Development of a new measure of health-related quality of life for people with dementia: DEMQOL

Randomised controlled trial of a nurse coordination intervention for people living with dementia and their carers: study protocol

INTRODUCTION

The multifaceted impact of dementia means that people living with dementia require multidisciplinary care across different services and settings; however, these care transitions pose a risk of fragmented care. Models that improve integration and coordination of care in the community are needed.

METHODS AND ANALYSIS

This randomised control trial will test the effectiveness and cost effectiveness of a dementia nurse-led intervention to: (1) increase days lived in the community at 12-month follow-up (primary outcome) among people living with dementia and (2) improve quality of life for people living with dementia and their carers, compared with usual care. Participants are recruited from several sources including private and public geriatric medicine clinics, carer support groups and self-referral. People living with dementia and their carers are randomised as a dyad to (1) usual care or (2) dementia nurse-led care-coordination. The dementia nurse will provide care coordination and direct support through a tailored, integrated and patient-centred approach. The needs of people living with dementia will be identified and addressed, with a focus on improving the management of comorbidities, risk reduction and symptoms. Carers will also receive support. The model for people living with dementia will focus on days lived in their community as the outcome variable. Differences between groups in quality of life at 12-month follow-up will be assessed using linear mixed effects regression. Analysis will follow the intention to treat principles. People living with dementia and carers' data will be analysed separately and collectively for the economic study.

ETHICS AND DISSEMINATION

The trial has been approved by the Hunter New England Research Ethics Committee (2023/ETH01221) and the University of Newcastle Ethics Committee (R-2024-0021). Trial findings will be disseminated via peer-reviewed publications and conference presentations. If the intervention is effective, the research team aims to further implement the intervention as usual care within the participating services and beyond.

TRIAL REGISTRATION NUMBER

The trial was prospectively registered via the Australian New Zealand Clinical Trials Registry: ACTRN12624000235505. Registration date: 11 March 2024.

Systematic review of the efficacy of pharmacological and non-pharmacological interventions for improving quality of life of people with dementia

BACKGROUND

People with dementia (PwD) and their carers often consider maintaining good quality of life (QoL) more important than improvements in cognition or other symptoms of dementia. There is a clinical need for identifying interventions that can improve QoL of PwD. There are currently no evidence-based guidelines to help clinicians, patients and policy makers to make informed decisions regarding QoL in dementia.

AIMS

To conduct the first comprehensive systematic review of all studies that investigated efficacy of any pharmacological or non-pharmacological intervention for improving QoL of PwD.

METHOD

Our review team identified eligible studies by comprehensively searching nine databases. We completed quality assessment, extracted relevant data and performed GRADE assessment of eligible studies. We conducted meta-analyses when three or more studies investigated an intervention for improving QoL of PwD.

RESULTS

We screened 14 389 abstracts and included 324 eligible studies. Our meta-analysis confirmed level 1 evidence supporting the use of group cognitive stimulation therapy for improving QoL (standardised mean difference 0.25; P = 0.003) of PwD. Our narrative data synthesis revealed level 2 evidence supporting 42 non-pharmacological interventions, including those based on cognitive rehabilitation, reminiscence, occupational therapy, robots, exercise or music therapy. Current evidence supporting the use of any pharmacological intervention for improving QoL in dementia is limited.

CONCLUSIONS

Current evidence highlights the importance of non-pharmacological interventions and multidisciplinary care for supporting QoL of PwD. QoL should be prioritised when agreeing care plans. Further research focusing on QoL outcomes and investigating combined pharmacological and non-pharmacological interventions is urgently needed.

Quality of Life of Older Adults Living With Dementia and Caregiver Strain in Benin

OBJECTIVES

This study aimed at assessing the quality of life (QoL) of older adults living with dementia and caregiver strain in Benin, a West African country.

METHODS

A cross-sectional study was conducted from October to November 2021, recruiting participants aged 60 and over and their caregivers from health facilities and a rural community in Benin. QoL of older adults and caregiver burden were collected using standardized instruments, namely the World Health Organization's dementia QoL and Zarit Burden Interview, respectively.

RESULTS

A total of 114 older adults (mean age 73 ± 10 years, 51% female) and their primary caregivers (mean age 49 ± 16 years, 70% female) participated, of whom 73 were recruited from health facilities and 41 from rural communities. Fifty percent of older adults were diagnosed with mild to severe dementia. The overall QoL was good, with rural participants scoring higher in daily life and urban participants scoring higher in emotion. Factors associated with decreased QoL were higher disability levels and greater caregiver burden. The mean caregiver burden score was 17 ± 13, with higher scores among those caring for older men. Increased disability in older adults and lower socioeconomic status were linked to higher caregiver strain, whereas better QoL in older adults and higher socioeconomic status reduced caregiver burden.

CONCLUSION

Enhancing access to healthcare, strengthening social support systems, and providing caregiver training and support are crucial for improving the well-being and care of individuals living with dementia in Benin.

Through Their Eyes: Defining 'good life' in dementia for health economics and outcomes research

Despite progress in involving people living with dementia in health research, disparities remain, particularly in the field of health economics and outcomes research, where excessive reliance on proxy reports from care partners or healthcare professionals persists even when people are capable of self-reporting, leading to inequitable inclusion. This study aimed to understand the concept of a 'good life' from the perspectives of people living with dementia and examine how well current preference-based outcome measures used in health economics and outcomes research capture these perspectives. Twenty-three community-dwelling people with mild to moderate dementia in Ireland participated in in-depth interviews (September 2022-February 2023). Data were analysed using an adapted Colaizzi's seven-step phenomenological method, followed by mapping identified themes against ten commonly used preference-based outcome measures in dementia research. Results show that participants perceive a 'good life' through independence, social connections, engagement with life, adaptation to changing abilities. As dementia progresses, perceptions shift from striving for independence and active life engagement to accepting assistance and increased social support. This transition reflects a journey of adaptation, where participants redefine their sense of a 'good life' with evolving challenges and capabilities. The mapping analysis reveal that current preference-based outcome measures vary considerably in their coverage of these themes (33-83%), with none fully capturing the dynamic and evolving nature of a 'good life' as described by participants. These findings expose disparities between lived experiences and current measurement frameworks in health economics and outcomes research in dementia, calling for developing flexible and adaptive approaches to quality of life assessment in progressive conditions-approaches that not only reflect quality of life as defined by those living with the condition but also accommodate its dynamic and evolving nature throughout individual disease trajectories.

Assessing the feasibility of measuring residents' quality of life in English care homes and the construct validity and internal consistency of measures completed by staff proxy: a cross-sectional study

OBJECTIVES

To assess the feasibility of capturing older care home residents' quality of life (QoL) in digital social care records and the construct validity (hypothesis testing) and internal consistency (Cronbach's alpha) of four QoL measures.

DESIGN

Cross-sectional data collected in wave 1 of the DACHA (Developing resources And minimum dataset for Care Homes' Adoption) study, a mixed-methods pilot of a prototype minimum dataset (MDS).

SETTING

Care homes (with or without nursing) registered to provide care for older adults (>65 years) and/or those living with dementia. All homes used a digital record system from one of two suppliers.

PARTICIPANTS

Data were extracted from 748 residents. All permanent residents, aged 65 years or older, were eligible to participate, including those lacking capacity to consent. Temporary residents and residents in their last weeks of life were excluded.

OUTCOME MEASURES AND ANALYSIS

The English language versions of Adult Social Care Outcomes Toolkit (ASCOT)-Proxy-Resident, ICEpop CAPability measure for Older people (ICECAP-O), EQ-5D-5L proxy and the QUALIDEM were added to the digital record. As there have not been any previous studies of the structural validity of the English language version of the QUALIDEM, ordinal exploratory factor analysis (EFA) was applied for this measure only. Feasibility (% missing by software provider and measure), % floor/ceiling effects (>15% at lower/upper end of the scales), convergent or divergent construct validity (criterion of >75% of hypotheses accepted) and internal consistency (Cronbach's alpha ≥0.7) were assessed for all four measures.

RESULTS

The ordinal EFA of QUALIDEM did not replicate the findings of previous research. A six-factor (36 item) solution was proposed and used in all subsequent analyses. There were low rates of missing data (<5%) for all items, except ASCOT-Proxy-Resident Control (5.1%) and Dignity (6.2%) and QUALIDEM item 35 (5.1%). Ceiling effects were observed for the ASCOT-Proxy-Resident and two of the QUALIDEM subscales. None of the scales had floor effects. Cronbach's alpha indicated adequate internal consistency (α ≥0.70) for the ASCOT-Proxy-Resident, ICECAP-O and EQ-5D-5L proxy. There were issues with two QUALIDEM subscales. Construct validity for all measures was adequate.

CONCLUSIONS

The findings support the use of EQ-5D-5L, ASCOT-Proxy-Resident and the ICECAP-O in care homes for older people. The choice of measure will depend on the construct(s) of interest. More research is needed to establish the psychometric properties of the QUALIDEM in an English care home setting.

Cost-utility analysis of adapted problem adaptation therapy for depression in mild-to-moderate dementia caused by Alzheimer's disease: PATHFINDER randomised controlled trial

BACKGROUND

Depression is common in people with dementia, and negatively affects quality of life.

AIMS

This paper aims to evaluate the cost-effectiveness of an intervention for depression in mild and moderate dementia caused by Alzheimer's disease over 12 months (PATHFINDER trial), from both the health and social care and societal perspectives.

