The Needs of the Caregiver in the Long-Term Treatment of Alzheimer Disease

Caregivers of people with dementia and mental health during COVID-19: findings from a cross-sectional study

BACKGROUND

There is sparse evidence on the impact on vulnerable populations of the COVID-19 pandemic. The aim of our study was to explore burden and mental wellbeing (including depressive, anxiety, and stress symptoms) in caregivers of people with dementia during the first wave of the pandemic in Italy and southern Switzerland, two bordering regions severely hit by the COVID-19 pandemic.

METHODS

We conducted an online cross-sectional survey with family carers of people with dementia between May and June 2020. We registered socio-demographic characteristics, and information about the relationship with the care recipient, dementia subtype, care inputs from others, and the need of care of the person with dementia. We measured caregiver burden with the Zarit Burden Interview (ZBI), psychological distress with the Depression, Anxiety and Stress Scale (DASS-21), and perceived isolation with the 3-item UCLA Loneliness Scale (UCLALS3).

RESULTS

Caregivers (N =571) reported moderate to severe care-related burden (mean=54.30; SD=18.33), moderate anxiety symptoms (mean=10.04; SD=6.93), mild depressive symptoms (mean=11.79; SD=6.12) and mild stress (mean=12.95; SD=5.53), and 72.3% of participants reported to feel lonely. All scores were significantly more severe in Swiss compared to Italian caregivers (all p values<0.001).

CONCLUSIONS

We found that caregivers' burden, anxiety symptoms, depression and perceived loneliness were marked during the first wave of the COVID-19 pandemic, in two severely hit bordering countries. Regional differences in the impact of the epidemic on caregivers could be due to contextual, societal, and cultural circumstances. As the pandemic endures, support to caregivers of people with dementia should be proportionate and tailored to needs and adapted to contextual factors.

Psychosocial interventions to support the mental health of informal caregivers of persons living with dementia - a systematic literature review

Background

Informal caregivers of persons living with dementia have an increased risk of adverse mental health effects. It is therefore important to systematically summarize published literature in order to find out which mental health interventions generate effective support for informal caregivers of persons living with dementia. The objective of this study is to conduct a systematic review of intervention content, effectiveness and subgroup differentiation of mental health interventions for informal caregivers of persons with dementia living at home.

Method

We searched four electronic databases (PubMed, PsychINFO, Scopus and CINAHL) and included only methodically high-quality randomized controlled trials (RCTs), published in English or German language between 2009 and 2018. The intervention programmes focused on mental health of family caregivers. A narrative synthesis of the included studies is given.

Results

Forty-eight publications relating to 46 intervention programmes met the inclusion criteria. Burden, depression and quality of life (QoL) are the predominant parameters that were investigated. Twenty-five of forty-six interventions (54.3%) show positive effects on at least one of the outcomes examined. Most often, positive effects are reported for the outcome subjective burden (46.2%). Only six studies explicitly target on a certain subgroup of informal dementia caregivers (13%), whereas all other interventions (87%) target the group as a whole without differentiation.

Conclusion

The most beneficial results were found for cognitive behavioural approaches, especially concerning the reduction of depressive symptoms. Besides this, leisure and physical activity interventions show some good results in reducing subjective caregiver burden. In order to improve effectiveness, research and practice may focus on developing more targeted interventions for special dementia informal caregiver subgroups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02020-4.

Randomized Controlled Trial of the Caregiver Orientation for Mobilizing Personal Assets and Strengths for Self-Care (COMPASS) for Caregiving Journey: A National Family Caregiver Support Program in a Long-Term Care Insurance System

OBJECTIVES

To investigate the effects of a national support program on family caregivers for long-term care (LTC) recipients.

DESIGN

A single-blinded randomized controlled trial compared the 8-week Caregiver Orientation for Mobilizing Personal Assets and Strengths for Self-Care (COMPASS) program consisting of 6 individual in-home, 3 group support, and 2 telephone sessions with a multicomponent intervention, and a control group.

SETTING AND PARTICIPANTS

In total, 969 caregivers who were living with LTC recipients assessed as having a high caregiving burden in 12 Korean cities.

MEASURES

The primary outcomes were depression, burden, and stress levels of caregivers, the secondary outcomes were caregiver self-efficacy, positive aspects of caregiving, social support, social activities, and health risk behaviors. These outcomes were measured at baseline and after the 8-week program, analyzed using modified intention-to-treat, per-protocol (PP), and non-PP analyses.

