Quality of Life and Utility Measurement in a Large Clinical Trial Sample of Patients with Mild to Moderate Alzheimer's Disease: Determinants and Level of Changes Observed

Methods and approaches to facilitate inclusion of the views, perspectives and preferences of people with moderate-to-severe dementia in research: A narrative systematic review

BACKGROUND

The perspectives of people with moderate-to-severe dementia are rarely directly elicited in research studies.

OBJECTIVES

This systematic review will explore methods and approaches for including the perspectives and preferences of people with moderate-to-severe dementia in research.

METHODS

AgeLine, CINAHL, Embase, PsycINFO, PubMed, Social Policy and Practice and Web of Science were searched until June 16 2022. Study quality was assessed using the 16-item Quality Assessment Tool. We described specific communication tools, reviewed the evidence for their effectiveness and considered their strengths and limitations. We examined the more general communication skills and techniques applied to support the use of these tools using thematic synthesis. The review protocol was registered with PROSPERO CRD42019130386 and the review was conducted and reported according to PRISMA guidelines.

RESULTS

Seven studies reported in 11 publications were included. In these studies five specific communication tools were used: Talking Mats, Augmentative and Alternative Communication Flexiboard, generic photographs in combination with a preference placement board, consultation ballot and personalised communication prescriptions. Each tool identified had advantages and disadvantages depending on dementia severity, verbal or physical ability, expense, researcher training requirements and ease of use. Thematic synthesis identified five general approaches to optimising communication that were employed to support use of the tools: ensuring conversations are individual and person-centred, managing external influences, engaging others, creating structure and facilitation skills.

CONCLUSION

All tools had some utility and there was no clear evidence to support the recommendation of any one specific tool; therefore, researchers are advised to select the tool most appropriate to their context.

IMPLICATIONS FOR PRACTICE

The findings offer general guidance for researchers and practitioners on how to facilitate communication with people with moderate-to-severe dementia.

Neurological Health: Not Merely the Absence of Disease: Current Wellbeing Instruments Across the Spectrum of Neurology

OBJECTIVE

Well-being and quality of life can vary independently of disease. Instruments measuring well-being and quality of life are commonly used in neurology, but there has been little investigation into the extent in which they accurately measure wellbeing/quality of life or if they merely reflect a diseased state of an individual.

DESIGN

Systematic searches, thematic analysis and narrative synthesis were undertaken. Individual items from instruments represented in ≥ 5 publications were categorised independently, without prior training, by five neurologists and one well-being researcher, as relating to 'disease-effect' or 'Well-being' with a study-created instrument. Items were additionally categorised into well-being domains.

DATA SOURCES

MEDLINE, EMBASE, EMCARE and PsycINFO from 1990 to 2020 were performed, across the 13 most prevalent neurological diseases.

RESULTS

301 unique instruments were identified. Multiple sclerosis had most unique instruments at 92. SF-36 was used most, in 66 studies. 22 instruments appeared in ≥ 5 publications: 19/22 'well-being' outcome instruments predominantly measured disease effect (Fleiss kappa = .60). Only 1/22 instruments was categorised unanimously as relating to well-being. Instruments predominantly measured mental, physical and activity domains, over social or spiritual.

CONCLUSIONS

Most neurological well-being or quality-of-life instruments predominantly measure disease effect, rather than disease-independent well-being. Instruments differed widely in well-being domains examined.