METHOD

A total of 336 participants were randomised to receive the adapted PATH intervention in addition to treatment as usual (TAU) (n = 168) or TAU alone (n = 168). Health and social care resource use were collected with the Client Service Receipt Inventory and health-related quality-of-life data with the EQ-5D-5L instrument at baseline and 3-, 6- and 12-month follow-up points. Principal analysis comprised quality-adjusted life-years (QALYs) calculated from the participant responses to the EQ-5D-5L instrument.

RESULTS

The mean cost of the adapted PATH intervention was estimated at £1141 per PATHFINDER participant. From a health and social care perspective, the mean difference in costs between the adapted PATH and control arm at 12 months was -£74 (95% CI -£1942 to £1793), and from the societal perspective was -£671 (95% CI -£9144 to £7801). The mean difference in QALYs was 0.027 (95% CI -0.004 to 0.059). At £20 000 per QALY gained threshold, there were 74 and 68% probabilities of adapted PATH being cost-effective from the health and social care and societal perspective, respectively.

CONCLUSIONS

The addition of the adapted PATH intervention to TAU for people with dementia and depression generated cost savings alongside a higher quality of life compared with TAU alone; however, the improvements in costs and QALYs were not statistically significant.

Clinical effectiveness of DREAMS START (Dementia Related Manual for Sleep; Strategies for Relatives) versus usual care for people with dementia and their carers: a single-masked, phase 3, parallel-arm, superiority randomised controlled trial

BACKGROUND

Sleep disturbances are common and distressing for people with dementia and their families. Non-pharmacological interventions should be first-line management, avoiding harmful pharmacological side-effects, but there is none with known effectiveness. We aimed to establish whether DREAMS START, a multicomponent intervention, reduced sleep disturbance in people with dementia living at home compared with usual care.

METHODS

We conducted a phase 3, two-arm, multicentre, parallel-arm, superiority randomised controlled trial with masked outcome assessment, recruiting dyads of people with dementia and sleep disturbance and family carers from community settings. Randomisation to the DREAMS START intervention (plus usual treatment) or usual treatment was conducted at dyadic level, blocked, and stratified by site, with a web-based system assigning allocation. DREAMS START is a six-session, manualised intervention delivered face to face or remotely by non-clinically trained graduates over an approximately 3-month period. The primary outcome was sleep disturbance measured by the Sleep Disorders Inventory (SDI) at 8 months. Analyses were on the intention-to-treat population. This trial is registered with ISRCTN 13072268.

FINDINGS

Between Feb 24, 2021, and March 5, 2023, 377 dyads were randomly assigned (1:1), 189 to usual treatment and 188 to intervention. The mean age of participants with dementia was 79·4 years (SD 9·0), and 206 (55%) were women. The mean SDI score at 8 months was lower in the intervention group compared with the usual treatment group (15·16 [SD 12·77], n=159, vs 20·34 [16·67], n=163]; adjusted difference in means -4·70 [95% CI -7·65 to -1·74], p=0·002). 17 (9%) people with dementia in the intervention group and 17 (9%) in the control group died during the trial; the deaths were unrelated to the intervention.

INTERPRETATION

To our knowledge, DREAMS START is the first multicomponent intervention to improve the sleep of people living at home with dementia more than usual clinical care. It had sustained effectiveness beyond intervention delivery. The intervention's delivery by non-clinically trained graduates increases the potential for implementation within health services, adding to usual clinical care.

FUNDING

National Institute for Health and Care Research Health Technology Assessment.

Understanding the influence of different proxy perspectives in explaining the difference between self-rated and proxy-rated quality of life in people living with dementia: a systematic literature review and meta-analysis

PURPOSE

Proxy assessment can be elicited via the proxy-patient perspective (i.e., asking proxies to assess the patient's quality of life (QoL) as they think the patient would respond) or proxy-proxy perspective (i.e., asking proxies to provide their own perspective on the patient's QoL). This review aimed to identify the role of the proxy perspective in explaining the differences between self-rated and proxy-rated QoL in people living with dementia.

METHODS

A systematic literate review was conducted by sourcing articles from a previously published review, supplemented by an update of the review in four bibliographic databases. Peer-reviewed studies that reported both self-reported and proxy-reported mean QoL estimates using the same standardized QoL instrument, published in English, and focused on the QoL of people with dementia were included. A meta-analysis was conducted to synthesize the mean differences between self- and proxy-report across different proxy perspectives.

RESULTS

The review included 96 articles from which 635 observations were extracted. Most observations extracted used the proxy-proxy perspective (79%) compared with the proxy-patient perspective (10%); with 11% of the studies not stating the perspective. The QOL-AD was the most commonly used measure, followed by the EQ-5D and DEMQOL. The standardized mean difference (SMD) between the self- and proxy-report was lower for the proxy-patient perspective (SMD: 0.250; 95% CI 0.116; 0.384) compared to the proxy-proxy perspective (SMD: 0.532; 95% CI 0.456; 0.609).

CONCLUSION

Different proxy perspectives affect the ratings of QoL, whereby adopting a proxy-proxy QoL perspective has a higher inter-rater gap in comparison with the proxy-patient perspective.

Evaluating a model of best practice in primary care led post-diagnostic dementia care: feasibility and acceptability findings from the PriDem study

OBJECTIVES

To evaluate the feasibility and acceptability of a primary care-based intervention for improving post-diagnostic dementia care and support (PriDem), and implementation study procedures.

DESIGN

A non-randomised, mixed methods, feasibility study.

SETTING

Seven general practices from four primary care networks (PCNs) in the Northeast and Southeast of England.

PARTICIPANTS

We aimed to recruit 80 people with dementia (PWD) and 66 carers INTERVENTION: Clinical Dementia Leads delivered a 12-month intervention in participating PCNs, to develop care systems, build staff capacity and capability, and deliver tailored care and support to PWD and carers.

OUTCOMES

Recruitment and retention rates were measured. A mixed methods process evaluation evaluated feasibility and acceptability of the intervention and study procedures. Using electronic care records, researchers extracted service use data and undertook a dementia care plan audit, preintervention and postintervention, assessing feasibility of measuring the primary implementation outcome: adoption of personalised care planning by participating general practices. Participants completed quality of life, and service use measures at baseline, 4 and 9 months.

RESULTS

60 PWD (75% of recruitment target) and 51 carers (77% of recruitment target) were recruited from seven general practices across four PCNs. Retention rate at 9 months was 70.0% of PWD and 76.5% of carers. The recruitment approach showed potential for including under-represented groups within dementia. Despite implementation challenges, the intervention was feasible and acceptable, and showed early signs of sustainability. Study procedures were feasible and accessible, although researcher capacity was crucial. Participants needed time and support to engage with the study. Care plan audit procedures were feasible and acceptable.

CONCLUSIONS

The PriDem model is an acceptable and feasible intervention. A definitive study is warranted to fully inform dementia care policy and personalised dementia care planning guidance. Successful strategies to support inclusion of PWD and their carers in future research were developed.

TRIAL REGISTRATION NUMBER

ISRCTN11677384.

Assessing social connection for long-term care home residents: Systematic review using COnsensus-based Standards for the selection of health Measurement INstruments guidelines

Social connection is important for long-term care (LTC) residents' quality of life and care. However, there is a lack of consensus on how to measure it and this limits ability to find what improves and impairs social connection in LTC homes. We therefore aimed to systematically review and evaluate the measurement properties of existing measures of social connection for LTC residents, to identify which, if any, measures can be recommended. We searched eight electronic databases from inception to April 2022 for studies which reported on psychometric properties of a measure of any aspect(s) of social connection (including social networks, interaction, engagement, support, isolation, connectedness, and loneliness) for LTC residents. We used COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines to evaluate the measurement properties reported for each identified measure and make recommendations. We identified 62 studies reporting on 38 measures; 21 measured quality of life, well-being or life satisfaction and included a social connection subscale or standalone items and 17 measures specifically targeted social connection. We found there was little high-quality evidence on psychometric properties such as sufficient content validity (n = 0), structural validity (n = 3), internal consistency (n = 3), reliability (n = 1), measurement error (n = 0), construct validity (n = 4), criterion validity (n = 0) and responsiveness (n = 0). No measures demonstrated satisfactory psychometric properties on all these aspects, so none could be recommended for use. Thirty-four measures have the potential to be recommended but require further research to assess their quality and the remaining four are not recommended for use. Our review therefore found that no existing measures have sufficient evidence to be recommended for assessment of social connection in residents of LTC homes. Further validation and reliability studies of existing instruments or the development of new measures are needed to enable accurate measurement of social connection in LTC residents for future observational and interventional studies.

Highlights

Social connection is fundamental to person-centered care in long-term care homes.There is insufficient evidence for the reliability and validity of existing measures.No current measures can be recommended for use based on existing evidence.A reliable and valid measure of social connection is needed for future research.

Adapted problem adaptation therapy for depression in mild to moderate Alzheimer's disease dementia: A randomized controlled trial

INTRODUCTION

Trials of effectiveness of treatment options for depression in dementia are an important priority.

METHODS

Randomized controlled trial to assess adapted Problem Adaptation Therapy (PATH) for depression in mild/moderate dementia caused by Alzheimer's disease.

RESULTS

Three hundred thirty-six participants with mild or moderate dementia, >7 on Cornell Scale for Depression in Dementia (CSDD), randomized to adapted PATH or treatment as usual. Mean age 77.0 years, 39.0% males, mean Mini-Mental State Examination 21.6, mean CSDD 12.9. For primary outcome (CSDD at 6 months), no statistically significant benefit with adapted PATH on the CSDD (6 months: -0.58; 95% CI -1.71 to 0.54). The CSDD at 3 months showed a small benefit with adapted PATH (-1.38; 95% CI -2.54 to -0.21) as did the EQ-5D (-4.97; 95% CI -9.46 to -0.48).