RESULTS

The modified intention-to-treat analysis revealed significant improvements in burden (effect size, = 0.010, P = .008), depression (η_p² = 0.012, P = .003), and health risk behaviors (η_p² = 0.010, P = .012) for the experimental group compared with the control group. However, there were no significant differences between the 2 groups in improving stress (P = .997), social support (P = .234), or social activities (P = .816). The PP analysis indicated that the COMPASS program was successful in increasing positive aspects of caregiving (η_p² = 0.013, P = .004) and self-efficacy (η_p² = 0.010, P = .032) compared with the control group.

CONCLUSIONS AND IMPLICATIONS

The COMPASS program was effective in family caregivers of LTC recipients in critical aspects of physical and psychological outcomes, especially in demonstrating the important role of participating in group support sessions. It is feasible for the program to become a formal national support program as part of the national insurance system in Republic of Korea.

Application of Ferulic Acid for Alzheimer's Disease: Combination of Text Mining and Experimental Validation

Alzheimer's disease (AD) is an increasing concern in human health. Despite significant research, highly effective drugs to treat AD are lacking. The present study describes the text mining process to identify drug candidates from a traditional Chinese medicine (TCM) database, along with associated protein target mechanisms. We carried out text mining to identify literatures that referenced both AD and TCM and focused on identifying compounds and protein targets of interest. After targeting one potential TCM candidate, corresponding protein-protein interaction (PPI) networks were assembled in STRING to decipher the most possible mechanism of action. This was followed by validation using Western blot and co-immunoprecipitation in an AD cell model. The text mining strategy using a vast amount of AD-related literature and the TCM database identified curcumin, whose major component was ferulic acid (FA). This was used as a key candidate compound for further study. Using the top calculated interaction score in STRING, BACE1 and MMP2 were implicated in the activity of FA in AD. Exposure of SHSY5Y-APP cells to FA resulted in the decrease in expression levels of BACE-1 and APP, while the expression of MMP-2 and MMP-9 increased in a dose-dependent manner. This suggests that FA induced BACE1 and MMP2 pathways maybe novel potential mechanisms involved in AD. The text mining of literature and TCM database related to AD suggested FA as a promising TCM ingredient for the treatment of AD. Potential mechanisms interconnected and integrated with Aβ aggregation inhibition and extracellular matrix remodeling underlying the activity of FA were identified using in vitro studies.

Using Machine Reading to Understand Alzheimer’s and Related Diseases from the Literature

Purpose

This paper aims to better understand a large number of papers in the medical domain of Alzheimer’s disease (AD) and related diseases using the machine reading approach.

Design/methodology/approach

The study uses the topic modeling method to obtain an overview of the field, and employs open information extraction to further comprehend the field at a specific fact level.

Findings

Several topics within the AD research field are identified, such as the Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), which can help answer the question of how AIDS/HIV and AD are very different yet related diseases.

Research limitations

Some manual data cleaning could improve the study, such as removing incorrect facts found by open information extraction.

Practical implications

This study uses the literature to answer specific questions on a scientific domain, which can help domain experts find interesting and meaningful relations among entities in a similar manner, such as to discover relations between AD and AIDS/HIV.

Originality/value

Both the overview and specific information from the literature are obtained using two distinct methods in a complementary manner. This combination is novel because previous work has only focused on one of them, and thus provides a better way to understand an important scientific field using data-driven methods.

PROGRESS IN CLINICAL NEUROSCIENCES: Canadian Guidelines for the Development of Antidementia Therapies: A Conceptual Summary

The magnitude of the problems faced by an aging Canadian society has been clearly identified. Perhaps the single most important problem is the increasing incidence of dementia. Alzheimer's disease (AD) accounts for 50-60% of the dementias in later life within a spectrum of other contributing dementias. Regulatory approval has been given to Acetylcholinesterase inhibitors for the symptomatic treatment of mild to moderate AD, and conditional approval to memantine for the symptoms of moderate to severe AD. There has been no regulatory approval for the treatment of the degenerative dementias beyond AD. The very rapid progress in the past decade in biotechnology and in the molecular biology of the dementias is supporting a new generation of innovative treatment strategies that will more directly target the underlying disease pathogenic mechanisms. Such treatments will foreseeably include immunotherapies, anti-aggregants that may prevent misfolding and deposition of proteins, and neuroregenerative interventions. These Guidelines follow the 2nd Canadian Conference on the Development of Antidementia Therapies, held in 2004, which covered a range of design, methodological and ethical issues facing clinical researchers and regulatory authorities. They are intended to provide a common point of reference and guidance in Canada for therapeutic development of the dementias.