The Humanistic and Economic Burden of Alzheimer's Disease

Alzheimer's disease (AD) is the leading cause of cognitive impairment and dementia in older individuals (aged ≥ 65 years) throughout the world. As a result of these progressive deficits in cognitive, emotional, and physical function, AD dementia can cause functional disability and loss of independence. To gain a deeper understanding of the recent literature on the burden of AD, including that of mild cognitive impairment (MCI) due to AD, we conducted a comprehensive targeted review of the PubMed-indexed literature (2014 to 2021) to examine the humanistic and economic burden of AD (including MCI) in North America, Europe, and Asia. Our literature review identified a range of factors associated with quality of life (QoL): some factors were positively associated with QoL, including caregiver relationship, religiosity, social engagement, and ability to engage in activities of daily living (ADL), whereas other factors such as neuropsychiatric symptoms were associated with poorer QoL. While patient- and proxy-rated QoL are highly correlated in patients with early AD dementia, proxy-rated QoL declines more substantially as severity worsens. The maintenance of self-reported QoL in patients with more severe AD dementia may be due to lack of awareness or to adaptation to circumstances. Compared to persons with normal cognition, MCI is associated with a greater cost burden, and individuals with MCI exhibit worse QoL. Key drivers of the societal economic burden of AD include disease severity, dependence level, institutionalization, and comorbidity burden. Evaluation of the impact of a hypothetical disease-modifying treatment delaying the progression from MCI to AD has suggested that such a treatment may result in cost savings.

Past, present and future of therapeutic strategies against amyloid-β peptides in Alzheimer's disease: a systematic review

Alzheimer's disease (AD) is the most prevalent neurodegenerative disease in ageing, affecting around 46 million people worldwide but few treatments are currently available. The etiology of AD is still puzzling, and new drugs development and clinical trials have high failure rates. Urgent outline of an integral (multi-target) and effective treatment of AD is needed. Accumulation of amyloid-β (Aβ) peptides is considered one of the fundamental neuropathological pillars of the disease, and its dyshomeostasis has shown a crucial role in AD onset. Therefore, many amyloid-targeted therapies have been investigated. Here, we will systematically review recent (from 2014) investigational, follow-up and review studies focused on anti-amyloid strategies to summarize and analyze their current clinical potential. Combination of anti-Aβ therapies with new developing early detection biomarkers and other therapeutic agents acting on early functional AD changes will be highlighted in this review. Near-term approval seems likely for several drugs acting against Aβ, with recent FDA approval of a monoclonal anti-Aβ oligomers antibody -aducanumab- raising hopes and controversies. We conclude that, development of oligomer-epitope specific Aβ treatment and implementation of multiple improved biomarkers and risk prediction methods allowing early detection, together with therapies acting on other factors such as hyperexcitability in early AD, could be the key to slowing this global pandemic.

Influence of Music Therapy and Music-Based Interventions on Dementia: A Pilot Study

According to national dementia plan in many countries, the music implementation into the daily routine as an adjunctive therapy to medication treatment is common. However, the ability of long-term care facilities to implement individualized music therapy (MT) and music-based interventions is not sufficiently taken into account. This pilot study examined the frequency of use and acceptance of MT and technology-based music interventions (TBMI) as well as the influence of high and low usage of both interventions of dementia on behavioral and psychological symptoms (BPSD) at two timepoints. Furthermore, the influence on the combination of MT and TBMI of dementia within the nursing home setting on BPSD with a focus on agitation, apathy, depression, and quality of life at all timepoints was considered. In the present study, data from 30 people with dementia (PwD) aged on average 81 years were analyzed within an eight-week noncontrolled intervention study, including four-week follow-up. Initial outcome data indicated significant decreases at times T2 and T3 in agitation and apathy among PwD with a high usage of MT and TBMI than among those with a low usage. In general, reductions were obtained from all observed BPSD at all timepoints. Significant results were found only for agitation over time. Considering the demonstrated results, a long-term implementation of music within daily routines in nursing homes for PwD should be strived for.

Quality of life in early-onset Alzheimer's disease due to a PSEN1-E280A mutation

PURPOSE

The present study aims to explore the association between the quality of life (QoL) score and the clinical and sociodemographic variables in patients with the PSEN1-E280A mutation. We also seek to evaluate the differences between the QoL reported by the patients (P-QoL) and the scores reported by the caregivers (C-QoL).