DISCUSSION

An eight-session course of adapted PATH plus two booster sessions administered within NHS dementia services was not effective treatment for depression in people with mild and moderate dementia. Future studies should examine the effect of more intensive and longer-term therapy.

Impact of the iWHELD digital person-centered care program on quality of life, agitation and psychotropic medications in people with dementia living in nursing homes during the COVID-19 pandemic: A randomized controlled trial

INTRODUCTION

iWHELD is a digital person-centered care program for people with dementia in nursing homes adapted for remote delivery during the COVID-19 pandemic.

METHODS

A 16-week two-arm cluster-randomized controlled trial in 149 UK nursing homes compared iWHELD with treatment as usual (TAU). Primary outcome was the overall quality of life with secondary outcomes of agitation and psychotropic use.

RESULTS

iWHELD conferred benefit to quality of life on the primary (F = 4.3, p = 0.04) and secondary measures of quality of life (F = 6.45, p = 0.01) and reduced psychotropic medication use (χ2  = 4.08, p = 0.04) with no worsening of agitation. Benefit was seen in participants who contracted COVID-19, those with agitation at baseline, and those taking psychotropic medications.

DISCUSSION

iWHELD confers benefits to quality of life and key measures of well-being, can be delivered during the challenging conditions of a pandemic, and should be considered for use alongside any emerging pharmacological treatment for neuropsychiatric symptoms.

HIGHLIGHTS

iWHELD is the only remote, digital delivery nursing home training programme for dementia care iWHELD improved quality of life in people with dementia and reduced antipsychotic use without worsening of agitation Residents who contracted Covid-19 during the study also experienced benefits from iWHELD iWHELD offers a valuable, pandemic-safe tool for improving dementia care.

Counting what counts: assessing quality of life and its social determinants among nursing home residents with dementia

BACKGROUND

Maximizing quality of life (QoL) is a major goal of care for people with dementia in nursing homes (NHs). Social determinants are critical for residents' QoL. However, similar to the United States and other countries, most Canadian NHs routinely monitor and publicly report quality of care, but not resident QoL and its social determinants. Therefore, we lack robust, quantitative studies evaluating the association of multiple intersecting social determinants with NH residents' QoL. The goal of this study is to address this critical knowledge gap.

METHODS

We will recruit a random sample of 80 NHs from 5 Canadian provinces (Alberta, British Columbia, Manitoba, Nova Scotia, Ontario). We will stratify facilities by urban/rural location, for-profit/not-for-profit ownership, and size (above/below median number of beds among urban versus rural facilities in each province). In video-based structured interviews with care staff, we will complete QoL assessments for each of ~ 4,320 residents, using the DEMQOL-CH, a validated, feasible tool for this purpose. We will also assess resident's social determinants of QoL, using items from validated Canadian population surveys. Health and quality of care data will come from routinely collected Resident Assessment Instrument - Minimum Data Set 2.0 records. Knowledge users (health system decision makers, Alzheimer Societies, NH managers, care staff, people with dementia and their family/friend caregivers) have been involved in the design of this study, and we will partner with them throughout the study. We will share and discuss study findings with knowledge users in web-based summits with embedded focus groups. This will provide much needed data on knowledge users' interpretations, usefulness and intended use of data on NH residents' QoL and its health and social determinants.

DISCUSSION

This large-scale, robust, quantitative study will address a major knowledge gap by assessing QoL and multiple intersecting social determinants of QoL among NH residents with dementia. We will also generate evidence on clusters of intersecting social determinants of QoL. This study will be a prerequisite for future studies to investigate in depth the mechanisms leading to QoL inequities in LTC, longitudinal studies to identify trajectories in QoL, and robust intervention studies aiming to reduce these inequities.

Clinical and cost-effectiveness of DREAMS START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives) for people living with dementia and their carers: a study protocol for a parallel multicentre randomised controlled trial

INTRODUCTION

Many people living with dementia experience sleep disturbance and there are no known effective treatments. Non-pharmacological treatment options should be the first-line sleep management. For family carers, relatives' sleep disturbance leads to interruption of their sleep, low mood and breakdown of care. Our team developed and delivered DREAMS START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives), a multimodal non-pharmacological intervention, showing it to be feasible and acceptable. The aim of this randomised controlled trial is to establish whether DREAMS START is clinically cost-effective in reducing sleep disturbances in people living with dementia living at home compared with usual care.

METHODS AND ANALYSIS

We will recruit 370 participant dyads (people living with dementia and family carers) from memory services, community mental health teams and the Join Dementia Research Website in England. Those meeting inclusion criteria will be randomised (1:1) either to DREAMS START or to usual treatment. DREAMS START is a six-session (1 hour/session), manualised intervention delivered every 1-2 weeks by supervised, non-clinically trained graduates. Outcomes will be collected at baseline, 4 months and 8 months with the primary outcome being the Sleep Disorders Inventory score at 8 months. Secondary outcomes for the person with dementia (all proxy) include quality of life, daytime sleepiness, neuropsychiatric symptoms and cost-effectiveness. Secondary outcomes for the family carer include quality of life, sleep disturbance, mood, burden and service use and caring/work activity. Analyses will be intention-to-treat and we will conduct a process evaluation.

ETHICS AND DISSEMINATION

London-Camden & Kings Cross Ethics Committee (20/LO/0894) approved the study. We will disseminate our findings in high-impact peer-reviewed journals and at national and international conferences. This research has the potential to improve sleep and quality of life for people living with dementia and their carers, in a feasible and scalable intervention.

TRIAL REGISTRATION NUMBER

ISRCTN13072268.

Enhancing Minds in Motion® as a virtual program delivery model for people living with dementia and their care partners

The Alzheimer Society of Ontario's Minds in Motion (MiM) program improves physical function and well-being of people living with dementia (PLWD) and their care partners (CP) (Regan et al., 2019). With the COVID-19 pandemic, there was an urgent need to transition to a virtual MiM that was similarly safe and effective. The purpose of this mixed methods study is to describe the standardized, virtual MiM and evaluate its acceptability, and impact on quality of life, and physical and cognitive activity of participants. Survey of ad hoc virtual MiM practices and a literature review informed the design of the standardized MiM program: 8 weeks of weekly 90-minute sessions that included 45-minutes of physical activity and 45-minutes of cognitive stimulation in each session. Participants completed a standardized, virtual MiM at one of 6 participating Alzheimer Societies in Ontario, as well as assessments of quality of life, physical and cognitive activity, and program satisfaction pre- and post-program. In all, 111 PLWD and 90 CP participated in the evaluation (average age of 74.6±9.4 years, 61.2% had a college/university degree or greater, 80.6% were married, 48.6% of PLWD and 75.6% of CP were women). No adverse events occurred. MiM participants rated the program highly (average score of 4.5/5). PLWD reported improved quality of life post-MiM (p = <0.01). Altogether, participants reported increased physical activity levels (p = <0.01) and cognitive activity levels (p = <0.01). The virtual MiM program is acceptable, safe, and effective at improving quality of life, cognitive and physical activity levels for PLWD, and cognitive and physical activity levels among CP.

Mild Behavioral Impairment and Cerebrovascular Profiles Are Associated with Early Cognitive Impairment in a Community-Based Southeast Asian Cohort

Background

Mild behavioral impairment (MBI) is one of the earliest observable changes when a person experiences cognitive decline and could be an early manifestation of underlying Alzheimer's disease neuropathology. Limited attention has been given to investigating the clinical applicability of behavioral biomarkers for detection of prodromal dementia.

Objective

This study compared the prevalence of self-reported MBI and vascular risk factors in Southeast Asian adults to identify early indicators of cognitive impairment and dementia.

Methods

This cohort study utilized baseline data from the Biomarkers and Cognition Study, Singapore (BIOCIS). 607 participants were recruited and classified into three groups: cognitively normal (CN), subjective cognitive decline (SCD), and mild cognitive impairment (MCI). Group comparisons of cognitive-behavioral, neuroimaging, and blood biomarkers data were applied using univariate analyses. Multivariate logistic regression analyses were conducted to investigate the association between cerebrovascular disease, vascular profiles, and cognitive impairment.

Results

SCD had significantly higher depression scores and poorer quality of life (QOL) compared to CN. MCI had significantly higher depression scores; total MBI symptoms, MBI-interest, MBI-mood, and MBI-beliefs; poorer sleep quality; and poorer QOL compared to CN. Higher Staals scores, glucose levels, and systolic blood pressure were significantly associated with MCI classification. Fasting glucose levels were significantly correlated with depression, anxiety, MBI-social, and poorer sleep quality.

Conclusions

The results reflect current research that behavioral changes are among the first symptoms noticeable to the person themselves as they begin to experience cognitive decline. Self-reported questionnaires may aid in early diagnoses of prodromal dementia. Behavioral changes and diabetes could be potential targets for preventative healthcare for dementia.

Assessing Quality of Life, Economic Burden, and Independence Across the Alzheimer's Disease Continuum Using Patient-Caregiver Dyad Surveys

Background

Alzheimer's disease (AD) and mild cognitive impairment (MCI) have negative quality of life (QoL) and economic impacts on patients and their caregivers and may increase along the disease continuum from MCI to mild, moderate, and severe AD.

Objective

To assess how patient and caregiver QoL, indirect and intangible costs are associated with MCI and AD severity.