Quality of Life in Dementia

There is a growing consensus that quality of life (QOL) is an important outcome for assessing the effectiveness of interventions for dementia, but there is no agreement about how to best measure it. Various approaches to QOL assessment have been employed to measure the QOL of persons with dementia, including patient self-report, caregiver proxy report and observational assessment by trained observers. Furthermore, several dementia-specific measures of QOL have been developed, and several generic measures of QOL have been used to assess QOL in dementia. However, to date, QOL has rarely been included as an outcome measure in clinical trials of pharmacotherapy for dementia. This manuscript reviews the current state of knowledge about QOL assessment in dementia.

Concept Analysis: Alzheimer's Caregiver Stress

AIM

The aim of this article was to analyze the concept of caregiver stress in the context of caring for a person with Alzheimer's disease and related dementias.

BACKGROUND

Currently, there are more than 15 million unpaid caregivers for persons suffering from Alzheimer's disease and related dementias. This unpaid care can be stressful for caregivers due to the chronic nature of the disease process, as well as other factors.

METHOD

The paper incorporates the modified method of Wilson's concept analysis procedure to analyze the concept of caregiver stress.

DATA SOURCES

A review of the literature was undertaken using the Cumulative Index to Nursing and Allied Health Literature, Google Scholar, and PubMed.

RESULTS

A theoretical definition of caregiver stress is provided, and the defining attributes, related concepts, antecedents, and consequences of caregiver stress are proposed, and case studies are presented.

CONCLUSIONS

The analysis demonstrates that caregiver stress is the unequal exchange of assistance among people who stand in close relationship to one another, which results in emotional and physical stress on the caregiver. Implications for future nursing research and practice conclude the paper.

Predictors of quality of life and caregiver burden among maternal and paternal caregivers of patients with eating disorders

This prospective study investigated quality of life and caregiver burden of 244 parent caregivers of 113 Spanish patients with Eating Disorders (ED). One hundred eleven mothers and 70 fathers fulfilled the inclusion criteria. ED patients completed the Hospital Anxiety and Depression Scale (HADS) and the Eating Attitudes Test-26. Caregivers completed the HADS, the Short Form-12 (SF-12), the Involvement Evaluation Questionnaire-EU version, and the Anorectic Behaviour Observation Scale. Descriptive statistics, ANOVA, Chi-square and Fisher's exact test were applied. Among mothers, anxiety and depression and patient age contributed to poorer quality of life. Caregiver variables that affected the burden for mothers were marital status, the mental subscale of the SF-12, and the mother's perception of the severity of her child's illness. Caregiver variables that affected the burden for fathers were the caregiver's anxiety and the physical domain of the SF-12. Among mothers but not fathers, being married was a protective factor of caregiver burden. Our findings suggest that mothers and fathers have different perceptions of their quality of life and caregiver burden, and that mothers of patients with ED may be in considerable need for extra psychosocial support.

'The path through the unknown': the experience of being a relative of a dementia-suffering spouse or parent

AIMS AND OBJECTIVES

To examine the experiences of relatives of a spouse or parent who suffers from dementia and examines whether there are similarities or differences between these experiences.

BACKGROUND

Dementia is an increasing illness in the world. Dementia affects not only the person with dementia but also the relatives. There is a lack of knowledge about the experience of being a relative to a dementia-suffering person.

DESIGN AND METHODS

Twenty-one stories from relatives were included in this study, and these stories were analysed by employing Kirsti Malterud's method 'systematic text condensation'. The relatives were divided into four groups: sons, husbands, daughters and wives.

RESULTS

Eight themes were identified in their stories, two in each of the four groups. From these eight themes, it was identified that they all experienced change, grief and negative personal sentiments. However, differences were also found, one of them being that the sons found it easier to adapt to new roles during the course of the illness, while the daughters found it more difficult. The husbands experienced being attacked by the people around them, while the wives were found to submit their dementia-suffering husbands to physical abuse. The wives also suffered from self-criticism.

