Comparative validity of seven scoring systems for the instrumental activities of daily living scale in rural elders

Incidence of preoperative instrumental activities of daily living (IADL) dependence and adverse outcomes in older surgical patients: A systematic review and meta-analysis

STUDY OBJECTIVE

Instrumental activities of daily living (IADLs) are essential to patient function and quality of life after surgery. In older surgical patients, the incidence of preoperative IADL dependence has not been well characterized in the literature. This systematic review and meta-analysis aimed to determine the pooled incidence of preoperative IADL dependence and the associated adverse outcomes in the older surgical population.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) were searched for relevant articles from 1969 to April 2022.

PATIENTS

Patients aged ≥60 years old undergoing surgery with preoperative IADL assessed by the Lawton IADL Scale.

INTERVENTIONS

Preoperative assessment.

MEASUREMENT

The primary outcome was the pooled incidence of preoperative IADL dependency. Additional outcomes included post-operative mortality, postoperative delirium [POD], functional status improvement, and discharge disposition.

MAIN RESULTS

Twenty-one studies (n = 5690) were included. In non-cardiac surgeries, the pooled incidence of preoperative IADL dependence was 37% (95% CI: 26.0%, 48.0%) among 2909 patients. Within cardiac surgeries, the pooled incidence of preoperative IADL dependence was 53% (95% CI: 24.0%, 82.0%) among 1074 patients. Preoperative IADL dependence was associated with an increased risk of postoperative delirium than those without IADL dependence (44.9% vs 24.4, OR 2.26; 95% CI: 1.42, 3.59; I2: 0%; P = 0.0005).

CONCLUSIONS

There is a high incidence of IADL dependence in older surgical patients undergoing non-cardiac and cardiac surgery. Preoperative IADL dependence was associated with a two-fold risk of postoperative delirium. Further work is needed to determine the feasibility of using the IADL scale preoperatively as a predictive tool for postoperative adverse outcomes.

Minimal Clinically Important Difference (MCID) in the Functional Status Measures in Patients with Stroke: Inverse Probability Treatment Weighting

This study proposed to evaluate the temporal trend, define the minimal clinically important difference (MCID) for five functional status measures, and identify risk factors for reaching deterioration in the MCID. This prospective cohort study analyzed 680 patients with ischemic stroke and 151 patients with hemorrhagic stroke at six hospitals between April 2015 and October 2021. All patients completed the functional status measures before rehabilitation (baseline), and at the 12th week and 2nd year after rehabilitation. Patients in the post-acute care (PAC) group exhibited significantly larger improvements for the functional status measures compared to those in the non-PAC group (p < 0.05). Patients with hemorrhagic stroke also displayed larger improvements in the functional status measures when compared to patients with ischemic stroke. Furthermore, the improvement in MCID ranged from 0.01 to 16.18 points when comparing baseline and the 12th week after rehabilitation, but the deterioration in MCID ranged from 0.38 to 16.12 points. Simultaneously, assessing the baseline and the second year after rehabilitation, the improvement in MCID ranged from 0.01 to 18.43 points, but the deterioration in MCID ranged from 0.68 to 17.26 points. Additionally, the PAC program, age, education level, body mass index, smoking, readmission within 30 days, baseline functional status score, use of Foley catheter and nasogastric tube, as well as a history of previous stroke are significantly associated with achieving deterioration in MCID (p < 0.05). These findings suggest that if the mean change scores of the functional status measures have reached the thresholds, the change scores can be perceived by patients as clinically important.

Performance on a virtual environment shopping task and adaptive functioning among older adults

Neuropsychologists are often asked to evaluate patients' functional capacities, yet traditional neuropsychological tests have limited correspondence with real-world outcomes. The Virtual Environment Grocery Store (VEGS) is a virtual environment that simulates shopping tasks. The purpose of this study was to investigate the relationship between older adults' performance on the VEGS in relation to their self-reported adaptive functioning as well as performance on a performance-based adaptive functioning measure. Older adults (n = 98; age 65-90, M = 75.82, SD = 6.27) were administered the VEGS, the Instrumental Activities of Daily Living Scale (IADLS), and the Texas Functional Living Scale (TFLS). Neither premorbid functioning nor the VEGS variables were associated with self-rated adaptive functioning. However, all three VEGS variables were associated with performance-based adaptive functioning (i.e., the TFLS). Performance on the VEGS measure of correct items in the shopping cart explained 13.9% of the variance in performance on the performance-based adaptive functioning task. Whether the participant picked up the VEGS prescription explained 12.6% of the variance in performance on the performance-based adaptive functioning task. Performance on VEGS long delay free recall explained 35.1% of the variance in performance on the performance-based adaptive functioning task. These results suggest that the VEGS demonstrates value in predicting older adults' functional capacities.

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 GIANT trial (ECOG-ACRIN EA2186) methods paper: A randomized phase II study of gemcitabine and nab-paclitaxel compared with 5-fluorouracil, leucovorin, and liposomal irinotecan in older patients with treatment-naïve metastatic pancreatic cancer - defining a new treatment option for older vulnerable patients

INTRODUCTION

Pancreatic cancer is the fourth leading cause of cancer-related death in the US with an increasing incidence in older adults (OA) over age 70. There are currently no treatment guidelines for OA with metastatic pancreatic cancer (mPCA) and selecting a chemotherapy regimen for these patients is subjective, based largely on chronologic age and performance status (PS). Geriatric screening tools provide a more objective and accurate evaluation of a patient's overall health but have not yet been validated in patient selection for mPCA treatment. This study aims to elucidate the optimal chemotherapy treatment of vulnerable OA with mPCA and understand the geriatric factors that affect outcomes in this population.

METHODS/DESIGN

The GIANT (ECOG-ACRIN EA2186) study is multicenter, randomized phase II trial enrolling patients over age 70 with newly diagnosed mPCA. This study utilizes a screening geriatric assessment (GA) which characterizes patients as fit, vulnerable, or frail. Patients with mild abnormalities in functional status and/or cognition, moderate comorbidities, or over age 80 are considered vulnerable. Enrolled patients are randomized to one of two dose-reduced treatment regimens (gemcitabine/nab-paclitaxel every other week, or dose-reduced 5-fluoruracil (5FU)/ liposomal irinotecan (nal-IRI) every other week). GA and quality of life (QoL) evaluations are completed prior to treatment initiation and at each disease evaluation. Overall survival (OS) is the primary endpoint, with secondary endpoints including progression free survival (PFS) and objective response rate (ORR). Enrolled patients will be stratified by age (70-74 vs ≥75) and ECOG PS (0-1 vs 2). Additional endpoints of interest for OA include evaluation of risk factors identified through GA, QoL evaluation, and toxicities of interest for older adults. Correlative studies include assessment of pro-inflammatory biomarkers of aging in the blood (IL-6, CRP) and imaging evaluation of sarcopenia as predictors of treatment tolerance.

DISCUSSION

The GIANT study is the first randomized, prospective national trial evaluating vulnerable OA with mPCA aimed at developing a tailored treatment approach for this patient population. This trial has the potential to establish a new way of objectively selecting vulnerable OA with mPCA for modified treatment and to establish a new standard of care in this growing patient population.

TRIAL REGISTRATION

This trial is registered with ClinicalTrial.gov Identifier NCT04233866.