METHODS

An analysis of 75 patients with the PSEN1-E280A mutation with mild cognitive impairment and dementia was performed. We used the Quality of Life in Alzheimer Disease (QoL-AD) survey to evaluate QoL as an outcome and evaluated its association with sociodemographic, lifestyle, clinical, and past medical history variables.

RESULTS

The largest difference in the median of the QoL-AD score was in those who needed help to eat, those with moderate or severe dementia, those classified as frail or pre-frail, those with moderate social risk, and those with depression. Also, C-QoL was lower than the P-QoL, and the QoL-AD of individuals with severe dementia was lower than for milder forms of the disease. Not needing help to eat, not having a stressful situation in the past 3 months, and the years of education were positively correlated with QoL-AD in the linear model.

CONCLUSION

As studies in similar populations with AD, factors with more impact on QoL are those related to loss of functionality and independence. These factors are also associated with variables related to the current literature with the burden of the disease for the caregivers.

Obtaining EQ-5D-5L utilities from the disease specific quality of life Alzheimer's disease scale: development and results from a mapping study

PURPOSE

The Quality of Life Alzheimer's Disease Scale (QoL-AD) is commonly used to assess disease specific health-related quality of life (HRQoL) as rated by patients and their carers. For cost-effectiveness analyses, utilities based on the EQ-5D are often required. We report a new mapping algorithm to obtain EQ-5D indices when only QoL-AD data are available.

METHODS

Different statistical models to estimate utility directly, or responses to individual EQ-5D questions (response mapping) from QoL-AD, were trialled for patient-rated and proxy-rated questionnaires. Model performance was assessed by root mean square error and mean absolute error.

RESULTS

The response model using multinomial regression including age and sex, performed best in both the estimation dataset and an independent dataset.

CONCLUSIONS

The recommended mapping algorithm allows researchers for the first time to estimate EQ-5D values from QoL-AD data, enabling cost-utility analyses using datasets where the QoL-AD but no utility measures were collected.

The positive and negative appraisals of caregiving (PANAC) scale: A new measure to examine the caregiving experience in Alzheimer's disease and related dementias

INTRODUCTION

Dementia caregiving is often examined as a monolithic experience describing the challenges caregivers face, exploring one construct at a time, with little research on the positive experiences of caregiving. To address this, we developed the Positive and Negative Appraisals of Caregiving (PANAC) scale.

METHODS

PANAC was validated in 253 patient-caregiver dyads. Factor analyses revealed a two-factor solution: Positive Appraisals (PAs) and Negative Appraisals (NAs). Psychometric properties were compared with patient and caregiver characteristics and outcomes, disease stage, and etiology.

RESULTS

Internal consistency was good with Cronbach's alpha: 0.82 NA and 0.80 PA (P  < 0.001). NA correlated with patient and caregiver characteristics, whereas PA correlated only with caregiver characteristics. The PA/NA ratio could be used to capture change due to an intervention.

DISCUSSION

The PANAC scale is a useful measure of the overall caregiver experience accounting for negative and positive experiences and may be used to tailor support to individual caregivers.

Global Mapping of Interventions to Improve Quality of Life of Patients with Alzheimer's Disease during 1990-2018

BACKGROUND

Alzheimer's disease (AD) with its high burden on disability is known as one of the critical public health issues worldwide. Hence, providing comprehensive care and effective symptomatic treatment are becoming a challenge for many healthcare systems. Quality of life (QOL) has been identified as an important indicator to develop holistic care for people living with AD since it reflects treatment response, the progression of AD, and activities of daily living. This study aimed to identify research trends and landscapes as well as important factors in QOL studies in the field of AD.

SUMMARY

English research was extracted from the online database Web of Science to analyze research publications' growth rate and content on AD and QOL. VOSviewer was used to visualize the correlations between terms in titles and abstracts. Research topics were created using Latent Dirichlet Allocation of abstracts' content and disciplines. Major landscapes in the QOL assessment included care and treatment for AD in epidemiological studies and clinical trials. Besides, most studies were conducted in high-income countries, such as the USA or the United Kingdom. Findings of our study also identified a lack of contextualized factors and research gaps in terms of QOL among individuals with AD. Key Messages: Further studies should be conducted taking an effort to assess QOL among demented patients as well as advancing knowledge, attitude, and practice among family caregivers.