Methods

An on-line survey of physician-identified patient-caregiver dyads living in the United States was conducted from June-October 2022 and included questions to both patients and their caregivers. Dementia Quality of Life Proxy, the Care-related Quality of Life, Work Productivity and Activity Impairment, and Dependence scale were incorporated into the survey. Regression analyses investigated the association between disease severity and QoL and cost outcomes with adjustment for baseline characteristics.

Results

One-hundred patient-caregiver dyads were assessed with the survey (MCI, n = 27; mild AD, n = 27; moderate AD, n = 25; severe AD, n = 21). Decreased QoL was found with worsening severity in patients (p < 0.01) and in unpaid (informal) caregivers (n = 79; p = 0.02). Dependence increased with disease severity (p < 0.01). Advanced disease severity was associated with higher costs to employers (p = 0.04), but not with indirect costs to caregivers. Patient and unpaid caregiver intangible costs increased with disease severity (p < 0.01). A significant trend of higher summed costs (indirect costs to caregivers, costs to employers, intangible costs to patients and caregivers) in more severe AD was observed (p < 0.01).

Conclusions

Patient QoL and functional independence and unpaid caregiver QoL decrease as AD severity increases. Intangible costs to patients and summed costs increase with disease severity and are highest in severe AD.

Cost consequence analysis of transcutaneous tibial nerve stimulation (TTNS) for urinary incontinence in care home residents alongside a randomised controlled trial

BACKGROUND

Urinary incontinence (UI) is prevalent in more than half of residents of nursing and residential care homes and can have a detrimental impact on dignity and quality of life. Care homes predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous tibial nerve stimulation (TTNS) is a non-invasive, safe, low-cost intervention with demonstrated effectiveness for reducing UI in adults. We examined the costs and consequences of delivering TTNS to care home residents in comparison to sham (inactive) electrical stimulation.

METHODS

A cost consequence analysis approach was used to assemble and present the resource use and outcome data for the ELECTRIC trial which randomised 406 residents with UI from 37 care homes in the United Kingdom to receive 12 sessions of 30 min of either TTNS or sham (inactive) TTNS. TTNS was administered by care home staff over 6 weeks. Health state utility was measured using DEMQOL-U and DEMQOL-PROXY-U at baseline, 6 weeks and 18 weeks follow-up. Staff completed a resource use questionnaire at baseline, 6 weeks and 18 weeks follow-up, which also assessed use of absorbent pads.

RESULTS

HRQoL did not change significantly in either randomised group. Delivery of TTNS was estimated to cost £81.20 per participant, plus training and support costs of £121.03 per staff member. 85% of participants needed toilet assistance as routine, on average requiring one or two staff members to be involved 4 or 5 times in each 24 h. Daily use of mobility aids and other assistive devices to use the toilet were reported. The value of staff time to assist residents to use the toilet (assuming an average of 5 min per resident per visit) was estimated as £19.17 (SD 13.22) for TTNS and £17.30 (SD 13.33) for sham (per resident in a 24-hour period).

CONCLUSIONS

Use of TTNS to treat UI in care home residents did not lead to changes in resource use, particularly any reduction in the use of absorbent pads and no cost benefits for TTNS were shown. Managing continence in care homes is labour intensive, requiring both high levels of staff time and use of equipment aids.

TRIAL REGISTRATION

ISRCTN98415244, registered 25/04/2018. NCT03248362 (Clinical trial.gov number), registered 14/08//2017.

Connecting Today: Feasibility and acceptability of a remote visiting program for people living with dementia in long-term care homes

OBJECTIVES

Social isolation and loneliness affect the quality of life of people living with dementia, yet few interventions have been developed for this population. The purpose of this study was to assess the feasibility and acceptability of 'Connecting Today', a remote visiting program designed for use with care home residents living with dementia.

METHODS

This was a feasibility study to assess whether Connecting Today can be delivered in care homes, and was acceptable to family and friends and people living with dementia. We used a single-group before/after design and included residents ≥ 65 years old with a dementia diagnosis from two care homes in Alberta, Canada. Connecting Today involved up to 60 min per week of facilitated remote visits for 6 weeks. To understand feasibility, we assessed rates and reasons for non-enrollment, withdrawal and missing data. We assessed acceptability with the Observed Emotion Rating Scale (residents) and a Treatment Perception and Preferences Questionnaire (family and friends). Data were analyzed with descriptive statistics.

RESULTS

Of 122 eligible residents, 19.7% (n = 24) enrolled (mean age = 87.9 years, 70.8% females). Three residents withdrew from the study before the first week of calls. Among 21 remaining residents, 62%-90% completed at least 1 call each week. All the calls were completed by videoconference, rather than by phone. Alertness and pleasure were observed for ≥92% of residents during calls. The 24 contacts rated Connecting Today as logical, effective and low risk.

CONCLUSIONS

Facilitated, remote visits are feasible and highly acceptable to residents and their family and friend contacts. Connecting Today shows promise to address social isolation and loneliness for people living with moderate to severe dementia because it can promote positive engagement in meaningful interactions with their family and friends while they are living in a care home. Future studies will test effectiveness of Connecting Today in a large sample.

A rehabilitation intervention to improve recovery after an episode of delirium in adults over 65 years (RecoverED): study protocol for a multi-centre, single-arm feasibility study

BACKGROUND

Delirium affects over 20% of all hospitalised older adults. Delirium is associated with a number of adverse outcomes following hospital admission including cognitive decline, anxiety and depression, increased mortality and care needs. Previous research has addressed prevention of delirium in hospitals and care homes, and there are guidelines on short-term treatment of delirium during admission. However, no studies have addressed the problem of longer-term recovery after delirium and it is currently unknown whether interventions to improve recovery after delirium are effective and cost-effective. The primary objective of this feasibility study is to test a new, theory-informed rehabilitation intervention (RecoverED) in older adults delivered following a hospital admission complicated by delirium to determine whether (a) the intervention is acceptable to individuals with delirium and (b) a definitive trial and parallel economic evaluation of the intervention are feasible.

METHODS

The study is a multi-centre, single-arm feasibility study of a rehabilitation intervention with an embedded process evaluation. Sixty participants with delirium (aged > 65 years old) and carer pairs will be recruited from six NHS acute hospitals across the UK. All pairs will be offered the intervention, with follow-up assessments conducted at 3 months and 6 months post-discharge home. The intervention will be delivered in participants' own homes by therapists and rehabilitation support workers for up to 10 intervention sessions over 12 weeks. The intervention will be tailored to individual needs, and the chosen intervention plan and goals will be discussed and agreed with participants and carers. Quantitative data on reach, retention, fidelity and dose will be collected and summarised using descriptive statistics. The feasibility outcomes that will be used to determine whether the study meets the criteria for progression to a definitive randomised controlled trial (RCT) include recruitment, delivery of the intervention, retention, data collection and acceptability of outcome measures. Acceptability of the intervention will be assessed using in-depth, semi-structured qualitative interviews with participants and healthcare professionals.

DISCUSSION

Findings will inform the design of a pragmatic multi-centre RCT of the effectiveness and cost-effectiveness of the RecoverED intervention for helping the longer-term recovery of people with delirium compared to usual care.

TRIAL REGISTRATION

The feasibility study was registered: ISRCTN15676570.

Do communication interventions affect the quality-of-life of people with dementia and their families? A systematic review

OBJECTIVES

Speech, language and communication difficulties are prevalent in all dementia subtypes and are likely to considerably impact the quality-of-life of people with dementia and their families. Communication interventions provided by trained professionals are recommended for this population, but little is known about their quality-of-life outcomes. This review aims to explore the quality-of-life outcomes of communication-related interventions for people with dementia and their families.

METHODS

Seven databases were systematically searched. Reference lists from included studies and relevant systematic reviews were also hand-searched. Primary research with quantitative quality-of-life outcomes were included. Narrative analysis was utilised to identify key intervention features and to describe quality-of-life outcomes.

RESULTS

1,174 studies were identified. Twelve studies were eligible for inclusion. Studies were heterogeneous in location, participant group, methodologies, interventions and outcome measures. Four studies reported increased quality-of-life for people with dementia following intervention. No studies reported increased quality-of-life for family members.

CONCLUSION

Further research is needed in this area. The studies which reported improved quality-of-life involved multi-disciplinary approaches to intervention, involvement of family caregivers, and functional communication intervention. However, data is limited so results should be interpreted with caution. The standardised use of a communication-focused quality-of-life outcome measure would improve sensitivity and comparability of future studies.

Protocol for the feasibility and implementation study of a model of best practice in primary care led postdiagnostic dementia care: PriDem

INTRODUCTION

Care is often inadequate and poorly integrated after a dementia diagnosis. Research and policy highlight the unaffordability and unsustainability of specialist-led support, and instead suggest a task-shared model, led by primary care. This study is part of the PriDem primary care led postdiagnostic dementia care research programme and will assess delivery of an evidence-informed, primary care based, person-centred intervention. The intervention involves Clinical Dementia Leads (CDLs) working in primary care to develop effective dementia care systems that build workforce capacity and support teams to deliver tailored support to people living with dementia and their carers.

METHODS AND ANALYSIS

This is a 15-month mixed-methods feasibility and implementation study, situated in four National Health Service (NHS) primary care networks in England. The primary outcome is adoption of personalised care planning by participating general practices, assessed through a patient records audit. Feasibility outcomes include recruitment and retention; appropriateness and acceptability of outcome measures; acceptability, feasibility and fidelity of intervention components. People living with dementia (n=80) and carers (n=66) will be recruited through participating general practices and will complete standardised measures of health and well-being. Participant service use data will be extracted from electronic medical records. A process evaluation will explore implementation barriers and facilitators through methods including semistructured interviews with people living with dementia, carers and professionals; observation of CDL engagement with practice staff; and a practice fidelity log. Process evaluation data will be analysed qualitatively using codebook thematic analysis, and quantitatively using descriptive statistics. Economic analysis will determine intervention cost-effectiveness.