Pre-operative physiotherapy for elderly patients undergoing abdominal surgery

Background

Elderly patients report a decrease in function and activities of daily living following abdominal surgery. The objectives of our pilot study were to determine the effects of a single pre-operative physiotherapy session consisting of education and exercise on clinical and physical function outcomes in elderly patients.

Methods/design

A single-blind pilot randomised controlled trial evaluated clinical and functional outcomes of elderly patients following surgery in a private hospital in Pretoria, South Africa. The outcomes included length of hospital stay (LOS), postoperative pulmonary complications (PPC), first mobilisation uptime, DeMorton Mobility Index (DEMMI), 6-minute walk test (6MWT), Lawton-Brody's instrumental activities of daily living (IADL) and the Functional Comorbidity Index (FCI). Descriptive and inferential statistics were undertaken, and statistical significance was set at p ≤ 0.05.

Discussion

Twelve participants (n = 11 female [91.67%] and n = 1 [8.33%] male) with a mean age of 65.75 (±4.47) years were included. Most participants (n = 10, 83.33%) underwent lower abdominal laparotomy (n = 10, 83.33%). The median hospital LOS was n = 4 (IQR 3.25-4) days; walking distance at first mobilisation was 130 m (IQR (85-225), with intervention participants walking further (intervention: 177 m, IQR 100-242.50; control: 90, IQR 60 m - 245 m; p = 0.59). Recruitment was low, with only 10.95% referrals and 47.82% nonconsents.

Conclusion

A single physiotherapy session prior to surgery demonstrated a potential favourable change in elderly patients' mobility postoperatively; however, further research is necessary.

Clinical implication

A once-off pre-operative physiotherapy session could enhance recovery in elderly patients.

Trial registration

Pan African Clinical Trial Registry, PACTR201809874713904, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3593.

Effects of a 12-month home-based exercise program on functioning after hip fracture - Secondary analyses of an RCT

BACKGROUND

Long-term functional limitations are common after hip fractures. Exercise may alleviate these negative consequences but there is no consensus on an optimal training program. The objective was to study the effects of a 12-month home-based supervised, progressive exercise program on functioning, physical performance, and physical activity.

METHODS

Secondary analysis of a randomized controlled trial targeting patients with surgical repair of a hip fracture, aged ≥60 years, Mini-Mental State Examination (MMSE) score of ≥12. The participants were randomized into Exercise (n = 61) or Usual care (n = 60). Assessments at baseline, 3, 6, and 12 months included Lawton's Instrumental Activities of Daily Living (IADL), Short Physical Performance Battery (SPPB), handgrip strength, and self-reported frequency of sessions of leisure-time physical activity. Analyzed using mixed-effects models.

RESULTS

Participants' (n = 121) mean age was 81 years (SD 7), and 75% were women. The mean IADL score at baseline was 17.1 (SD 4.5) in the exercise group, and 17.4 (5.1) in the usual care group. The mean SPPB scores were 3.9 (1.6) and 4.2 (1.8), and handgrip strength was 17.7 (8.9) kg and 20.8 (8.0) kg, respectively. The age- and sex-adjusted mean changes in IADL over 12 months were 3.7 (95% CI 2.8-4.7) in the exercise and 2.0 (1.0-3.0) in the usual care group (between-group difference, p = 0.016); changes in SPPB 4.3 (3.6-4.9) and 2.1 (1.5-2.7) (p < 0.001); and changes in handgrip strength 1.2 kg (0.3-2.0) and 1.0 kg (-1.9 to -0.2) (p < 0.001), respectively. We found no between-group differences in changes in the frequency of leisure-time activity sessions.

CONCLUSION

A 12-month home-based supervised, progressive exercise program improved functioning and physical performance more than usual care among patients with hip fractures. However, the training did not increase leisure-time physical activity.

Exploring Patient Outcomes After Participation in an Inpatient Occupation-Based Group: A Longitudinal Observational Cohort Study

IMPORTANCE

Occupation-based interventions are used during inpatient rehabilitation, and group models may enhance intervention delivery. However, little is known about the impact of occupation-based groups on patient outcomes.

OBJECTIVE

To examine the effect of an occupation-based group on patient outcome measures of instrumental activities of daily living (IADL) skills over time and explore demographic differences among patients.

DESIGN

Longitudinal observational cohort study with four time points: preintervention, postintervention, 30-day follow-up, and 90-day follow-up.

SETTING

Tertiary hospital general rehabilitation ward.

PARTICIPANTS

Inpatient adults age 18 or older recruited using consecutive sampling from those referred to the group.

INTERVENTION

The LifeSkills group, which focused on repetitive practice of meaningful occupation-based activities.

OUTCOMES AND MEASURES

Demographic data were obtained, and the Canadian Occupational Performance Measure (COPM), Goal Attainment Scaling, Lawton IADL scale, and a self-efficacy scale were administered at each data point.

RESULTS

Thirty people (21 women, 9 men; ages 35-91 yr) participated, with 5 lost to follow-up. A statistically significant increase in scores postintervention occurred on all measures and was also seen at 90-day follow-up for COPM occupational performance, satisfaction, and self-efficacy scores. Lawton IADL scale scores at follow-up were lower than those at preintervention and statistically significant. No significant differences were found for age and diagnosis.

CONCLUSIONS AND RELEVANCE

Positive patient outcomes of goal achievement, occupational performance, satisfaction, and self-efficacy were seen at discharge, with evidence of sustainability over time. This could be a resource alternative for addressing skill retraining because people with different diagnoses and in different age groups benefited equally. What This Article Adds: Occupation-based group programs have encouraging application in general inpatient rehabilitation for addressing patient outcomes.

Predicting 30-Day Readmission for Stroke Using Machine Learning Algorithms: A Prospective Cohort Study

Background

Machine learning algorithms for predicting 30-day stroke readmission are rarely discussed. The aims of this study were to identify significant predictors of 30-day readmission after stroke and to compare prediction accuracy and area under the receiver operating characteristic (AUROC) curve in five models: artificial neural network (ANN), K nearest neighbor (KNN), random forest (RF), support vector machine (SVM), naive Bayes classifier (NBC), and Cox regression (COX) models.

Methods

The subjects of this prospective cohort study were 1,476 patients with a history of admission for stroke to one of six hospitals between March, 2014, and September, 2019. A training dataset (n = 1,033) was used for model development, and a testing dataset (n = 443) was used for internal validation. Another 167 patients with stroke recruited from October, to December, 2019, were enrolled in the dataset for external validation. A feature importance analysis was also performed to identify the significance of the selected input variables.

Results

For predicting 30-day readmission after stroke, the ANN model had significantly (P &lt; 0.001) higher performance indices compared to the other models. According to the ANN model results, the best predictor of 30-day readmission was PAC followed by nasogastric tube insertion and stroke type (P &lt; 0.05). Using a machine learning ANN model to obtain an accurate estimate of 30-day readmission for stroke and to identify risk factors may improve the precision and efficacy of management for these patients.

Conclusion

Using a machine-learning ANN model to obtain an accurate estimate of 30-day readmission for stroke and to identify risk factors may improve the precision and efficacy of management for these patients. For stroke patients who are candidates for PAC rehabilitation, these predictors have practical applications in educating patients in the expected course of recovery and health outcomes.

Gender and physical frailty modify the association between abdominal obesity and functional disability in older adults

BACKGROUND

Abdominal obesity is associated with functional disability in older adults.

AIM

We evaluated whether this association was modified by gender and/or physical frailty.