Disease severity accounts for minimal variance of quality of life in people with dementia and their carers: analyses of cross-sectional data from the MODEM study

BACKGROUND

Due to the progressive nature of dementia, it is important to understand links between disease severity and health-related outcomes. The aim of this study is to explore the relationship between disease severity and the quality of life (QoL) of people with dementia and their family carers using a number of disease-specific and generic measures.

METHODS

In the MODEM cohort study, three-hundred and seven people with clinically diagnosed dementia and their carers were recruited on a quota basis to provide equal numbers of people with mild (standardised Mini-Mental State Examination (sMMSE), n = 110), moderate (sMMSE 10-19, n = 100), and severe (sMMSE 0-9, n = 97) cognitive impairment. A series of multiple regression models were created to understand the associations between dementia severity and the QoL of people with dementia and the QoL of their carers. QoL was measured using self- (DEMQOL, EQ-5D, CASP-19) and proxy-reports (DEMQOL-Proxy, EQ-5D) of disease-specific and generic QoL of the person with dementia. Carer generic QoL was measured by self-report (EQ-5D, SF-12).

RESULTS

Disease severity, as measured by the sMMSE, was not significantly associated with the QoL of the person with dementia or the carer (p > 0.05), even after controlling for potential confounding variables for self-reported instruments. Proxy measures (rated by the carer) differed systematically in that there were small, but statistically significant proportions of the variance of QoL was explained by severity of cognitive impairment in multiple adjusted models. We also found little in the way of statistically significant relationships between the QoL of people with dementia and that of their carers except between DEMQOL-Proxy scores and the carer EQ-5D scores and carer SF-12 mental sub-scores.

CONCLUSIONS

The data generated supports the somewhat counterintuitive argument that severity of cognitive impairment (and therefore severity of dementia) is not associated with lower QoL for the person with dementia when self-report measures are used. However, in absolute terms, as judged by the variance in the multivariate models, it is clear that the contribution of dementia severity to the QoL of people with dementia is minimal whatever the measurement used, be it self- or proxy-rated, or disease-specific or generic.

Disease severity accounts for minimal variance of quality of life in people with dementia and their carers: analyses of cross-sectional data from the MODEM study

BACKGROUND

Due to the progressive nature of dementia, it is important to understand links between disease severity and health-related outcomes. The aim of this study is to explore the relationship between disease severity and the quality of life (QoL) of people with dementia and their family carers using a number of disease-specific and generic measures.

METHODS

In the MODEM cohort study, three-hundred and seven people with clinically diagnosed dementia and their carers were recruited on a quota basis to provide equal numbers of people with mild (standardised Mini-Mental State Examination (sMMSE), n = 110), moderate (sMMSE 10-19, n = 100), and severe (sMMSE 0-9, n = 97) cognitive impairment. A series of multiple regression models were created to understand the associations between dementia severity and the QoL of people with dementia and the QoL of their carers. QoL was measured using self- (DEMQOL, EQ-5D, CASP-19) and proxy-reports (DEMQOL-Proxy, EQ-5D) of disease-specific and generic QoL of the person with dementia. Carer generic QoL was measured by self-report (EQ-5D, SF-12).

RESULTS

Disease severity, as measured by the sMMSE, was not significantly associated with the QoL of the person with dementia or the carer (p > 0.05), even after controlling for potential confounding variables for self-reported instruments. Proxy measures (rated by the carer) differed systematically in that there were small, but statistically significant proportions of the variance of QoL was explained by severity of cognitive impairment in multiple adjusted models. We also found little in the way of statistically significant relationships between the QoL of people with dementia and that of their carers except between DEMQOL-Proxy scores and the carer EQ-5D scores and carer SF-12 mental sub-scores.