CONCLUSIONS

The similarities between the four groups are more significant than the differences. Sons, husbands, daughters and wives of a person suffering from dementia should be considered on an equal basis in terms of their experiences of grief, change and personal negative sentiments.

RELEVANCE TO CLINICAL PRACTICE

Relatives play a significant role in the well-being of their parent or spouse suffering from dementia. Therefore, professionals need to focus on both relatives and patient when they meet a person with dementia in clinical practice.

Locomoção, distúrbios neuropsiquiátricos e alterações do sono de pacientes com demência e seus cuidadores

INTRODUÇÃO: Os distúrbios neurodegenerativos representam condições clínicas graves, por provocar declínio neuropsíquico. OBJETIVO: Analisar a prevalência dos distúrbios neuropsiquiátricos em pacientes com demência, em relação à sua locomoção (independentes vs. dependentes), e no que se refere ao desgaste emocional e à qualidade do sono dos cuidadores. MATERIAIS E MÉTODOS: Participaram do estudo 34 sujeitos, assim divididos: dez pacientes independentes para locomoção e sete dependentes (cadeirantes); dez cuidadores dos pacientes independentes e sete cuidadores de pacientes dependentes. Os sujeitos foram avaliados no Ambulatório de Neuropsiquiatria da Universidade Estadual de Campinas. Para avaliar as funções cognitivas, utilizou-se o CAMCOOG; para quantificar frequência, intensidade e desgaste do cuidador, aplicou-se o Inventário Neuropsiquiátrico; e para mensurar as alterações do sono dos cuidadores, foi utilizado o Miniquestionário do Sono. A análise estatística foi realizada por meio dos testes U - Mann Whitney e índice de correlação de Spearman, ambos com 5% de significância. RESULTADOS: Com relação à prevalência dos distúrbios neuropsiquiátricos entre os pacientes, observou-se diferença estatisticamente significativa entre os grupos, especificamente no que se refere à irritabilidade (p < 0,05) e ao escore total dos distúrbios neuropsiquiátricos (p < 0,01). Também foram encontradas diferenças entre os grupos de cuidadores, com relação às alterações do sono (p < 0,05). CONCLUSÃO: Idosos independentes para locomoção apresentam menor prevalência dos distúrbios neuropsiquiátricos, quando comparados a idosos dependentes de cadeira de rodas. A locomoção parece não influenciar no desgaste físico e emocional do cuidador, mas constitui uma variável relevante na qualidade do sono dos cuidadores de idosos com diagnóstico de demência vascular e mista.

Burden of caregiving amongst family caregivers of patients with eating disorders

BACKGROUND

Eating disorders (EDs) in a close relative can be particularly stressful for family members.

AIMS

To assess the perceived burden of caregivers of patients with EDs and to identify demographic and clinical variables that could predict this burden.

METHOD

We conducted a cross-sectional study involving 145 ED patients and 246 related caregivers. ED patients completed the Health-Related Quality of Life in ED-short form, the Hospital Anxiety and Depression Scale, and the Short Form-12. Caregivers completed the Involvement Evaluation Questionnaire-EU version, the Short Form-12, the Hospital Anxiety and Depression Scale, and the Anorectic Behaviour Observation Scale. Descriptive statistics, ANOVA, Chi-square, and Fisher's exact test were applied to examine the inter-variable relationships.

RESULTS

A high burden of caregiving was associated with being divorced (β = 14.23, SE = 3.88; p = 0.001), having a low level of education (β = 4.70, SE = 1.96; p = 0.02), having high levels of anxiety (β = 5.45, SE = 2.13; p = 0.01) or depression (β = 5.74, SE = 2.80; p = 0.04), and caring for a relative with a low physical quality of life (β = 5.91, SE = 1.78; p = 0.002).

CONCLUSIONS

Evaluating family caregivers of patients with ED for risk factors for increased caregiver burden and offering them assistance could reduce their perceived burden of caregiving.

Predictors of change in perceived burden among caregivers of patients with eating disorders

BACKGROUND

Little is known about whether the perceived burden of caring for someone with an eating disorder (ED) changes over time or what may predict such change.