ETHICS AND DISSEMINATION

The study has received favourable ethical opinion from Wales REC4. NHS Confidentiality Advisory Group support allows researchers preconsent access to patient data. Results will inform intervention adaptations and a future large-scale evaluation. Dissemination through peer-review journals, engagement with policy-makers and conferences will inform recommendations for dementia services commissioning.

TRIAL REGISTRATION NUMBER

ISRCTN11677384.

Endovis Nail versus Dynamic Hip Screw for Unstable Pertrochanteric Fractures: A Feasibility Randomised Control Trial including Patients with Cognitive Impairment

A prospective, feasibility, randomised study was performed to compare intramedullary versus extramedullary fixation of unstable pertrochanteric fractures and to assess the feasibility of including patients with dementia. From July 2016 to November 2017, 60 consecutive patients with an unstable pertrochanteric (OTA/AO 31-A2) fracture were randomized to either receive a short cephalomedullary nail (Endovis EBA², Citieffe) or a dynamic hip screw (DHS, Zimmer Biomet). Primary feasibility measures included randomisation, recruitment, and retention rates. Secondary outcomes included peri-operative parameters, patient-reported outcomes and radiographic outcomes. Patients were followed-up at two, four, and twelve weeks. There was no difference in the randomisation rate between patients with and without cognitive impairment. Significantly more patients without cognitive impairment attended the 12-week follow-up. The overall recruitment rate was 0.9 patients per week. Patients treated with the nail had less pain at 2 weeks and less neck collapse, medialisation, and leg shortening at all time points. The rest of secondary outcomes were similar. Patients with dementia can successfully be enrolled in a randomised trial on hip fractures. Patients treated with the Endovis nail had lower levels of pain at two weeks and better radiographic outcomes.

Outcome measures for Alzheimer's disease: A global inter-societal Delphi consensus

INTRODUCTION

We aim to provide guidance on outcomes and measures for use in patients with Alzheimer's clinical syndrome.

METHODS

A consensus group of 20 voting members nominated by 10 professional societies, and a non-voting chair, used a Delphi approach and modified GRADE criteria.

RESULTS

Consensus was reached on priority outcomes (n = 66), measures (n = 49) and statements (n = 37) across nine domains. A number of outcomes and measurement instruments were ranked for: Cognitive abilities; Functional abilities/dependency; Behavioural and neuropsychiatric symptoms; Patient quality of life (QoL); Caregiver QoL; Healthcare and treatment-related outcomes; Medical investigations; Disease-related life events; and Global outcomes.

DISCUSSION

This work provides indications on the domains and ideal pertinent measurement instruments that clinicians may wish to use to follow patients with cognitive impairment. More work is needed to develop instruments that are more feasible in the context of the constraints of clinical routine.

The impact of a cognitive impairment support program on patients in an acute care setting: a pre-test post-test intervention study

BACKGROUND

Patients with cognitive impairment are at greater risk of hospital acquired complications, longer hospital stays, and poor health outcomes compared to patients without cognitive impairment. The Cognitive Impairment Support Program is a multi-disciplinary approach to improve screening rates and awareness of patients with cognitive impairment and guide clinician response and communication during their hospitalisation to improve health outcomes.

OBJECTIVE

This study evaluated the impact of implementing the Cognitive Impairment Support Program on patient hospital acquired complications, patient reported quality of life and staff satisfaction in an outer metropolitan hospital.

DESIGN

A pre-test post-test design was used to collect data in two 6-month time periods between March 2020 and November 2021.

PARTICIPANTS

Patients aged ≥ 65 years, admitted to a participating ward for > 24 h.

INTERVENTION

The Cognitive Impairment Support Program consisted of four components: cognitive impairment screening, initiation of a Cognitive Impairment Care Plan, use of a Cognitive Impairment Identifier and associated staff education.

MEASURES

The primary outcome was hospital acquired complications experienced by patients with cognitive impairment identified using clinical coding data. Secondary outcomes were patient quality of life and a staff confidence and perceived organisational support to care for patients with cognitive impairment.

RESULTS

Hospital acquired complication rates did not vary significantly between the two data collection periods for patients experiencing cognitive impairment with a 0.2% (95% confidence interval: -5.7-6.1%) reduction in admissions with at least one hospital acquired complication. Patients in the post intervention period demonstrated statistically significant improvements in many items in two of the Dementia Quality of Life Measure domains: memory and everyday life. The staff survey indicated statistically significant improvement in clinical staff confidence to care for patients with cognitive impairment (p = 0.003), satisfaction with organisational support for patients (p = 0.004) and job satisfaction (p ≤ 0.001).

CONCLUSION

This study provides evidence that a multicomponent Cognitive Impairment Support Program had a positive impact on staff confidence and satisfaction and patient quality of life. Broader implementation with further evaluation of the multicomponent cognitive impairment intervention across a range of settings using varied patient outcomes is recommended.

A co-designed health information system implementation into residential aged care: A mixed-method evaluation

INTRODUCTION

Internationally, the adoption of technology into residential aged care settings has been slow and fraught with multiple challenges for residents, staff and service providers. The aim of this study was to evaluate the acceptability, efficiency, and quality of health information system implementation into aged care.

METHODS

Three-stage, mixed-methods participatory action research, concurrent with the natural experiment of a co-designed health information system implementation into a 169-bed aged care home in Australia. Data were collected pre-, during, and post implementation between 2019 and 2021. Qualitative data included focus groups, interviews, and observations. Quantitative data included work observations, pedometers, record audits, incident reports and staff and resident surveys. There were 162 participants composed of 65 aged care residents, 90 staff, and 7 managers/consultants.

RESULTS

Improved work efficiency included reduced staff time searching for information (6%); reduced nurse time on documentation (20.4% to 6.4%), and 25% less steps. Documentation improvement included resident assessments (68% to 96%); resident-focused goals (56% to 88%) and evaluations (31% to 88%). The staff reported being better equipped to manage the 'delicacies of dignity'.

CONCLUSION

Implementation of a health information system into a residential aged care facility was associated with improved resident-focused care and staff efficiency.

CLINICAL RELEVANCE

Technology can support nurses and care staff to spend more time with residents in residential aged care homes, improve the quality of resident care, and assist meeting regulatory reporting requirements. Flexible and tailored co-design strategies can enhance both effectiveness and success of technology implementation into residential aged care.

Psychological well-being in persons with dementia: The role of caregiver expressed emotion

OBJECTIVES

Dementia is a growing health concern. Persons with dementia experience higher levels of anxiety and depression, which correlates with poorer quality of life, disability and hospitalization. This is one of the few studies to use a longitudinal design to assess the impact of expressed emotion (EE) on well-being in dementia over time.

METHODS

Sixty-one people with dementia and their main informal caregiver were recruited from memory services. Caregiver EE was coded from a Camberwell Family Interview conducted at time one. Person with dementia's outcome measures (quality of life, depression and anxiety) were collected at time one and at 6-months follow-up.

RESULTS

Caregiver high EE was associated with higher levels of depression in people with dementia and greater anxiety at follow-up. Emotional over involvement predicted greater anxiety and critical comments predicted greater depression. Low EE appeared to have a protective effect on well-being in people with dementia. People with dementia with low EE caregivers experienced a small reduction in depression and anxiety over time, whereas those with high-EE caregivers maintained baseline levels of depression and anxiety.

CONCLUSIONS

Caregiver high EE is associated with poorer psychological outcomes for people with dementia over time. Psychological therapies, such as cognitive behavioural therapy informed family interventions should be used to reduce high EE within carer and person with dementia relationships.

Psychometric Evaluation of the Chinese Version of Mild Cognitive Impairment Questionnaire among Older Adults with Mild Cognitive Impairment

BACKGROUND

There is a lack of instruments for measuring quality of life (QOL) in Chinese patients with mild cognitive impairment (MCI). This study aimed to translate the Mild Cognitive Questionnaire (MCQ) into the Chinese language and to evaluate the reliability and construct validity of the MCQ-Chinese among older adults with MCI.

METHODS

Linguistic translation and validation of the questionnaire were conducted according to the MCQ developer and Oxford University Innovation guidelines. After a pilot test, the final version of the MCQ-Chinese was applied to a convenience sample of older adults with MCI (n = 186). Cronbach's alpha and confirmatory factor analyses were used to assess the reliability and construct validity of the MCQ-Chinese. In addition, non-parametric analysis was used to assess convergent and discriminant validity.

RESULTS

The total scale and all the factors had good internal consistency, with Cronbach's alpha values ranging from 0.90 to 0.92. Confirmatory factor analysis indicated satisfactory goodness of fit for the 2-factor MCQ. The MCQ-Chinese had a good convergent validity, and the discriminant validity was confirmed with a significant difference in MCQ scores in different health conditions.