CONCLUSIONS

The data generated supports the somewhat counterintuitive argument that severity of cognitive impairment (and therefore severity of dementia) is not associated with lower QoL for the person with dementia when self-report measures are used. However, in absolute terms, as judged by the variance in the multivariate models, it is clear that the contribution of dementia severity to the QoL of people with dementia is minimal whatever the measurement used, be it self- or proxy-rated, or disease-specific or generic.

Cognition and Quality of Life in Symptomatic Carotid Occlusion

PURPOSE

Carotid occlusion may result in stroke, TIA, and cognitive reductions. Whether cognition predicts quality of life (QOL) for patients with carotid occlusion is unknown. Depression is also known to affect QOL. We examined whether cognition and depression predicted QOL in patients with carotid occlusive disease who have not had revascularization.

METHODS

Patients with unilateral carotid occlusion and history of TIA or a remote history of minor stroke were included. Patients underwent exam of memory, language, motor, and executive function skills and completed depression and QOL questionnaires (Center for Epidemiological Studies-Depression [CES-D], Stroke Specific QOL [SSQOL]). Deficits from remote stroke were assessed with the NIH Stroke Scale (NIHSS). Z-scores for cognitive tests were averaged (Cog-Z). The SSQOL scores were averaged across subgroup domains. Analyses of patients with all depression levels were followed by subgroup analyses for patients with minimal depression. Correlation findings were used to select the variables in a regression model to predict SSQOL.

RESULTS

Among 37 patients with all depression levels, QOL was predicted by deficits from remote stroke and depression (F(3, 36) = 21.15, P<.0005; NIHSS Beta = -.392, P = .001; CES-D Beta = -.577, P < .0005). Among 22 patients with minimal depression, QOL was predicted by cognitive and depression scores, (F(2,21) = 7.88, P = .003; Cog-Z Beta = .364, P = .05; CES-D Beta = -.495, P = .01).

CONCLUSIONS

In patients with carotid occlusive disease without major stroke and without revascularization, cognitive and depression scores independently predicted QOL. These data demonstrate the clinical relevance of cognitive and mood decline among patients with carotid occlusion.

Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018

OBJECTIVE

It is useful for reviewers of economic evaluations to assess quality in a manner that is consistent and comprehensive. Checklists can allow this, but there are concerns about their reliability and how they are used in practice. We aimed to describe how checklists have been used in systematic reviews of health economic evaluations.

METHODS

Meta-review with snowball sampling. We compiled a list of checklists for health economic evaluations and searched for the checklists' use in systematic reviews from January 2010 to February 2018. We extracted data regarding checklists used, stated checklist function, subject area, number of reviewers, and issues expressed about checklists.

RESULTS

We found 346 systematic reviews since 2010 that used checklists to assess economic evaluations. The most common checklist in use was developed in 1996 by Drummond and Jefferson, and the most common stated use of a checklist was quality assessment. Checklists and their use varied within subject areas; 223 reviews had more than one reviewer who used the checklist.

CONCLUSIONS

Use of checklists is inconsistent. Eighteen individual checklists have been used since 2010, many of which have been used in ways different from those originally intended, often without justification. Different systematic reviews in the same subject areas would benefit from using one checklist exclusively, using checklists as intended, and having 2 reviewers complete the checklist. This would increase the likelihood that results are transparent and comparable over time.

Neurodegenerative Diseases: Regenerative Mechanisms and Novel Therapeutic Approaches

Regeneration refers to regrowth of tissue in the central nervous system. It includes generation of new neurons, glia, myelin, and synapses, as well as the regaining of essential functions: sensory, motor, emotional and cognitive abilities. Unfortunately, regeneration within the nervous system is very slow compared to other body systems. This relative slowness is attributed to increased vulnerability to irreversible cellular insults and the loss of function due to the very long lifespan of neurons, the stretch of cells and cytoplasm over several dozens of inches throughout the body, insufficiency of the tissue-level waste removal system, and minimal neural cell proliferation/self-renewal capacity. In this context, the current review summarized the most common features of major neurodegenerative disorders; their causes and consequences and proposed novel therapeutic approaches.

