of MCI on different facets of the WHOQOL-OLD. We controlled for age, gender, marital status, education, living situation, daily living skills, and the ability to walk, see, and hear.

RESULTS

Univariate analyses showed that individuals with MCI exhibited lower QOL with regard to the facets autonomy; past, present, and future activities; social participation; and intimacy, but less fears related to death and dying. No significant difference was shown with regard to the facet sensory abilities. In multivariate analyses controlling for age, gender, marital status, education, living situation, daily living skills, and the ability to walk, see and hear, MCI-status was significantly associated with QOL in the facet autonomy.

CONCLUSION

Effects of MCI go beyond cognition and significantly impact the lives of those affected. Further research and practice will benefit from utilizing specific facets of QOL rather than a total score.

Relationships Between Cognitive Complaints and Quality of Life in Older Adults With Mild Cognitive Impairment, Mild Alzheimer Disease Dementia, and Normal Cognition

PURPOSE

To examine in persons with varying degrees of cognitive impairment the relationship between self-reports of cognitive complaints and quality of life (QOL).

METHODS

Older adults (n=259) with normal cognition, mild cognitive impairment (MCI), and mild stage Alzheimer disease (AD) dementia completed tests of cognition and self-report questionnaires about QOL and 3 kinds of cognitive complaints: cognitive difficulties, distress from cognitive difficulties, and believing you had more memory problems than most people. Bivariate, multivariable, and multivariate regression analyses assessed relationships between domains of QOL and each cognitive complaint.

RESULTS

Bivariate and multivariable analyses controlling for severity of cognitive and functional impairment found that cognitive complaints were related to relatively lower quality of daily life (QOL-AD, Dementia Quality of Life Scale), greater depression (GDS), more anxiety (BAI), higher perceived stress (PSS), and lower general mental well-being (SF-12 MCS).

DISCUSSION

Cognitive complaints have robust associations with QOL. These findings have implications for AD prevention trials and management of clinical populations.

Evaluation of MESSAGE communication strategy combined with group reminiscence therapy on elders with mild cognitive impairment in long-term care facilities

OBJECTIVE

This study aims to evaluate combined effects of MESSAGE communication strategy and group reminiscence therapy (GRT) on elders with mild cognitive impairment (MCI) in long-term care facilities in Changchun, China.

METHODS

This study is a nonrandomized controlled trial. Subjects included 60 elders with MCI. Participants were divided into intervention (MESSAGE communication strategy combined with GRT) and control groups (without any intervention). Primary outcomes comprised cognitive function and quality of life of elderly people, as measured by the Beijing version of the Montreal Cognitive Assessment and the Chinese (mainland) version of Short-Form 36 Health Survey assessment.

RESULTS

We observed significant changes in cognitive function with mean difference of 1.962 after 12 weeks (P = .000; 95% confidence interval [CI] = 1.341, 2.582), delayed memory dimension of 1.115 (P = .003; 95% CI = 0.417, 1.813). The intervention group exhibited the following improvements: general health of 14.731 (P = .000; 95% CI = 8.511, 20.951), mental health of 21.038 (P = .000; 95% CI = 17.301, 24.776), role-emotional of 26.925 (P = .003; 95% CI = 10.317, 45.533), and vitality of 14.231 (P = .000; 95% CI = 10.084, 18.377).

CONCLUSIONS

Using a sample of Chinese elderly people with MCI and residing in long-term care facilities, we concluded that application of MESSAGE communication strategy combined with GRT resulted in improved cognitive function and quality of life.

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.

Health-Related Quality of Life in Patients with Subjective Cognitive Decline and Mild Cognitive Impairment and its Relation to Activities of Daily Living

BACKGROUND

Health related quality of life (HRQOL) is an important issue in the context of dementia care.

OBJECTIVES

The purpose of this study was to investigate HRQOL in patients with subjective cognitive decline (SCD) and mild cognitive impairment (MCI) and its relation to Activity of Daily Living (ADL).

METHODS

In this cross sectional study, four experimental groups (each n = 98), controls, SCD, naMCI and aMCI, were compared. For data collection, neuropsychological methods (NTBV) and psychological questionnaires (SF-36 and B-ADL) were used. Multivariate analysis of variance was calculated to detect differences in HRQOL between groups. Correlations between HRQOL and ADL were explored.

RESULTS

The dimensions of HRQOL showed mainly consistent differences between the control and the SCD group and MCI subgroups. In almost every dimension of HRQOL, the control group scored higher than subjects with SCD, naMCI, or aMCI. The controls showed low to moderate negative correlations between HQROL and B-ADL in some dimensions of the HRQOL. In the SCD group, low negative correlations with ADL were observed in some HRQOL scales. Low to moderate correlations were found between each scale of the SF-36 and the B-ADL in both MCI subtypes. We found gender differences in HRQOL.

CONCLUSION

In conclusion, we could demonstrate that patients with SCD report reduced quality of life. This knowledge is important to get a better understanding of the individuals with SCD and may pave the way for the development of early intervention.

Exploring the affective dimension of the life review process: Facilitators’ interactional strategies for fostering personhood and social value among older adults with early dementia

We employed an auto-ethnography approach to explore the affective dimension of life review sessions with community-dwelling older military veterans with minor cognitive impairment (MCI) and early dementia. Using researchers’ analytic memos, we identified facilitators’ interactional strategies that fostered the participant’s sense of personal identity, dignity and social self-worth. Interaction among participant, caregiver, and facilitators evoked a range of emotional responses, offering a window into the affective world of MCI and early dementia. Positive emotional responses outnumbered negative emotional responses by a ratio of two-to-one in the life review sessions; however, negative emotions were more revelatory of current struggles with declines in health and function. Facilitators utilized two interactional strategies, in particular, to foster personhood and social value of participants: focusing on the participant and creating an empathic connection with the participant. Further work is needed to understand the role of emotions in research interactions and to examine the psychosocial mechanisms through which positive affect functions in promoting identity, personhood and social value among persons with MCI and early dementia.