CONCLUSIONS

MCQ-Chinese is a reliable tool for assessing QOL among Chinese older adults with MCI.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sustaining Our Relationship: Dyadic Interactions Supported by Technology for People with Dementia and Their Informal Caregivers

Impaired memory function and challenges in communication affect the ability of people living with dementia to interact with family caregivers socially. The onset of dementia in a family member and the communication challenges that follow can lead to conflict, isolation and loss of closeness in the relationship. I-CARE is a tablet-based technology providing leisure activities specifically designed for people living with dementia to do in tandem with caregivers. The intention is that caregiving dyads engage with I-CARE together, using the activities contained in the system as the basis for positive social interactions. This paper reports on a mixed-methods feasibility study of I-CARE, evaluating the system's usability and assessing the impact on caregiving dyads. We also explored barriers and facilitators to independent use of the technology among community-dwelling people living with dementia and their family caregiver. Results suggest that I-CARE is a feasible tool to facilitate positive experiences in dementia caregiving dyads. Important relationship outcomes for the participating dyads were enrichment in social interactions, facilitated communication, having a shared activity and relationship sustenance. Successful uptake requires continuous proactive support tailored to the needs and preconditions of users over an extended time until they feel confident using the system independently.

Social care-related quality of life of people with dementia and their carers in England

People with dementia and their carers are a growing subgroup of people who use community-based social care. These services are designed to maintain people's quality of life while living at home. The ASCOT measure of social care-related quality of life (SCRQoL), designed to evaluate quality and effectiveness of social care, has been adapted for proxy-report when someone is unable to self-report. The ASCOT-Carer has been developed to measure carer's own SCRQoL. This study sought to establish the factors related to SCRQoL of people living with dementia (PLWD, proxy-reported by carers) and their carers. Data were collected via a self-administered postal or online survey of 313 carers in England, from January 2020 to April 2021. Carers were eligible if they supported someone living with dementia at home, who was unable to self-complete questionnaires. The person living with dementia or their carer had to use at least one social care service, e.g. home care. We recruited participants via an online volunteer panel and NHS sites. Multiple regression was applied to explore the factors significantly related to ASCOT SCRQoL by self- and proxy-report. Key influences on carers' own SCRQoL were their health, financial difficulties associated with caring, and satisfaction with social care support. Inadequate home design was significantly negatively associated with SCRQoL for PLWD. The latter stages of the pandemic-related restrictions (the tier system from 2nd December 2020 to study end, April 2021) were associated with significantly worse SCRQoL for PLWD, but not for carers. The study offers insight into the factors associated with SCRQoL. In particular, the findings highlight the importance of adequate home design for people with dementia; satisfactory social care support and limiting any adverse financial impact of caring are important for carers. The findings indicate a negative effect of COVID restrictions on SCRQoL of people with dementia.

Longitudinal Trajectories of Quality of Life Among People With Mild-to-Moderate Dementia: A Latent Growth Model Approach With IDEAL Cohort Study Data

OBJECTIVES

We aimed to examine change over time in self-rated quality of life (QoL) in people with mild-to-moderate dementia and identify subgroups with distinct QoL trajectories.

METHODS

We used data from people with mild-to-moderate dementia followed up at 12 and 24 months in the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study (baseline n = 1,537). A latent growth model approach examined mean change over time in QoL, assessed with the QoL-AD scale, and investigated associations of baseline demographic, cognitive, and psychological covariates with the intercept and slope of QoL. We employed growth mixture modeling to identify multiple growth trajectories.

RESULTS

Overall mean QoL scores were stable and no associations with change over time were observed. Four classes of QoL trajectories were identified: 2 with higher baseline QoL scores, labeled Stable (74.9%) and Declining (7.6%), and 2 with lower baseline QoL scores, labeled Stable Lower (13.7%) and Improving (3.8%). The Declining class had higher baseline levels of depression and loneliness, and lower levels of self-esteem and optimism, than the Stable class. The Stable Lower class was characterized by disadvantage related to social structure, poor physical health, functional disability, and low psychological well-being. The Improving class was similar to the Stable Lower class but had lower cognitive test scores.

DISCUSSION

Understanding individual trajectories can contribute to personalized care planning. Efforts to prevent decline in perceived QoL should primarily target psychological well-being. Efforts to improve QoL for those with poorer QoL should additionally address functional impairment, isolation, and disadvantage related to social structure.

The impact of an occupational therapy group cognitive rehabilitation program for people with dementia

INTRODUCTION

This study was conducted to examine the impact of a group cognitive rehabilitation program for people with dementia on everyday memory function and quality of life.

METHODS

Participants included in the study were community-dwelling adults with a diagnosis of dementia. The intervention was a 5-week occupational therapy lead group cognitive rehabilitation program delivered once a week for 1.5 h. Outcome measures included standardised memory tests, subjective everyday memory function and quality of life ratings. The measures were completed at baseline, post-intervention and 3-month post-intervention.

RESULTS

Outcome measures were completed with 58 participants. Statistically significant improvements in standardised memory scores were noted following the intervention. Similarly, self-rated everyday memory function and quality of life scores significantly improved following the intervention. All standardised scores and subjective ratings were maintained at 3-month follow-up.

CONCLUSION

Group-based cognitive rehabilitation programs can positively impact the quality of life and everyday memory function among people with dementia.

An intervention to promote self-management, independence and self-efficacy in people with early-stage dementia: the Journeying through Dementia RCT

BACKGROUND

There are few effective interventions for dementia.

AIM

To determine the clinical effectiveness and cost-effectiveness of an intervention to promote self-management, independence and self-efficacy in people with early-stage dementia.

OBJECTIVES

To undertake a randomised controlled trial of the Journeying through Dementia intervention compared with usual care, conduct an internal pilot testing feasibility, assess intervention delivery fidelity and undertake a qualitative exploration of participants' experiences.

DESIGN

A pragmatic two-arm individually randomised trial analysed by intention to treat.

PARTICIPANTS

A total of 480 people diagnosed with mild dementia, with capacity to make informed decisions, living in the community and not participating in other studies, and 350 supporters whom they identified, from 13 locations in England, took part.

INTERVENTION

Those randomised to the Journeying through Dementia intervention (n = 241) were invited to take part in 12 weekly facilitated groups and four one-to-one sessions delivered in the community by secondary care staff, in addition to their usual care. The control group (n = 239) received usual care. Usual care included drug treatment, needs assessment and referral to appropriate services. Usual care at each site was recorded.

MAIN OUTCOME MEASURES

The primary outcome was Dementia-Related Quality of Life score at 8 months post randomisation, with higher scores representing higher quality of life. Secondary outcomes included resource use, psychological well-being, self-management, instrumental activities of daily living and health-related quality of life.

RANDOMISATION AND BLINDING

Participants were randomised in a 1 : 1 ratio. Staff conducting outcome assessments were blinded.

DATA SOURCES

Outcome measures were administered in participants' homes at baseline and at 8 and 12 months post randomisation. Interviews were conducted with participants, participating carers and interventionalists.

RESULTS

The mean Dementia-Related Quality of Life score at 8 months was 93.3 (standard deviation 13.0) in the intervention arm (n = 191) and 91.9 (standard deviation 14.6) in the control arm (n = 197), with a difference in means of 0.9 (95% confidence interval -1.2 to 3.0; p = 0.380) after adjustment for covariates. This effect size (0.9) was less than the 4 points defined as clinically meaningful. For other outcomes, a difference was found only for Diener's Flourishing Scale (adjusted mean difference 1.2, 95% confidence interval 0.1 to 2.3), in favour of the intervention (i.e. in a positive direction). The Journeying through Dementia intervention cost £608 more than usual care (95% confidence interval £105 to £1179) and had negligible difference in quality-adjusted life-years (-0.003, 95% confidence interval -0.044 to 0.038). Therefore, the Journeying through Dementia intervention had a mean incremental cost per quality-adjusted life-year of -£202,857 (95% confidence interval -£534,733 to £483,739); however, there is considerable uncertainty around this. Assessed fidelity was good. Interviewed participants described receiving some benefit and a minority benefited greatly. However, negative aspects were also raised by a minority. Seventeen per cent of participants in the intervention arm and 15% of participants in the control arm experienced at least one serious adverse event. None of the serious adverse events were classified as related to the intervention.

LIMITATIONS

Study limitations include recruitment of an active population, delivery challenges and limitations of existing outcome measures.

CONCLUSIONS

The Journeying through Dementia programme is not clinically effective, is unlikely to be cost-effective and cannot be recommended in its existing format.

FUTURE WORK

Research should focus on the creation of new outcome measures to assess well-being in dementia and on using elements of the intervention, such as enabling enactment in the community.

TRIAL REGISTRATION

This trial is registered as ISRCTN17993825.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 24. See the NIHR Journals Library website for further project information.

The Cognition and Flow Study (CogFlowS): A Mixed Method Evaluation of a Randomized Feasibility Trial of Cognitive Training in Dementia

Background: Cognitive training (CT) may be beneficial in delaying the onset or slowing dementia progression. CT has been evaluated quantitatively and qualitatively, but none have used mixed methods approaches. Objective: The aim of this study was to use a mixed methods approach to identify those who may selectively benefit from CT. Methods: This was an explanatory sequential mixed methods study involving a quantitative randomized trial of 12 weeks multi-domain CT in healthy older adults (HC, n = 20), and people living with mild cognitive impairment (MCI; n = 12) and dementia (n = 24). Quantitative outcomes included: cognition, mood, quality of life, and activities of daily living. 28 (10 HC, 6 MCI, 12 dementia) training participants completed semi-structured interviews with their carer. Quantitative and qualitative data were integrated using joint displays. Results: Three participants dropped out from the training early-on, leaving 25 participants with follow-up data for full integration (10 HC, 6 MCI, 9 dementia). Dropouts and lower adherence to training were more common in dementia participants with greater non-modifiable barriers. High adherers were more resilient to negative emotions, and poorer or fluctuating performance. Integrated analysis found the majority of participants (n = 24) benefited across outcomes, with no clear profile of individuals who benefited more than others. Participants made a number of key recommendations to improve adherence and minimize dropout to CT. Conclusion: Reasons for dropout and low adherence were identified, with recommendations provided for the design of CT for dementia. An individual approach to training should be adopted and low adherence should not preclude engagement with CT.