METHODS

We used cross-sectional data from 12,583 participants in the third follow-up of the population-based Singapore Chinese Health Study, when participants had mean age of 74 years (range 63-97). Abdominal obesity was defined using waist circumference, physical frailty was established using the modified Cardiovascular Health Study phenotype, and functional disability was determined by the Lawton Instrumental Activities of Daily Living Scale. We used logistic regression models to compute odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between abdominal obesity and disability.

RESULTS

Abdominal obesity was associated with increased likelihood of functional disability, and this association was stronger in women than in men [OR (95% CI): 1.27 (1.11-1.46) vs. 1.08 (0.93-1.25); P for interaction < 0.001]. Furthermore, there was a significantly stronger association between abdominal obesity and functional disability in participants who were physically frail compared to those who were not [OR (95% CI): 1.57 (1.19-2.08) vs. 1.11 (0.99-1.23); P for interaction = 0.003], and this phenomenon was observed in both genders. When compared to participants who were neither abdominally obese nor physically frail, participants who were both abdominally obese and physically frail had a synergistically increased risk of functional disability [OR (95% CI): 3.61 (3.03-4.30)].

CONCLUSIONS

Women with abdominal obesity had higher risk of functional disability compared to men, and older adults who were both abdominally obese and physically frail had a synergistically increased risk of disability.

A conceptual model for achieving well-being in adults with mild cognitive impairment

OBJECTIVE

Low well-being is common among people with Mild Cognitive Impairment (MCI). We propose a model to examine how different types of resources work together to maintain well-being in people with MCI.

METHODS

Participants included 121 community dwelling adults over the age of 60 who were diagnosed with MCI. Structural equation modeling assessed suggested relationships between resources and well-being.

RESULTS

Emotional intelligence, general mental ability, morbidity, economic status, basic activities of daily living, and age were correlated to well-being in a triple mediation process through cognitive function, instrumental activities of daily living, and social support. Model fit was excellent (RMSEA-0.04; IFI-.96; CFI-.96; CMIN/DF-1.23), CONCLUSION: Achieving well-being when coping with MCI requires a combination of objective resources and subjective evaluation of the situation. Ultimately, social support determines an individual's level of well-being. Findings suggest the need to understand what kind of social support is required by those coping with MCI.

Effect of 12-month supervised, home-based physical exercise on functioning among persons with signs of frailty - Randomized Controlled Trial

OBJECTIVES

To investigate the effects of a 12-month home-based exercise program on functioning and falls among persons with signs of frailty.

DESIGN

A randomized controlled trial with a 1:1 allocation SETTING: Home-based PARTICIPANTS: Home-dwelling persons aged ≥65 years meeting at least one frailty phenotype criteria (n=300).

INTERVENTION

12-month, individually tailored, progressive and physiotherapist-supervised, physical exercise twice a week (n=150) vs. usual care (n=149).

MAIN OUTCOME MEASURES

Functional Independence Measure (FIM), Short Physical Performance Battery (SPPB), handgrip strength, instrumental activities of daily living (IADL), and self-reported falls and physical activity (other than intervention). Assessed four times at home over 12 months.

RESULTS

The mean age of the participants was 82.2 (SD 6.3), 75% were women, 61% met 1-2 frailty criteria and 39% ≥3 criteria. FIM deteriorated in both groups over 12 months, -4.1 points (95% CI: -5.6 to -2.5) in the exercise group and -6.9 (-8.4 to -2.3) in the usual care group (group p=0.014, time p<0.001, interaction p=0.56). The mean improvement in SPPB was significantly greater in the exercise group [1.6 (1.3 to 2.0)] than in the usual care group [0.01 (-0.3 to 0.3)] (group p<0.001, time p=0.11, interaction p=0.027). The exercise group reported significantly fewer falls per person-year compared to the usual care group (incidence rate ratio, IRR 0.47 [95% CI 0.40 to 0.55]; p<0.001). There was no significant difference between the groups over 12 months in terms of handgrip strength, IADL function or self-reported physical activity.

CONCLUSIONS

One year of physical exercise improved physical performance and decreased the number of falls among people with signs of frailty. FIM differed between the groups at 12 months, but exercise did not prevent deterioration of FIM, IADL or handgrip strength.

Do Communication Patterns Affect the Association between Cognitive Impairment and Hearing Loss among Older Adults in Vietnam?

This study examined the prevalence of cognitive impairment among older adults in central Vietnam and the roles of communication (with or without communication devices) in the association between cognitive impairment and hearing loss. This cross-sectional study was performed on 725 randomly selected community-dwelling older adults aged ≥60 years from Thua Thien Hue province, Vietnam. Participants attended a face-to-face survey. Sociodemographic characteristics, social interaction with or without communication devices, health status and cognitive function using the Mini-Mental State Examination were reported. Ordinal logistic regression analysis was performed to quantify the association between hearing loss and cognitive function by frequency of communication with and without devices. Mild and severe cognitive impairment had prevalence rates of 23.6% and 19.3%, respectively. Cognitive impairment was more prevalent among older adults with hearing-loss, vision loss and difficulties with instrumental activities of daily living (IADL). The association between hearing loss and cognitive impairment was not significant when older adults had frequent communication with others using devices. This study presented the relatively high prevalence of cognitive impairment in community-dwelling older adults in Vietnam. Frequent communication using devices attenuated the association between hearing loss and cognitive impairment.

Associations of Performance-Based Functional Assessments and Adverse Outcomes in CKD

Background

The comparative utility of performance-based functional assessments in predicting adverse outcomes in CKD is unknown. To examine their relative utility, we examined three performance-based functional assessments in an observational cohort of patients with CKD.

Methods

We recruited 350 participants with stage II-V, predialysis CKD. Participants were administered three performance-based functional assessments: Short Physical Performance Battery (SPPB), Modified Mini-Mental Status Exam (M3SE), and Lawton Instrumental Activities of Daily Living (IADL). Scores were dichotomized on the basis of the median and combined into a summary score. Outcomes included 50% GFR reduction, ESKD, and death. We used Cox proportional hazards to assess the association of performance-based functional assessments with outcomes.

Results

Compared with high performers, low SPPB performers had the highest adjusted rate of death, ESKD, or 50% reduction in GFR (HR, 1.96; 95% CI, 1.28 to 2.99). Low SPPB had the strongest association with death when adjusted for multiple covariates (HR, 2.43; 95% CI, 1.36 to 4.34). M3SE performance was not associated with any adverse outcome. None of the performance-based functional assessments were associated with ESKD, but a low IADL score was associated with a lower hazard ratio for ESKD or 50% decline GFR (HR, 0.49; 95% CI, 0.24 to 1.00).

Conclusions

Low SPPB score was the strongest predictor of death and all adverse outcomes as a composite. Future trials should determine if outcomes for patients with CKD who have poor physical performance and low SPPB scores are improved by targeted interventions.

Clinical Trial registry name and registration number

Safe Kidney Care Cohort Study, NCT01407367.