METHODS

In this prospective study of ED patients and their caregivers, caregivers answered the Involvement Evaluation Questionnaire - EU Version (IEQ-EU), the Hospital Anxiety and Depression Scale (HADS), the SF-12, and the Anorectic Behaviour Observation Scale (ABOS) at baseline and after one and two years of follow-up. On the same schedule, patients answered the HADS and the SF-12, as well as the Eating Attitudes Test (EAT-26) and the Health-Related Quality of Life in ED - short form (HeRQoLED-s). The psychiatrists assessed ED severity using the Clinical Global Impressions (CGI) scale.

RESULTS

Perceived caregiver burden significantly improved over the first year of follow-up; no further improvement was observed with longer follow-up. Reduction in perceived burden was associated with lower anxiety in caregivers and patients, and lower caregiver's perception of the severity of the patient's ED. With a decrease in patients' depressive symptoms, caregivers felt less need to urge them to carry out activities of self-care.

LIMITATIONS

The IEQ-EU evaluates burden of caring in psychosis and mood disorders, but not for EDs. Loss of participants during the study could limit the generalization of results for the second year of follow-up.

CONCLUSIONS

These data corroborate the need to monitor the health of caregivers of ED patients and provide them with tools to manage the consequences of these disorders, because these consequences can determine the burden perception independent of patients' symptoms.

Impact of neuropsychiatric symptoms on caregiver burden in patients with Alzheimer’s disease

SUMMARY Neuropsychiatric symptoms (NPS) are very common amongst patients with Alzheimer’s disease and contribute significantly to caregiver burden. Different NPS may contribute differently to caregiver burden. This has important implications for targeting treatment. Medline was searched using the keywords ‘caregiver burden’, ‘BPSD’, ‘behavioral problems’, ‘Alzheimer’s disease’, ‘dementia’ and ‘dementia of the Alzheimer type’. After an extensive search, 14 papers were identified. Caregiver burden and related quality-of-life measures were significantly associated with NPS in all studies. When compared with other factors, NPS had a stronger association than demographic and cognitive factors and a similar association with functional impairment. Psychotic symptoms were consistently associated with increased caregiver burden compared with other NPS. Pharmacological and nonpharmacological interventions should focus on addressing the NPS that are most associated with increased caregiver burden.

The Coping with Caregiving Group Program for Chinese caregivers of patients with Alzheimer's disease in Hong Kong

OBJECTIVE

This pilot study evaluated the effectiveness of Coping with Caregiving (CWC) psychoeducational program for Chinese family caregivers of patients with Alzheimer's disease in Hong Kong.

METHOD

Twenty-seven female primary caregivers were randomized to join the treatment group or wait-list control group. The caregivers in the treatment group participated in 13 weekly training sessions which taught specific cognitive-behavioral strategies to handle caregiving stress.

RESULTS

As compared to the wait-list control group, caregivers completing the CWC program demonstrated a significant increase in their self-efficacy for controlling their upsetting thoughts and handling disruptive behaviors of the care recipients. They also reported a significant increase in the use of both problem-focused and emotion-focused coping strategies.

CONCLUSION

These findings suggested that cognitive-behavioral programs can be effective in improving the resourcefulness of Chinese caregivers of persons with dementia in Hong Kong.

PRACTICE IMPLICATIONS

Future CWC programs will have to enhance participants' ability to differentiate among various coping skills and to use situation-appropriate strategies.

Diagnosis and treatment of dementia: 6. Management of severe Alzheimer disease

BACKGROUND

The management of severe Alzheimer disease often presents difficult choices for clinicians and families. The disease is characterized by a need for full-time care and assistance with basic activities of daily living. We outline an evidence-based approach for these choices based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.

METHODS

We developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. We selected articles published from January 1996 to December 2005 that dealt with the management of severe Alzheimer disease. Subsequent to the conference, we searched for additional articles published from January 2006 to March 2008 using the same search terms. We graded the strength of the evidence using the criteria of the Canadian Task Force on Preventive Health Care.

RESULTS

We identified 940 articles, of which 838 were selected for further study. Thirty-four articles were judged to be of at least good or fair quality and were used to generate 17 recommendations. Assessment of severe Alzheimer disease should include the measurement of cognitive function and the assessment of behaviour, function, medical status, nutrition, safety and caregiver status. Management could include treatment with a cholinesterase inhibitor or memantine, or both. Treatment of neuropsychiatric symptoms begins with nonpharmacologic approaches to addressing behavioural problems. Severe agitation, aggression and psychosis, which are potentially dangerous to the patient, the caregiver and others in the environment, can be treated with atypical antipsychotics, with consideration of their increased risk of cerebrovascular events and death. All pharmacologic approaches require careful monitoring and periodic reassessment to determine whether continued treatment is necessary. Caregiver support and use of community resources are essential.