The Journeying through Dementia psychosocial intervention versus usual care study: a single-blind, parallel group, phase 3 trial

BACKGROUND

There is an urgent clinical need for evidence-based psychosocial interventions for people with mild dementia. We aimed to determine the clinical benefits and cost-effectiveness of Journeying through Dementia (JtD), an intervention designed to promote wellbeing and independence in people with mild dementia.

METHODS

We did a single-blind, parallel group, individually randomised, phase 3 trial at 13 National Health Service sites across England. People with mild dementia (Mini-Mental State Examination score of ≥18) who lived in the community were eligible for inclusion. Patients were centrally randomly assigned (1:1) to receive the JtD intervention plus standard care (JtD group) or standard care only (standard care group). Randomisation was stratified by study site. The JtD intervention included 12 group and four one-to-one sessions, delivered in the community at each site. The primary endpoint was Dementia Related Quality of Life (DEMQOL) 8 months after randomisation, assessed according to the intention-to-treat principle. Only outcome assessors were masked to group assignment. A cost-effectiveness analysis reported cost per quality-adjusted life-year (QALY) from a UK NHS and social care perspective. The study is registered with ISRCTN, ISRCTN17993825.

FINDINGS

Between Nov 30, 2016, and Aug 31, 2018, 1183 patients were screened for inclusion, of whom 480 (41%) participants were randomly assigned: 241 (50%) to the JtD group and 239 (50%) to the standard care group. Intervention adherence was very good: 165 (68%) of 241 participants in the JtD group attended at least ten of the 16 sessions. Mean DEMQOL scores at 8 months were 93·3 (SD 13·0) for the JtD group and 91·9 (SD 14·6) for the control group. Difference in means was 0·9 (95% CI -1·2 to 3·0; p=0·38) after adjustment for covariates, lower than that identified as clinically meaningful. Incremental cost per QALY ranged from £88 000 to -£205 000, suggesting that JtD was not cost-effective. Unrelated serious adverse events were reported by 40 (17%) patients in the JtD group and 35 (15%) patients in the standard care group.

INTERPRETATION

In common with other studies, the JtD intervention was not proven effective. However, this complex trial successfully recruited and retained people with dementia without necessarily involving carers. Additionally, people with dementia were actively involved as participants and study advisers throughout. More research into methods of measuring small, meaningful changes in this population is needed. Questions remain regarding how services can match the complex, diverse, and individual needs of people with mild dementia, and how interventions to meet such needs can be delivered at scale.

FUNDING

UK National Institute of Health Research Health Technology Assessment Programme.

Covid-19 and the quality of life of people with dementia and their carers-The TFD-C19 study

Introduction

COVID-19 has placed unprecedented pressure on dementia health and social care systems worldwide. This has resulted in reduced services and support for people with dementia and their family carers. There are gaps in the evidence on the impact of the pandemic on Quality of Life (QoL). We carried out a study on the impact of the pandemic on the QoL of a group of people with dementia and their family carers who were part of a larger existing cohort study.

Methods

We quantitatively measured QoL, on two occasions during the two national lockdowns in 2020 and compared these data with those obtained when they entered the study (before the pandemic). Measures used included: DEMQOL-Proxy, Clinical Dementia Rating Scale and C-DEMQOL. To understand how QoL changed over time, a repeated measures ANOVA was run for each dependent variable with the following variables entered as co-variates: duration in study, baseline dementia severity, gender of the family carer, gender of the person with dementia, family carer relationship, dementia type, living status, age of the person with dementia, and age of the family carer.

Results

248 participants took part in the study. QoL scores did not significantly decline between either time period for the person with dementia or their family carer. There was variation in subgroups; with co-resident status, carer relationship, gender of the person with dementia, age of the person with dementia, and baseline cognitive status influencing QoL outcomes in family carers.

Discussion

It is striking that people with dementia and their carers did not report a decline in QoL during the pandemic or in the months following restrictions suggesting the possibility of resilience. Variation in subgroups suggests that specific groups of family carers were more vulnerable to lower QoL; indicating the need for more tailored, nuanced support during this period.

Care home residents with dementia: Prevalence, incidence, and associations with sleep disturbance in an English cohort study

INTRODUCTION

People living with dementia in care homes often have sleep disturbances, but little is known about incidence and importance.

METHODS

We interviewed 1483 participants in 97 care homes and report prevalence, 1-year incidence, and baseline associations of clinically significant sleep disturbance in people with dementia.

RESULTS

Baseline prevalence of clinically significant sleep disturbance was 13.7% (200/1460); 31.3% (457/1462) had them at least once over 16 months. One-year incidence was 25.2%. At baseline, residents with sleep disturbance had lower quality of life (mean difference -4.84; 95% confidence interval [CI] -6.53 to -3.16) and were more frequently prescribed sleep medications (odds ratio 1.75; CI 1.17 to 2.61) than other residents.

DISCUSSION

Approximately one-third of care home residents with dementia have or develop sleep disturbances over 1 year. These are associated with lower quality of life and prescription of sedatives, which may have negative outcomes; therefore, it is important to develop effective treatments.

A multidomain decision support tool to prevent falls in older people: the FinCH cluster RCT

BACKGROUND

Falls in care home residents are common, unpleasant, costly and difficult to prevent.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness and cost-effectiveness of the Guide to Action for falls prevention in Care Homes (GtACH) programme.

DESIGN

A multicentre, cluster, parallel, 1 : 1 randomised controlled trial with embedded process evaluation and economic evaluation. Care homes were randomised on a 1 : 1 basis to the GtACH programme or usual care using a secure web-based randomisation service. Research assistants, participating residents and staff informants were blind to allocation at recruitment; research assistants were blind to allocation at follow-up. NHS Digital data were extracted blindly.

SETTING

Older people's care homes from 10 UK sites.

PARTICIPANTS

Older care home residents.

INTERVENTION

The GtACH programme, which includes care home staff training, systematic use of a multidomain decision support tool and implementation of falls prevention actions, compared to usual falls prevention care.

OUTCOMES

The primary trial outcome was the rate of falls per participating resident occurring during the 90-day period between 91 and 180 days post randomisation. The primary outcome for the cost-effectiveness analysis was the cost per fall averted, and the primary outcome for the cost-utility analysis was the incremental cost per quality adjusted life-year. Secondary outcomes included the rate of falls over days 0-90 and 181-360 post randomisation, activity levels, dependency and fractures. The number of falls per resident was compared between arms using a negative binomial regression model (generalised estimating equation).

RESULTS

A total of 84 care homes were randomised: 39 to the GtACH arm and 45 to the control arm. A total of 1657 residents consented and provided baseline measures (mean age 85 years, 32% men). GtACH programme training was delivered to 1051 staff (71% of eligible staff) over 146 group sessions. Primary outcome data were available for 630 GtACH participants and 712 control participants. The primary outcome result showed an unadjusted incidence rate ratio of 0.57 (95% CI 0.45 to 0.71; p < 0.01) in favour of the GtACH programme. Falls rates were lower in the GtACH arm in the period 0-90 days. There were no other differences between arms in the secondary outcomes. Care home staff valued the training, systematic strategies and specialist peer support, but the incorporation of the GtACH programme documentation into routine care home practice was limited. No adverse events were recorded. The incremental cost was £20,889.42 per Dementia Specific Quality of Life-based quality-adjusted life-year and £4543.69 per quality-adjusted life-year based on the EuroQol-5 dimensions, five-level version. The mean number of falls was 1.889 (standard deviation 3.662) in the GtACH arm and 2.747 (standard deviation 7.414) in the control arm. Therefore, 0.858 falls were averted. The base-case incremental cost per fall averted was £190.62.

CONCLUSION

The GtACH programme significantly reduced the falls rate in the study care homes without restricting residents' activity levels or increasing their dependency, and was cost-effective at current thresholds in the NHS.

FUTURE WORK

Future work should include a broad implementation programme, focusing on scale and sustainability of the GtACH programme.

LIMITATIONS

A key limitation was the fact that care home staff were not blinded, although risk was small because of the UK statutory requirement to record falls in care homes.

TRIAL REGISTRATION

This trial is registered as ISRCTN34353836.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 9. See the NIHR Journals Library website for further project information.

Effects of Drama Therapy on Depressive Symptoms, Attention, and Quality of Life in Patients With Dementia

BACKGROUND

The prevalence of dementia in Taiwan continues to rise, and related patient care is becoming challenging for family members and caregivers. Nondrug treatments are often used as a care strategy to alleviate the behaviors associated with worsening dementia. Many international researchers have examined the effectiveness of drama therapy on dementia care. However, there is a lack of related studies in Taiwan.

PURPOSE

The aim of this study was to examine the effects of drama therapy in terms of improving depressive symptoms, attention, and quality of life in patients with senile dementia.

METHODS

A two-group pretest-and-posttest design was employed in this randomized controlled trial. Cluster sampling was employed at four dementia daycare centers in central Taiwan. Two centers were randomly assigned to the experimental group, and the other two centers were assigned to the control group.

RESULTS

Forty-two patients with dementia (23 in the experimental group and 19 in the control group) participated in this study. The study results showed that, after 8 weeks of drama therapy, the experimental group showed a significant improvement in depressive symptoms (β = -5.07, p < .001), attention (β = 5.86, p < .001), and quality of life (β = -6.08, p < .001). Furthermore, after 12 weeks of drama therapy, the experimental group continued to show a significant improvement in depressive symptoms (β = -4.65, p < .01), attention (β = 6.76, p < .001), and quality of life (β = -4.94, p < .01).