The pre-efficacy phase testing for PAfitME™-A behavioral physical activity intervention to manage moderate and severe symptoms among advanced stage cancer patients

Fatigue and pain are the most frequently reported symptoms among advanced-stage cancer patients. Although physical activity (PA) is known to improve the aforementioned symptoms, few patients demonstrate the physically active behavior that adheres to the clinical guidelines regarding PA. The current article presents an exemplar that used the National Institute of Health's Obesity-Related Behavioral Intervention Trial (ORBIT) model and developed a behavioral intervention known as the personalized Physical Activity intervention with fitness graded Motion Exergames (PAfitME™). There were two phases of testing in the ORBIT model presented in the current paper. In Phase I testing, a standardized exergame prescription was evaluated by an advisory board and a single-case study was used to evaluate the personalized exergame prescription with personalization of the fitness levels. In Phase IIa, a within-group pre- and posttest design was used to evaluate the personalized exergame prescriptions with personalization of the fitness levels, self-efficacy, and variation in fatigue/pain. Subsequently, a complete intervention package was developed in accordance with a logic model, driven from the result of the Phase IIa testing with clinically significant findings. Currently, PAfitME™ is under Phase IIb testing in a randomized clinical trial with a control group. PAfitME™ employs a personalized approach to initiate and promote physically active behavior, to facilitate the management of fatigue and pain in cancer patients. Positive results from an efficacy trial would support the use of PAfitME™ in the management of fatigue and pain in advanced-stage cancer patients.

Elevated Procalcitonin as a Risk Factor for Postoperative Delirium in the Elderly after Cardiac Surgery-A Prospective Observational Study

One of the most common complications after cardiac surgery with cardiopulmonary bypass (CBP) is delirium. The purpose of this study was to prospectively investigate the risk of developing postoperative delirium in a group of elderly patients using a multivariate assessment of preoperative and intraoperative risk factors. A total of 149 elderly patients were included. Thirty patients (20%) developed post-operative delirium. Preoperative procalcitonin (PCT) above the reference range (>0.05 ng/mL) was recorded more often in patients who postoperatively developed delirium than in the non-delirium group (50% vs. 27%, p = 0.019). After surgery, PCT was significantly higher in the delirium than the non-delirium group: ICU admission after surgery: 0.08 ng/mL vs. 0.05 ng/mL p = 0.011), and for consecutive days (day 1: 0.59 ng/mL vs. 0.25 ng/mL, p = 0.003; day 2: 1.21 ng/mL vs. 0.36 ng/mL, p = 0.006; day 3: 0.76 ng/mL vs. 0.34 ng/mL, p = 0.001). Patients with delirium were older (74 vs. 69 years, p = 0.038), more often had impaired daily functioning (47% vs. 28%, p = 0.041), depressive symptoms (40% vs. 17%, p = 0.005), and anemia (43% vs. 19%, p = 0.006). In a multivariable logistic regression model, preoperative procalcitonin (odds ratio (OR) = 3.05), depressive symptoms (OR = 5.02), age (OR = 1.14), impaired daily functioning (OR = 0.76) along with CPB time (OR = 1.04) were significant predictors of postoperative delirium.

Health Status and Functional Abilities of Elderly Males Visiting Primary Health-care Centers in Khamis Mushait, Saudi Arabia

Background

There is an aging population all over the world, and Saudi Arabia is no exception to it. An aging population poses several challenges to the health-care sector.

Aim

The aim of this study was to examine the health status and functional abilities of elderly people visiting primary health-care centers in Khamis Mushait, Saudi Arabia.

Methods

This cross-sectional study involved elderly male Saudi nationals aged 60 years and above. Self-rated health status and body pain, functional status, geriatric review of systems and other relevant data were collected using the Geriatric Health Questionnaire of University of Iowa Health Care. All statistical analyses were performed using SPSS version 21.

Results

The study results showed that the overall health of the elderly was either good (32.9%) or very good (32.3%), while 14.2% rated their health as excellent. Only two participants rated their health as poor. The majority of the participants (71.9%) had no functional impairment in basic activities of daily living (BADL), while 35.7% had mild impairment in instrumental activities of daily living (IADL). Only two participants were found to have total impairment in IADL. The most common limitation among BADL was walking (21.1%) and among IADL was doing the housework. The notable factors associated with functional impairment in BADL and IADL were old age (≥80 years), poor eyesight, memory impairment, having trouble with control of bladder, falls twice or more, taking more than two medications, being sexually inactive, poor self-rated general health and severe self-rated body pain (all P<0.05) among others.

Conclusion

The majority of the elderly were able to perform BADL independently and to a lesser extent IADL; the overall self-rated general health was found to be good. Further research in the field of geriatrics is warranted to plan better, and design public health policies and provide efficient care to elderly patients.

Informal help in a local setting: The Dutch Social Support Act in practice

The Dutch Social Support Act provides municipal social support for people that experience limitations in daily life and cannot rely on informal help from their social network to compensate these limitations. In this paper, we study whether the probability and intensity (number of services) of receiving municipal social support for daily limitations is affected by informal help by the social network (i.e. family, friends and neighbors). This study took place in Breda, a middle large city in the South of the Netherlands. We combined data from the Municipal Personal Records Database, the registration containing information on demographics and municipal social support receipt of all inhabitants, with data from the Municipality Policy Monitor, a survey containing information on daily limitations and informal help (n = 5256). We find that people experiencing daily limitations are more likely to receive municipal social support and also receive a higher number of support services (intensity). However, the perceived help from family and friends does not decrease either the probability or intensity of receiving municipal social support. Informal help from neighbors decreased the likelihood of receiving of municipal social support, but not the intensity. This implies that the overall relation between daily limitations and municipal social support is not different for people who indicate that they can or cannot rely on their informal network for help.

Relationship between executive dysfunction and neuropsychiatric symptoms and impaired instrumental activities of daily living among patients with very mild Alzheimer's disease

OBJECTIVES

Patients with Alzheimer's disease (AD) experience a gradual loss in their ability to perform instrumental activities of daily living (IADLs) from the early stage. A better understanding of the possible factors associated with IADL decline is important for the development of effective rehabilitation and support programs for patients with AD. Thus, we examined the relationships between comprehensive cognitive functions and neuropsychiatric symptoms and IADLs in patients with very mild AD.

METHODS

In total, 230 outpatients with probable AD were recruited from the Memory Clinic at Kumamoto University Hospital between May 2007 and October 2016. All patients scored ≥21 points on the Mini-Mental State Examination at the first assessment. Relationships between the subdomains of the Lawton IADL scale and neuropsychological/neuropsychiatric tests were examined by multiple regression analysis. All analyses were performed separately in men and women.

RESULTS

In female patients, scores on the Frontal Assessment Battery were significantly associated with telephone use ability, shopping, and ability to handle finances. Apathy scores in the Neuropsychiatric Inventory (NPI) were associated with telephone use ability, housekeeping, responsibility for own medications, and ability to handle finances. NPI agitation scores were associated with food preparation and housekeeping. Geriatric Depression Scale scores were associated with telephone use ability and ability to handle finances. In male patients, only NPI apathy scores were associated with telephone use ability.

CONCLUSIONS

These results suggest the importance of properly assessing executive function, depression, and apathy at interventions for impaired IADLs among female patients with very mild AD.

Predicting Functional Dependence in Mild Cognitive Impairment: Differential Contributions of Memory and Executive Functions

BACKGROUND AND OBJECTIVES

Diagnostic criteria for mild cognitive impairment (MCI) exclude functional deficits, yet recent studies suggest that older adults with MCI can exhibit impairment in instrumental activities of daily living (IADL). To assist health care providers in detecting functional vulnerabilities that often precipitate loss of independence, we: (a) compared IADL dependence in MCI to older adults without cognitive impairment and those with dementia, (b) estimated the odds of dependence on specific IADLs in MCI, and (c) investigated the differential contributions of memory and executive functions to IADL dependence.