Passive Aβ Immunotherapy: Current Achievements and Future Perspectives

Passive immunotherapy has emerged as a very promising approach for the treatment of Alzheimer’s disease and other neurodegenerative disorders, which are characterized by the misfolding and deposition of amyloid peptides. On the basis of the amyloid hypothesis, the majority of antibodies in clinical development are directed against amyloid β (Aβ), the primary amyloid component in extracellular plaques. This review focuses on the current status of Aβ antibodies in clinical development, including their characteristics and challenges that came up in clinical trials with these new biological entities (NBEs). Emphasis is placed on the current view of common side effects observed with passive immunotherapy, so-called amyloid-related imaging abnormalities (ARIAs), and potential ways to overcome this issue. Among these new ideas, a special focus is placed on molecules that are directed against post-translationally modified variants of the Aβ peptide, an emerging approach for development of new antibody molecules.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessing quality of life in Alzheimer's disease: Implications for clinical trials

Introduction

Characterization of the quality of life (QOL) in Alzheimer's disease (AD) scale within the context of a clinical trial may inform its applicability in future trials.

Methods

Using data from 1322 patients enrolled in two phase-III studies (EXPEDITION 1 [NCT00905372] and 2 [NCT00904683]) of intravenous solanezumab in outpatients with mild AD dementia, correlations between patient- and caregiver-assessed QOL and between QOL and clinical outcome measures were examined. Longitudinal effects of solanezumab over 80 weeks were explored, controlling for patient and caregiver baseline characteristics.

Results

Caregivers rated patients' QOL worse than did patients themselves. Patients' QOL was correlated, albeit modestly, with clinical/health measures. Patients' QOL changed minimally over 80 weeks, although a treatment effect of solanezumab on QOL was detected.

Discussion

Further investigations are needed to determine the optimal measures with which to quantify and qualify QOL of patients with mild AD.

Reliability, validity and clinical correlates of the Quality of Life in Alzheimer's disease (QoL-AD) scale in medical inpatients

Background

There is a lack of standardisation in quality of life (QoL) measurements to be used in older multimorbid patients. An ideal QoL measurement should be reliable, valid, subjective, multidimensional, feasible and generic. We hypothesised that the QoL-AD (Quality of Life in Alzheimer’s Disease) scale could have these properties. Our aim was to determine the psychometric properties and clinical correlations of QoL-AD in a population of elderly, multimorbid medical inpatients.

Methods

QoL-AD was performed in 200 medical inpatients, and available caregivers. Reliability was determined using cronbach’s alpha and corrected item-total correlations. The agreement between patient and proxy ratings were examined using intra-class correlations (ICC). Correlations between QoL-AD and demographic data, comorbidity, cognitive tests, ADL (activities of daily living) and depression were examined. To characterise the underlying constructs of QoL-AD, an exploratory factor analysis was performed.

Results

In total, 199 patients fulfilled the QoL-AD rating, with 139 proxy ratings. Cronbach’s alpha (95 % CI) was 0.74 (0.68–0.79) for patients and 0.86 (0.83–0.90) for proxies. Patient-proxy ICC (95 % CI) was 0.31 (0.16–0.46). Lower QoL was correlated to depression, cognitive impairment, ADL impairment and solitary living, but not with comorbidity. The factor analysis gave a three-factor solution, with factors representing phsyical, social and psychological well-being.

Conclusion

The QoL-AD scale showed some promising properties but more research is needed before it can be recommended in this setting. If replicated, the finding that cognitive impairment, depression and ADL impairment were more associated with lower QoL than somatic comorbidity could have clinical implications for further studies aiming to improve QoL in this population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-016-0493-8) contains supplementary material, which is available to authorized users.