CONCLUSIONS

On the basis of the results of this study, patients with senile dementia who participate in 8- and 12-week drama therapy programs significantly improved in terms of depressive symptoms, attention, and quality of life. The authors hope that the findings of this study provide a reference for the intervention method, content, frequency, and timing of drama therapy in patients with dementia.

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

OBJECTIVES

To determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes.

DESIGN

Multicentre, parallel, cluster randomised controlled trial.

SETTING

Long term care homes in the UK, registered to care for older people or those with dementia.

PARTICIPANTS

1657 consenting residents and 84 care homes. 39 were randomised to the intervention group and 45 were randomised to usual care.

INTERVENTIONS

Guide to Action for Care Homes (GtACH): a multifactorial fall prevention programme or usual care.

MAIN OUTCOME MEASURES

Primary outcome measure was fall rate at 91-180 days after randomisation. The economic evaluation measured health related quality of life using quality adjusted life years (QALYs) derived from the five domain five level version of the EuroQoL index (EQ-5D-5L) or proxy version (EQ-5D-5L-P) and the Dementia Quality of Life utility measure (DEMQOL-U), which were self-completed by competent residents and by a care home staff member proxy (DEMQOL-P-U) for all residents (in case the ability to complete changed during the study) until 12 months after randomisation. Secondary outcome measures were falls at 1-90, 181-270, and 271-360 days after randomisation, Barthel index score, and the Physical Activity Measure-Residential Care Homes (PAM-RC) score at 91, 180, 270, and 360 days after randomisation.

RESULTS

Mean age of residents was 85 years. 32% were men. GtACH training was delivered to 1051/1480 staff (71%). Primary outcome data were available for 630 participants in the GtACH group and 712 in the usual care group. The unadjusted incidence rate ratio for falls between 91 and 180 days was 0.57 (95% confidence interval 0.45 to 0.71, P<0.001) in favour of the GtACH programme (GtACH: six falls/1000 residents v usual care: 10 falls/1000). Barthel activities of daily living indices and PAM-RC scores were similar between groups at all time points. The incremental cost was £108 (95% confidence interval -£271.06 to 487.58), incremental QALYs gained for EQ-5D-5L-P was 0.024 (95% confidence interval 0.004 to 0.044) and for DEMQOL-P-U was 0.005 (-0.019 to 0.03). The incremental costs per EQ-5D-5L-P and DEMQOL-P-U based QALY were £4544 and £20 889, respectively.

CONCLUSIONS

The GtACH programme was associated with a reduction in fall rate and cost effectiveness, without a decrease in activity or increase in dependency.

TRIAL REGISTRATION

ISRCTN34353836.

An intervention to increase physical activity in care home residents: results of a cluster-randomised, controlled feasibility trial (the REACH trial)

BACKGROUND

Care home (CH) residents are mainly inactive, leading to increased dependency and low mood. Strategies to improve activity are required.

DESIGN AND SETTING

Cluster randomised controlled feasibility trial with embedded process and health economic evaluations. Twelve residential CHs in Yorkshire, United Kingdom, were randomised to the MoveMore intervention plus usual care (UC) (n = 5) or UC only (n = 7).

PARTICIPANTS

Permanent residents aged ≥65 years.

INTERVENTION

MoveMore: a whole home intervention involving all CH staff designed to encourage and support increase in movement of residents.

OBJECTIVES AND MEASUREMENTS

Feasibility objectives relating to recruitment, intervention delivery, data collection and follow-up and safety concerns informed the feasibility of progression to a definitive trial. Data collection at baseline, 3, 6 and 9 months included: participants' physical function and mobility, perceived health, mood, quality of life, cognitive impairment questionnaires; accelerometry; safety data; intervention implementation.

RESULTS

300 residents were screened; 153 were registered (62 MoveMore; 91 UC). Average cluster size: MoveMore: 12.4 CHs; UC: 13.0 CHs. There were no CH/resident withdrawals. Forty (26.1%) participants were unavailable for follow-up: 28 died (12 MoveMore; 16 UC); 12 moved from the CH. Staff informant/proxy data collection for participants was >80%; data collection from participants was <75%; at 9 months, 65.6% of residents provided valid accelerometer data; two CHs fully, two partially and one failed to implement the intervention. There were no safety concerns.

CONCLUSIONS

Recruiting CHs and residents was feasible. Intervention implementation and data collection methods need refinement before a definitive trial. There were no safety concerns.

Development, feasibility, and acceptability of an intervention to improve care for agitation in people living in nursing homes with dementia nearing the end-of-life

OBJECTIVES

To develop a staff training intervention for agitation in people with severe dementia, reaching end-of-life, residing in nursing homes (NHs), test feasibility, acceptability, and whether a trial is warranted.

DESIGN

Feasibility study with pre- and post-intervention data collection, qualitative interviews, and focus groups.

SETTING

Three NHs in South East England with dementia units, diverse in terms of size, ownership status, and location.

PARTICIPANTS

Residents with a dementia diagnosis or scoring ≥2 on the Noticeable Problems Checklist, rated as "severe" on Clinical Dementia Rating Scale, family carers, and staff (healthcare assistants and nurses).

INTERVENTION

Manualized training, delivered by nonclinical psychology graduates focusing on agitation in severe dementia, underpinned by a palliative care framework.

MEASUREMENTS

Main outcomes were feasibility of recruitment, data collection, follow-up, and intervention acceptability. We collected resident, family carer, and staff demographics. Staff provided data on resident's agitation, pain, quality of life, and service receipt. Staff reported their sense of competence in dementia care. Family carers reported on satisfaction with end-of-life care. In qualitative interviews, we explored staff and family carers' views on the intervention.

RESULTS

The target three NHs participated: 28 (49%) residents, 53 (74%) staff, and 11 (85%) family carers who were eligible to participate consented. Eight-four percent of staff attended ≥3 sessions, and we achieved 93% follow-up. We were able to complete quantitative interviews. Staff and family carers reported the intervention and delivery were acceptable and helpful.

CONCLUSIONS

The intervention was feasible and acceptable indicating a larger trial for effectiveness may be warranted.

Effect of a multi-domain intervention on the quality of life in older adults with major neurocognitive disorder: A pilot study

PURPOSE

Major neurocognitive disorders (MND) have multiple negative consequences on patients' lives and on their caregivers' health. Occupational therapy and cognitive stimulation have failed to show any significant efficacy on quality of life (QoL), cognitive functioning and behavioural symptoms. Bretonneau Hospital's Day Care Unit offers personalized and structured multi-domain interventions to cognitively impaired older patients on a weekly basis, for a 3-month period.

OBJECTIVES

Our objective was to determine whether a specific rehabilitation day care unit (RDCU) could influence the QoL of cognitively impaired community-dwelling elderly patients. We also aimed to better understand the characteristics of patients who had the most benefited from the RDCU.

METHODS

Retrospective study based on a sample of outpatients participating in RDCU during three months. All patients underwent a cognitive (MMS), functional (IADl, ADL) and behavioral (NPI) assessment. We compared QoL using the QoL-Alzheimer's Disease (QoL-AD) scale before and after RDCU.

RESULTS

Overall, we included 60 outpatients in our study (mean age 83.3±5.8; women=70%). We found a statistically significant improvement of QoL-AD scores after RDCU (31.8±4.9 to 32.9±5.2, P=0.008). Patients who benefitted the most from RDCU were older (P=0.01) and had lower baseline QoL (P=0.04). We did not find any other characteristics associated with QoL-AD score improvement in our population.

CONCLUSION

RDCU showed positive effects on QoL in this uncontrolled pilot study of older adults with MND. These findings should be confirmed in a future randomized controlled trial to corroborate the potential benefits of RDCU on QoL in older cognitively impaired patients.

Health-Related Quality of Life in Oral Cancer Patients: Scoping Review and Critical Appraisal of Investigated Determinants

BACKGROUND

health-related quality of life (HRQOL) represents a secondary endpoint of medical interventions in oncological patients. Our aim was to highlight potential sources of bias that could be encountered when evaluating HRQOL in oral cancer patients.

METHODS

this review followed PRISMA-ScR recommendations.

PARTICIPANTS

patients treated for oral cancer.

CONCEPT

HRQOL assessed by EORTC QLQ-C30 and QLQ-H&N35/QLQ-H&N43. A critical appraisal of included studies was performed to evaluate the accuracy of data stratification with respect to HRQOL determinants.

RESULTS

overall, 30 studies met the inclusion criteria, totaling 1833 patients. In total, 8 sociodemographic (SDG) and 15 disease/treatment-specific (DT) HRQOL determinants (independent variables) were identified. The mean number of the independent variables was 6.1 (SD, 4.3)-5.0 (SD, 4.0) DT-related and 1.1 (SD, 1.8) SDG-related variables per article. None of the included papers considered all the identified determinants simultaneously.

CONCLUSIONS

a substantial lack of evidence regarding HRQOL determinants was demonstrated. This strongly weakens the reliability of the reported findings due to the challenging presence of baseline confounding, selection, and omitted variable biases. The proposed approach recommends the use of further evaluation tools that gather more variables in a single score together with a selection of more homogeneous, reproducible, and comparable cohorts based on the identified baseline confounding.

Enteral tube feeding for people with severe dementia

BACKGROUND

The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing.

OBJECTIVES

To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers.

DATA COLLECTION AND ANALYSIS

Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study.

MAIN RESULTS

We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence).  Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia.

AUTHORS' CONCLUSIONS

We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.