RESEARCH DESIGN AND METHODS

Participants were older adults (Mage = 77.58 ± 11.05) in Maryland, USA (N = 512) community and postacute rehabilitation settings. Analysis was performed on Brief Cognitive Assessment Tool (BCAT) and the Functional Activities Questionnaire (FAQ) data that assessed participants' cognitive functioning and IADL dependence, respectively.

RESULTS

61.04% of participants with MCI were dependent on one or more IADLs. MCI was associated with significantly greater odds of dependence than normal cognition on 7 of the 10 IADLs (odds ratios = 2.62-4.66). Impairment in memory and executive functions significantly predicted IADL dependence (18.52% of variance beyond demographics); executive functions were the stronger predictor, particularly for complex finances, complex cooking, and remembering events.

DISCUSSION AND IMPLICATIONS

IADL dependence can occur even in MCI. Testing suggestive of MCI should alert clinicians to further investigate the older adult's profile of cognitive and functional limitations to highlight targets for caregiver support and promote independence by "right-sizing" community or facility resources.

Independent Older Adult's IADL and Executive Function According to Cognitive Performance

Participation in Instrumental Activities of Daily Living (IADL) is essential in occupational therapy aiming to improve the life situation of elderly. Effective executive function (EF) is important to successful functioning in IADL. The purpose of this study was to examine EF and IADL performance differences according to cognitive levels as measured by the Montreal Cognitive Assessment (MoCA), age, and gender. In all, 80 elderly (49% female; age M = 73.4) were assessed at home, with Weekly Calendar Planning Activity (WCPA-10), IADL scale, and MoCA as a cognitive screening tool for dividing into normal cognitive (NC) level and mild cognitive impairment (MCI). The comparison between the MoCA groups on the WCPA-10 and IADL shows significant differences between the groups; gender and age differed only in IADL. IADL and WCPA-10 performance among independent elderly relates to their cognitive level. We suggest that intervention that will focus on EF may assist in improving performance and maintaining participation in occupation.

[Predictive validity of the VIDA questionnaire on functional decline, institutionalisation or death in patients with multiple morbidities]

INTRODUCTION

The VIDA Spanish questionnaire assesses instrumental activities of daily living (IADL) in elderly people, and has shown to have adequate content, construct validity, and reliability. The objective was to analyse its predictive validity in patients with multiple morbidities aged ≥65 years without severe/total dependence in basic activities (BADL, Barthel index ≥60 points), by measuring any changes in this severe/total level of dependence, institutionalisation, or death at 8 and 18 months of follow-up.

METHODS

A prospective study of a diagnostic test was conducted on 197 patients (8 months) and 185 (18 months) included in the multiple morbidities program according to stratification by Adjusted Clinical Groups (ACG) or by fulfilling the Ollero criteria. Patients that were institutionalised, at the end of life, or on dialysis, or with a baseline Barthel index ≥60 points were excluded. The VIDA questionnaire was applied at baseline. The other baseline variables included age, gender, Charlson index, number of drugs, and Lawton-Brody index. The outcome event was changing the Barthel index to <60, or institutionalisation, or death, in each follow-up period.

RESULTS

The median age was 81 years (IQR 74.5-85), and 45.2% were women. At 8 months, the best cut-off point for VIDA was ≤31 points (Sensitivity [S] 81.5%, [95% CI; 61.2-93.0]; Specificity (Sp) 58.2% [95% CI; 50.4-65.7], PPV 23.7%; NPV 95.2%), ≤30 in women, ≤34 in men. And at 18 months, ≤29 points (S 61.4 [95% CI; 47.6-73.7]; Sp 76.6 [95% CI; 68.1-83.4]; PPV 53.9; NPV 81.7).

CONCLUSIONS

Overall cut-off points are provided as well as those for gender, predicting severe/total BADL decline, or institutionalization or death in patients with multiple morbidities. It seems to detect short-term events better and rules them out in the long term.

Verbal test of practical judgment (VPJ): a new test of judgment that predicts functional skills for older adults

OBJECTIVES

The clinical assessment of older adults' judgment is important for mitigating safety risks that often precipitate loss of independence. Our national survey of geriatric healthcare providers (N = 496; M years of experience = 17.11 ± 10.60) indicated that formal judgment tests are underutilized in clinical practice. We developed the Verbal Test of Practical Judgment (VPJ) as a new test of judgment for older adults intended to identify difficulty performing instrumental activities of daily living (IADL).

METHOD

In two prospective studies, participants were long-term care facility residents (age ≥ 50) in Maryland, USA (Study 1, N = 51; Study 2, N = 110) referred to licensed psychologists for neuro-cognitive and mood evaluation by facility attending physicians. Psychometric analyses were performed to examine the construct validity of the VPJ.

RESULTS

The VPJ evidenced adequate reliability and strong construct validity across both studies. Receiver operating characteristic analysis yielded an optimal VPJ cut score for identifying impaired judgment. The VPJ significantly predicted IADL performance beyond clinician and participant ratings.

CONCLUSION

The VPJ appears to be a valid tool for assessing judgment among older adults with suspected cognitive impairment. VPJ score inferences can inform clinicians on the odds of requiring assistance for specific IADLs.

Aerobic Fitness and Instrumental Activities of Daily Living in People with Multiple Sclerosis: A Cross-sectional Study

Background

There is ample evidence that aerobic fitness is reduced in people with multiple sclerosis (MS), and this may yield a reduction in independence in instrumental activities of daily living (IADLs). This study examined the association between aerobic fitness and self-reported IADLs in persons with MS.

Methods

Sixty-two adults with MS completed an incremental exercise test as a measure of aerobic fitness (peak oxygen consumption), a demographic questionnaire, and an IADL scale and underwent a neurologic examination for characterization of disability level (ie, Expanded Disability Status Scale) in a single session.

Results

The analysis revealed a weak but significant association between aerobic fitness and total IADL score (r = 0.28 [95% CI, 0.03-0.49], P = .033). Those reporting dependence in different IADL categories (eg, shopping, food preparation, housekeeping, laundry, and responsibility for own medication) presented with lower aerobic fitness compared with those reporting independence, although the difference was not statistically significant.

Conclusions

These findings extend previous studies on activities of daily living in people with MS and underscore the need for studies examining the potential effect of aerobic exercise interventions on independence regarding IADLs in this population.

[Comparison of scaling methods for activities of daily living in older people]

OBJECTIVE

To compare the psychometric properties of scales top measure activities of daily living, constructed with different scaling methods, and to check whether the most complex scales have higher discriminatory capacity.

METHOD

Sample of elderly people from the Spanish Survey on Disability, Personal Autonomy and Dependency We used 14 items that measured activities of daily living. Five scaling methods were applied: Sum and Rasch (both for dichotomous and polytomous items) and Guttman (dichotomous). We evaluated the discriminatory capacity (relative precision [RP]) and area under the curve (AUC).

RESULTS

All methods showed high Pearson correlations among them (0.765-0.993). They had similar discriminatory power when comparing extreme categories of individuals with no disability with severely limited (RP: 0.93-1.00). The polytomous Sum procedure showed the highest AUC (0.934; 95% confidence interval [95%CI]: 0.928-0.939) and Guttman the lowest (0.853; 95%CI: 0.845-0.861).

CONCLUSIONS

Polytomous items have greater reliability than the dichotomous ones. Simplest methods (Sum) and most complex (Rasch) are equally valid. Guttman method presented worse discriminatory capacity.