INTERPRETATION

Severe Alzheimer disease requires frequent monitoring by health professionals. Simple nonpharmacologic approaches may address problems with mood and agitation. Antipsychotic drug therapy is occasionally necessary despite the inherent risks. Therapy with a cholinesterase inhibitor and memantine may be useful for selected patients.

Dementia of the Alzheimer type

Dementia of the Alzheimer type is a progressive, fatal neurodegenerative condition characterized by deterioration in cognition and memory, progressive impairment in the ability to carry out activities of daily living, and a number of neuropsychiatric symptoms. This narrative review summarizes the literature regarding descriptive epidemiology, clinical course, and characteristic neuropathological changes of dementia of the Alzheimer type. Although there are no definitive imaging or laboratory tests, except for brain biopsy, for diagnosis, brief screening instruments and neuropsychiatric test batteries used to assess the disease are discussed. Insufficient evidence exists for the use of biomarkers in clinical practice for diagnosis or disease management, but promising discoveries are summarized. Optimal treatment requires both nonpharmacological and pharmacological interventions, yet none have been shown to modify the disease's clinical course. This review describes the current available options and summarizes promising new avenues for treatment. Issues related to the care of persons with dementia of the Alzheimer type, including caregiver burden, long-term care, and the proliferation of dementia special care units, are discussed. Although advances have been made, more research is needed to address the gaps in our understanding of the disease.

Social support and caregiving circumstances as predictors of caregiver burden in Taiwan

Previous research has failed to consider the importance of caregiving circumstances and their impact on social support and caregiver burden. Hence, this study aimed to investigate the association between perceived and received social support and caregiver burden. This cross-sectional study was carried out on 301 family caregivers. Data was collected using structured questionnaires which included a Social Support Scale, Family APGAR (adaptation, partnership, growth, affection, resolve), and Caregiver Burden Scale. Findings showed that the caregiver burden was best predicted by two perceived and one received social support variables. Caregiver burden was likely to be higher when the caregivers had lower levels of family function and social support. Perceived social support was better at predicting caregiver burden than received social support. Our study indicates that family function has an important influence on caregiver burden. Further studies on family based interventions are needed to determine approaches for effectively reducing caregiver burden. The role of perceived social support in the health of caregivers should be further investigated as a possible protective determinant in the caring process.

Cranial electrical stimulation: potential use in reducing sleep and mood disturbances in persons with dementia and their family caregivers

Family caregivers of persons with dementia and their care recipients frequently experience sleep and mood disturbances throughout their caregiving and disease trajectories. Because conventional pharmacologic treatments of sleep and mood disturbances pose numerous risks and adverse effects to elderly persons, the investigation of other interventions is warranted. As older adults use complementary and alternative medicine interventions for the relief of sleep and mood disturbances, cranial electrical stimulation, an energy-based complementary and alternative medicine, may be a viable intervention. The proposed mechanism of action and studies that support cranial electrical stimulation as a modality to reduce distressing symptoms are reviewed. Directions for research are proposed.

Activities enjoyed by patients with dementia together with their spouses and psychological morbidity in carers

Caring for a spouse with dementia is stressful and respite care is sometimes used to reduce this burden. Spouses may find some aspects of caring rewarding but the literature on positive aspects of caring is limited. To describe activities enjoyed by patients with dementia together with their spouses, and examine their relationship with psychological morbidity in carers. A convenience sample of 46 patients with mild to moderate dementia (91% with Alzheimer's disease, AD) and their spouses were interviewed at home. Spouses completed the Pleasant Events Schedule (PES-AD) to identify activities enjoyed by patients and spouses on their own and together. Psychological morbidity in spouses was assessed using the General Health Questionnaire (GHQ-12). Cognitive functions, and non-cognitive symptoms were also assessed in patients. Multiple regression analysis using age, Mini-Mental State Examination, Cornell Scale for Depression in Dementia, Revised Memory and Behaviour Problems (RMBP) checklist frequency, and PES-AD- together scores as independent variables found PES-AD-together and RMBP-frequency to be independent predictors of GHQ-12 scores in spouses, but the model could explain only 28% of variance. Facilitating activities that are enjoyed by both patients with dementia and spouses may be an alternative intervention strategy to reduce carer burden.