Minimal Detectable Change on the Lawton Instrumental Activities of Daily Living Scale in Community-Dwelling Patients With Schizophrenia

The main purpose of this study was to estimate the minimal detectable change (MDC) on the Lawton Instrumental Activities of Daily Living (LIADL) scale in community-dwelling patients with schizophrenia. Fifty-seven patients completed the LIADL assessment twice, about 14 days apart. Two scoring methods (dichotomous and polytomous) were used to record the patients' performance on the LIADL scale. The MDCs of the LIADL scale were 1.5 (dichotomous) and 4.4 (polytomous) points. The MDC percentages were 22.0% (dichotomous) and 22.5% (polytomous), both of which are within acceptable measurement errors. The test-retest reliabilities of the LIADL scale were both acceptable with two different scoring methods (dichotomous = .75; polytomous = .76). Users can choose the scoring method according to their individual needs.

Effects of a Community-Based Exercise Program on Older Adults’ Physical Function, Activities of Daily Living, and Exercise Self-Efficacy: Feeling Fit Club

Community-based exercise programs have demonstrated feasibility, yet many lack controlled studies examining their efficacy. This study examined the efficacy of a community-based exercise program, using a controlled design. Participants ( N = 262, Mage = 74.0 years, SD = 8.4) were women (77%) and men recruited from senior centers served by the county Area Agency on Aging. Intervention participants ( n = 133) were newly enrolled in classes. Controls ( n = 129) were recruited from matched sites not offering classes. Validated measures of physical function, exercise self-efficacy, balance, and activities of daily living (ADL) confidence were administered at baseline and 3 months. Significant improvements in upper and lower body strength, aerobic endurance, mobility, exercise self-efficacy, and balance were found in the exercisers but not controls. No changes in ADL confidence occurred in exercisers, while significant decreases occurred in controls. Findings support the efficacy of the county-wide program. Building an evidence base for community-delivered programs should provide impetus for increased dissemination through state and national agencies thereby increasing program impact.

Instrumental Activities of Daily Living Dysfunction among People with Schizophrenia

BACKGROUND

Life skills are the basic skills that are needed to live independently and that support meaningful, productive roles. The negative symptoms and cognitive dysfunction seen in schizophrenia may lead to deterioration in the life skills of the patient. The assessment of current life skills of the patient and subsequent intervention becomes necessary for comprehensive rehabilitation of people with mental illness. This study attempted to assess the instrumental activities of daily living among people with schizophrenia in India.

METHODS

One hundred consecutive patients with schizophrenia, between 18 and 60 years, who presented to a tertiary psychiatric facility were assessed using (i) Lawton instrumental activities of daily living scale (LIADL), (ii) positive and negative symptom scale (PANSS), (iii) pro forma for sociodemographic and clinical characteristics.

RESULTS

The majority of the patients were male, young adults, married, with secondary school education, middle socioeconomic status, from nuclear families, unemployed and were diagnosed to have paranoid schizophrenia. The reported IADL dysfunction included difficulties in handling medications (86%), preparing food (85%), shopping (78%), handling finances (61%), doing laundry (52%), housekeeping (47%), using public transport (32%), and using telephones (5%). The dysfunction documented differs from that reported in the west. Total PANSS score (P = 0.015) and its general psychopathology subscale (P = 0.005) correlated inversely with the total LIADL score; PANSS scores and sociodemographic variables were associated with some subscales of LIADL.

CONCLUSIONS

IADL dysfunction, common in people with schizophrenia, demands detailed assessment, and tailored training to ensure optimum functioning.

A Systematic Review of the Measurement of Function in Late-Life Depression

Recovery of everyday premorbid function is a primary goal in the treatment of depression. Measurement of function is an important part of achieving this goal. A multitude of scales have been used to measure function in depression, reflecting the complex, multifaceted nature of functioning. Currently, however, there are no evidence-based guidelines to assist the researcher or clinician in deciding which instruments are best suited to measure function in late-life depression (LLD). Thus, the aims of this study are to 1) systematically review and identify the instrumental activities of daily living and social functioning assessment instruments used in the LLD literature; 2) identify and appraise the measurement properties of these instruments; and 3) suggest factors for LLD researchers and clinicians to consider when selecting functional assessment instruments and make pertinent recommendations. We performed a systematic review of MEDLINE and CINAHL to identify studies that i) incorporated subjects aged 60 years and older with a depressive disorder, and ii) measured instrumental activities of daily living and/or social functioning. Our search yielded 21 functional assessment instruments. Only two of these instruments, the 36-Item Short Form Survey and the Performance Assessment of Self-Care Skills, have formal validation data in LLD. Four additional instruments, although not formally validated, have relevant data regarding their measurement properties. The primary finding of this study is that very few functional assessment instruments have been validated in LLD, and the available measurement property data are mixed; there is a need for further instrument validation in late-life depression. With this caveat in mind, we provide evidence-based suggestions for researchers and clinicians assessing functioning in LLD patients.

Measurement of function in older adults transitioning from hospital to home: an integrative review

Older adults often experience decline in functional status during the transition from hospital to home. In order to determine the effectiveness of interventions to prevent functional decline, researchers must have instruments that are reliable and valid for use with older adults. The purpose of this integrative review is to: (1) summarize the research uses and methods of administering functional status instruments when investigating older adults transitioning from hospital to home, (2) examine the development and existing psychometric testing of the instruments, and (3) discuss gaps and implications for future research. The authors conducted an integrative review of forty research studies that assessed functional status in older adults transitioning from hospital to home. This review reveals important gaps in the functional status instruments' psychometric testing, including limited testing to support their validity and reliability when administered by self-report and limited evidence supporting their ability to detect change over time.

The influence of computer-based cognitive flexibility training on subjective cognitive well-being after stroke: A multi-center randomized controlled trial

Background

Stroke can result in cognitive complaints that can have a large impact on quality of life long after its occurrence. A number of computer-based training programs have been developed with the aim to improve cognitive functioning. Most studies investigating their efficacy used only objective outcome measures, whereas a reduction of subjective cognitive complaints may be equally important for improving quality of life. A few studies used subjective outcome measures but were inconclusive, partly due to methodological shortcomings such as lack of proper active and passive control groups.

Objective

The aim of the current study was to investigate whether computer-based cognitive flexibility training can improve subjective cognitive functioning and quality of life after stroke.

Methods

We performed a randomized controlled double blind trial (RCT). Adults (30–80 years old) who had a stroke 3 months to 5 years ago, were randomly assigned to either an intervention group (n = 38), an active control group (i.e., mock training; n = 35), or a waiting list control group (n = 24). The intervention and mock training consisted of 58 half-hour sessions within 12 weeks. The primary subjective outcome measures were cognitive functioning (Cognitive Failure Questionnaire), executive functioning (Dysexecutive Functioning Questionnaire), quality of life (Short Form Health Survey), instrumental activities of daily living (IADL; Lawton & Brody IADL scale), and participation in society (Utrecht Scale for Evaluation of Rehabilitation-Participation). Secondary subjective outcome measures were recovery after stroke, depressive symptoms (Hospital Anxiety Depression Scale—depression subscale), fatigue (Checklist Individual Strength—Fatigue subscale), and subjective cognitive improvement (exit list). Finally, a proxy of the participant rated the training effects in subjective cognitive functioning, subjective executive functioning, and IADL.