Impact on health-related quality of life and perceived burden of informal caregivers of individuals with Alzheimer's disease

This study assessed the impact on health-related quality of life (HRQL) and the perceived burden of informal caregivers of individuals with Alzheimer's disease (AD) on the Canary Islands (Spain). We utilized a multicenter, cross-sectional design, based on questionnaire responses of 237 informal caregivers of AD patients. Patients were classified according to the degree of severity utilizing the Clinical Dementia Rating Scale. Sociodemographic, HRQL (EQ-5D) and functional dependency data were gathered together with the degree of caregiver burden. Caregivers had a higher frequency of problems than did the general population for every EQ-5D dimension. Caregivers' HRQL was inversely associated with the subject dependency level and caregiver age. HRQL was higher for more educated caregivers. Variables with a negative and/or significant effect on caregivers' HRQL were high feelings of burden, more committed time to care, and older age. The caregiver burden quantified by the Zarit scale showed 83.3% of caregivers with a high level of burden.

Factors Causing Delay in Discharge of Elderly Patients in an Acute Care Hospital

Introduction: Prolonged hospitalisation not only increases cost, it is also associated with other complications. Length of stay (LOS) is one of the indicators that reflect total cost of care during hospitalisation. So, it is of paramount importance to find out why elderly patients overstay in acute care hospitals and address these issues proactively. Since no local data is available, a study was planned to ascertain reasons why the discharging of elderly patients from hospital is delayed and whether these reasons are avoidable. Materials and Methods: Long-stay patients were defined as those whose LOS had notably exceeded the average LOS for the Diagnosis Related Group (DRG), based on principal admitting diagnosis. A separate analysis showed that the specialty-specific long-stay marker for geriatric medicine was 28 days, so casenote review was done for all patients with LOS of more than 28 days who were discharged from geriatric medicine service of an acute care hospital during a 1-year study period. Information was collected on demographic profile, functional and cognitive status, past medical and social history, admitting medical diagnoses, discharge limiting and delaying factors. Results: During the study period, 150 patients stayed over 28 days and 137 casenotes were available for review. The mean age of the patients was 84 years, 55.5% were female, 77.4% were Chinese, mean abbreviated mental test (AMT) score was 3 and mean modified Barthel’s score was 11. The commonest primary diagnosis was sepsis followed by neurological problems, falls-related complication and cardiovascular diseases. The 2 most common discharge limiting factors (the final event which resulted in delay in discharge) were social issues (54, 39.4%) and sepsis (47, 34.3%). Of 47 patients with sepsis, 37 (78.7%) were nosocomial infection. Urinary tract infection and pneumonia were the 2 most common nosocomial infections. The 4 most common factors contributing to delayed discharge (various problems that surfaced throughout the hospital stay) were sepsis (94, 68.6%), decondi- tioning (65, 47.4%), social issues (52, 38.0%) and cardiovascular disorders (37, 27.0%). Conclusion: Elderly patients are more prone to hospitalisation-related complications like nosocomial infection and deconditioning leading to prolonged hospital stay. Early interventions can reduce these complications. Early identification of social issues and prompt discharge planning should be done to avoid delay in discharge. Key words: Deconditioning, Discharge planning, Nosocomial infections, Social

Efficacy and Safety of Memantine in Moderate-to-Severe Alzheimer Disease: The Evidence to Date

Memantine, a moderate-affinity, uncompetitive N-methyl-D-aspartate receptor antagonist, is currently the only agent approved for moderately severe to severe Alzheimer disease (AD) in Europe and for moderate-to-severe Alzheimer disease in the United States. In clinical trials, memantine has consistently demonstrated a reduced rate of deterioration on global, cognitive, functional, and behavioral measures, across a range of outcome measures compared with usual care. Notably, improvements versus placebo were seen in individual activities of daily living and behavior, particularly agitation. Efficacy was demonstrated in patients with newly diagnosed Alzheimer disease, patients previously or currently receiving acetylcholinesterase inhibitors, and both institutionalized and community-dwelling Alzheimer disease patients. Memantine has a tolerability profile similar to placebo. This review presents the results of key clinical trials, and includes clinically relevant analyses, such as numbers-needed-to-treat and effect sizes. Increased dependency and institutionalization are significant cost drivers in Alzheimer disease. Memantine is able to reduce dependency, caregiver time required, and mean monthly caregiver and societal costs. Recent studies of the relationship between Alzheimer disease progression, caregiver burden, and healthcare costs emphasize the need for treatments such as memantine that can slow the rate of decline in Alzheimer disease.