Results and conclusions

All groups improved on the two measures of subjective cognitive functioning and subjective executive functioning, but not on the other measures. These cognitive and executive improvements remained stable 4 weeks after training completion. However, the intervention group did not improve more than the two control groups. This suggests that improvement was due to training-unspecific effects. The proxies did not report any improvements. We, therefore, conclude that the computer-based cognitive flexibility training did not improve subjective cognitive functioning or quality of life after stroke.

Multidimensional measures validated for home health needs of older persons: A systematic review

OBJECTIVE

To conduct a systematic review of the literature on valid and reliable multidimensional instruments to assess home health needs of older persons.

DESIGN

Systematic review.

DATA SOURCE

Electronic databases, PubMed/Medline, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Scientific Electronic Library Online and the Latin American and Caribbean Health Sciences Information.

REVIEW METHODS

All English, Portuguese and Spanish literature which included studies of reliability and validity of instruments that assessed at least two dimensions: physical, psychological, social support and functional independence, self-rated health behaviors and contextual environment and if such instruments proposed interventions after evaluation and/or monitoring changes over a period of time.

PARTICIPANTS

Older persons aged 60 years or older.

RESULTS

Of the 2397 studies identified, 32 were considered eligible. Two-thirds of the instruments proposed the physical, psychological, social support and functional independence dimensions. Inter-observer and intra-observer reliability and internal consistency values were 0.7 or above. More than two-thirds of the studies included validity (n=26) and more than one validity was tested in 15% (n=4) of these. Only 7% (n=2) proposed interventions after evaluation and/or monitoring changes over a period of time.

CONCLUSION

Although the multidimensional assessment was performed, and the reliability values of the reviewed studies were satisfactory, different validity tests were not present in several studies. A gap at the instrument conception was observed related to interventions after evaluation and/or monitoring changes over a period of time. Further studies with this purpose are necessary for home health needs of the older persons.

Serum markers of inflammation and oxidative stress in sarcopenia

BACKGROUND

Sarcopenia is a geriatric syndrome characterized by the presence of low muscle mass and function. Possible mechanisms underlying sarcopenia include oxidative stress and elevation of inflammatory cytokines.

AIMS

The aim of the study was to evaluate the relationship between sarcopenia and biomarkers that may be involved in its pathogenesis and hence early detection.

METHODS

A total of 72 patients (36 sarcopenic and 36 non-sarcopenic) were included in the study. An experienced geriatric team applied comprehensive geriatric assessment to all patients. Anthropometric measures, gait speed and handgrip strength were recorded. Bioelectrical impedance analysis was used to assess skeletal muscle mass. In addition to routine clinical laboratory tests, serum adiponectin, thioredoxin-1 and pentraxin-3 levels were measured. Sarcopenia was defined according to the European Working Group on Sarcopenia in older Adults as the presence of low muscle mass and low muscle function or muscle performance.

RESULTS

Sarcopenic patients were more likely to be functionally dependent and had lower scores on comprehensive geriatric assessment tools. Erythrocyte sedimentation rate (ESR) and C-reactive protein levels were significantly higher in the sarcopenic group. There was no significant difference in serum levels of thioredoxin-1 and pentraxin-3. Sarcopenic patients had lower levels of hemoglobin, albumin, total protein, calcium, triglycerides, uric acid and adiponectin (p < 0.05). Hypertension and body mass index were inversely correlated with sarcopenia whereas ESR was positively correlated.

DISCUSSION AND CONCLUSION

The present study demonstrated an association of sarcopenia with inflammatory markers CRP, ESR and adiponectin. Long-term prospective studies are warranted to confirm the relationship between markers oxidative stress and age related muscle decline.

Residential area characteristics and disabilities among Dutch community-dwelling older adults

Background

Living longer independently may be facilitated by an attractive and safe residential area, which stimulates physical activity. We studied the association between area characteristics and disabilities and whether this association is mediated by transport-related physical activity (TPA).

Methods

Longitudinal data of 271 Dutch community-dwelling adults aged 65 years and older participating in the Elderly And their Neighbourhood (ELANE) study in 2011–2013 were used. Associations between objectively measured aesthetics (range 0–22), functional features (range 0–14), safety (range 0–16), and destinations (range 0–15) within road network buffers surrounding participants’ residences, and self-reported disabilities in instrumental activities of daily living (range 0–8; measured twice over a 9 months period) were investigated by using longitudinal tobit regression analyses. Furthermore, it was investigated whether self-reported TPA mediated associations between area characteristics and disabilities.

Results

A one unit increase in aesthetics within the 400 m buffer was associated with 0.86 less disabilities (95% CI −1.47 to −0.25; p < 0.05), but other area characteristics were not related to disabilities. An increase in area aesthetics was associated with more TPA, and more minutes of TPA were associated with less disabilities. TPA however, only partly mediated the associated between area aesthetics and disabilities.

Conclusions

Improving aesthetic features in the close by area around older persons’ residences may help to prevent disability.

Association of psychological, cognitive, and functional variables with self-reported executive functioning in a sample of nondemented community-dwelling older adults

Subjective executive functioning (EF) measures provide valuable information about real-world difficulties, although it is unclear what variables actually associate with subjective EF scores. We investigated subjective EF in 245 nondemented, community-dwelling older adults (aged 70 and above) from the Einstein Aging Study. Partial correlational analyses controlling for age were performed between the nine Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A) clinical scales and objective EF tests, self-reported mood and personality, and informant-reported activities of daily living. The significance level was set at p < .006 for all analyses (two-tailed). Most notably, higher worry/oversensitivity, physiological anxiety, and fear of aging were significantly associated with increased EF difficulties on all nine BRIEF-A scales. Additionally, increased EF difficulties on five or more BRIEF-A scales were significantly associated with lower conscientiousness, higher neuroticism, and higher depressive symptom scores. The only objective neuropsychological test that significantly correlated with increased EF difficulties (on four BRIEF-A scales) was a measure of practical judgment. Overall, results indicate that interpretation of subjective EF scores must account for self-report of mood and personality. Moreover, the BRIEF-A only minimally taps objective EF as measured by performance-based measures. We discuss the theoretical and practical implications of these findings.

Burden of Care and Patient's Neuropsychiatric Symptoms Influence Carer's Evaluation of Cognitive Impairment

OBJECTIVES

The aim of this study was to explore what effects the carer's burden and patient's neuropsychiatric symptoms have on carer's report on patient's cognitive functioning and instrumental activities of daily living (IADL).

METHODS

We included 1,832 patients, 742 with mild cognitive impairment and 1,090 with dementia [mean age 75.2 years (SD 9.5), 56% women]. The following scales were used: Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Lawton and Brody IADL Scale, Neuropsychiatric Inventory Questionnaire (NPI-Q), Relatives' Stress Scale (RSS), Mini-Mental State Examination (MMSE), and Clock Drawing Test (CDT). Correlation analyses and multiple linear regression analyses were carried out to explore which factors were associated with IQCODE and IADL.

RESULTS

Spouses scored lower on the IQCODE compared with non-spouses in spite of equivalent MMSE and CDT scores. In a multiple linear regression analysis using IQCODE as a dependent variable, beta for MMSE was -0.368 (p < 0.001) adjusted for demographic factors. After adjusting also for RSS and NPI-Q, MMSE beta was -0.279 (p < 0.001), RSS beta 0.294 (p < 0.001), and NPI beta 0.237 (p < 0.001). Similar results were found using IADL as the dependent variable.

CONCLUSION

Carer's burden and neuropsychiatric symptoms of the patient are important biasing factors when carers report on cognitive function and IADL.

Old tool, new tricks? A new adaptation of the Modified Falls Efficacy Scale

Aim:

Measuring outcomes is important in community rehabilitation programs (CRPs), both at the individual and service level. Identifying global outcome measures that can be used for all patients is challenging given the diversity of this client group.

Method:

This observational study explored measurement properties of the Modified Efficacy Scale (MES), which is an adaptation of the Modified Falls Efficacy Scale. The MES was used to assess patient confidence in performing activities without reference to falls and was trialled with 221 CRP patients. Floor and ceiling effects, responsiveness to change and minimal clinically important difference (MCID) scores were measured and compared with scores for the same sample of patients using the Lawton Instrumental Activities of Daily Living (IADL) scale.

Results:

The MES showed evidence of convergent validity and was responsive to change. Both scales showed ceiling effects on discharge, although this was more pronounced with the Lawton IADL scale (40%) than the MES (21%). Both scales had small values for MCID relative to scale width.

Conclusions:

The MES demonstrated evidence of validity and has a less pronounced ceiling effect compared with the Lawton IADL scale. The implications of a ceiling effect should be considered in the context of the assessment purpose.

Is expressed emotion related to estimates of ability made by older people with cognitive impairments and their partners?

OBJECTIVES

Discrepancies in ratings of ability are used to assess awareness in people with cognitive impairments, and previously have been found to be associated with comorbid depression and carer distress. This study explored how the degree of discrepancy between self-ratings of ability made by older people with a cognitive impairment and informant ratings made by their partners relates to aspects of their relationship quality. It was hypothesised that discrepancies between self- and partner ratings would be associated with partner's expressed emotion (EE), and replicate previous findings for associations with depression and carer distress.

METHOD

Forty-six people aged over 65 with mild cognitive impairment or early-stage dementia were recruited through NHS mental health services for older people. In a semi-structured interview, they and their partners gave separate ratings of cognitive abilities and instrumental activities of daily living (IADL). Partners also completed a 5-minute speech sample task to assess the type of EE. Depression in cognitively impaired participants and partner distress were also measured.

RESULTS

High EE, depression and carer distress were associated with larger discrepancies in ratings of ability on the cognitive measure. EE was not associated with self-ratings or partner ratings of cognitive or IADL ability.

CONCLUSION

The findings suggest that where disagreement about the abilities of an older person with cognitive impairments is greater, the affective environment around that person is more likely to be characterised by criticism and/or emotional over-involvement. The implications of this for assessment, diagnosis, and helping couples adjust to cognitive deterioration are discussed.

Quality of life in Alzheimer's disease: different factors associated with complementary ratings by patients and family carers

BACKGROUND

Quality of life (QoL) in dementia is a complex construct and factors that predict QoL ratings are unclear. We designed this study to determine: (1) the agreement in QoL ratings between community-dwelling patients with mild to moderate dementia and family carers; and (2) the factors associated with self-reported and two types of carer-reported QoL ratings: carer-carer perspective and carer-patient perspective.

METHODS

A cross-sectional study was carried out of 80 community-dwelling patients with the diagnosis of probable Alzheimer's disease (AD) of mild or moderate severity according to NINCDS-ADRD criteria, and their 80 family carers. The QoL-AD was the primary outcome measure. We collected patients' self-reported QoL ratings and two types of carer-reported QoL ratings: carer-patient and carer-carer perspectives. Explanatory variables included demographics, lifestyle, and clinical information from patients and carers, along with cognition, awareness, psychopathology, burden-of-care, and functionality in daily life. Bland-Altman plots guided the interpretation of agreement by visualizing the distribution of all the ratings. Univariate and multivariate regression analyses were conducted to examine the contribution of candidate explanatory factors.

RESULTS

Patients and their carers showed good agreement in their QoL ratings, although the total scores of carers (regardless of perspective) were lower than the scores of patients. Depression, insight and use of anti-dementia agents were associated with QoL self-ratings, whereas cognitive function was directly associated and depression inversely associated with carers' QoL ratings.

CONCLUSION

Mild to moderate community-dwelling AD patients and their carers (with different perspectives) agree within an acceptable range in QoL ratings but the ratings are driven by different factors, and consequently are not interchangeable but complementary. They provide valuable information when used separately, not in a composite score.

(Instrumental) activities of daily living in older adults with intellectual disabilities

Daily living skills are important to ageing adults with intellectual disabilities (ID). The purpose of this study was to investigate the level of these skills in older adults with ID and to investigate the influence of gender, age, level of ID and mobility on these skills. Daily living skills were measured with the Barthel Index (for Activities of Daily Living, ADL) and the Lawton IADL scale (for Instrumental Activities of Daily Living, IADL) in 989 adults with ID aged 50 years and over living in community-based and institutional settings. Descriptives were presented by categories of gender, age, level of ID and mobility. Regression analysis was used to investigate the influence of these variables on total and item scores of ADL and IADL questionnaires. ADL and IADL scores in older adults with ID are comparable to those of vulnerable patient groups. Total ADL score was mainly determined by mobility, while total IADL score was mainly determined by level of ID. Of all 18 separate items of these questionnaires, 11 were determined more by mobility than level of ID. The Barthel Index and Lawton IADL scale are recommended for future use in research and clinical practice in this group. This study stresses the need to support mobility older adults with ID as much as possible, in order to optimize independency in this group.

The classic measure of disability in activities of daily living is biased by age but an expanded IADL/ADL measure is not

OBJECTIVES

To evaluate, by age, the performance of 2 disability measures based on needing help: one using 5 classic activities of daily living (ADL) and another using an expanded set of 14 activities including instrumental activities of daily living (IADL), walking, getting outside, and ADL (IADL/ADL).

METHODS

Guttman and item response theory (IRT) scaling methods are used with a large (N = 25,470) nationally representative household survey of individuals aged 18 years and older.

RESULTS

Guttman scalability of the ADL items increases steadily with age, reaching a high level at ages 75 years and older. That is reflected in an IRT model by age-related differential item functioning (DIF) resulting in age-biased measurement of ADL. Guttman scalability of the IADL/ADL items also increases with age but is lower than the ADL. Although age-related DIF also occurs with IADL/ADL items, DIF is lower in magnitude and balances out without causing age bias.

DISCUSSION

An IADL/ADL scale measuring need for help is hierarchical, unidimensional, and unbiased by age. It has greater content validity for measuring need for help in the community and shows greater sensitivity by age than the classic ADL measure. As demand for community services is increasing among adults of all ages, an expanded IADL/ADL measure is more useful than ADL.

Family members providing home-based palliative care to older adults: the enactment of multiple roles

Canadians are experiencing increased life expectancy and chronic illness requiring end-of-life care. There is limited research on the multiple roles for family members providing home-based palliative care. Based on a larger ethnographic study of client-family-provider relationships in home-based palliative care, this qualitative secondary analysis explores the enactment of multiple roles for family members providing home-based palliative care to seniors with advanced cancer. Family members had multiple expectations to provide care but felt their expectations of services were unmet. The process of enacting multiple roles was depicted by three interrelated themes: balancing, re-prioritizing, and evolving. Positive and negative health responses resulted from attempts to minimize personal health while simultaneously maintaining health. "True" family-centred care was found to be lacking, but should be a goal of health professionals involved in end-of-life care.