Behavioural changes and psychological symptoms in dementia disorders

The traditional view of dementia is that the features most important to accurate diagnosis and management are cognitive decline and functional disability. Behavioural and psychological symptoms have generally been thought to be of secondary importance, but new evidence suggests that these are important determinants of patients' distress, carer burden, and outcome in dementia; they can also be valuable diagnostic pointers to the underlying pathological cause and disease diagnosis. Better methods to detect and measure the severity of behavioural and psychological symptoms are needed and these could be used in well-designed intervention trials. Although pharmacological management is a commonly used option, it is often limited in its effects and can be associated with a substantial risk of side-effects. Progress in understanding the pathophysiological mechanisms underpinning behavioural and psychological symptoms in dementia will assist in developing more effective treatment approaches.

Longitudinal study on the relationship between symptomatology of dementia and levels of subjective burden and depression among family caregivers in memory clinic patients

The objective was to evaluate the course and severity of dementia-related symptoms and their relationship to caregivers' subjective burden and depression over time. Forty-five patients with dementia and their caregivers were followed over a period of 2 years. Patients' cognition, function, and behavioral/psychological symptoms were assessed by the Mini Mental State Examination, Syndrome Kurz Test, Geriatric Depression Screening scale, Instrumental Activities of Daily Living Scale, Physical Self Maintenance Scale, Behavioral Abnormalities in Alzheimer's Disease Rating Scale, and Nurses Observation Scale for Geriatric Patients. Caregivers' depression and subjective burden were evaluated by the Geriatric Depression Screening scale or Beck Depression Inventory and the Caregiver Burden Interview. Global dementia severity, functional impairment, and behavioral disturbances increased significantly over the 2-year observation period. Caregivers' burden remained stable, and severe depression decreased over time. There were significant associations between burden and dementia-related symptoms. For deficits in activities of daily living as well as behavioral disturbances, these associations became stronger over time. It was concluded that stage of dementia, functional deficits, and behavioral disturbances are important factors when evaluating the relationship between patients' symptoms and caregivers' well-being.

A hybrid qualitative method for pretesting questionnaires: The example of a questionnaire to caregivers of Alzheimer disease patients

A hybrid method based on cognitive interviewing and consensus panels was developed to pretest a questionnaire for caregivers of persons with Alzheimer disease (AD). The objective of the questionnaire was to elicit caregivers' attitudes and opinions on the use of medications to treat the disease. Thirty-one caregivers were divided into five pretest groups, within which each participant was asked to comment on questionnaire wording and design. The comments from participants in the first three groups were used to revise the questionnaire, and the revised version was given to participants in the remaining two groups. Overall, 81% (118/146) of the participants' comments were implemented. The number of comments made in the last two groups decreased relative to the number of comments made in the first three groups. The hybrid method enhanced the user-friendliness of the questionnaire and can serve as an alternative to common ad hoc pretest approaches that have little basis in theory.

Health-Related Quality-of-Life of Care-Givers as a Predictor of Nursing-Home Placement of Patients With Dementia

Care-giver health-related quality-of-life (QoL) as a predictor of nursing-home placement of family-member patients with dementia was evaluated (using the SF-36 questionnaire) in 181 care providers (78% females; mean age 63 years) at the start and at the end of 12 months of follow-up. The patients and their carers were evaluated at home or at the local Primary Health-care Centers (n = 37) in the area of Barcelona (Catalunya, Spain). Data were evaluated using logistic regression analysis with nursing-home placement of patients as the main outcome measure, and the care-givers' QoL, demographic, medical, social and cognitive variables as covariates. The incidence rate of nursing-home placement was 10.5% (95%CI: 6.4-15.9). Carers of patients who had not been placed in a nursing home had better QoL scores, even after controlling for potential confounding factors. The adjusted odds ratio of being admitted to a nursing home was 6.4 (95%CI: 2.1-19.0) for patients cared-for by relatives who rated their health as being much worse compared with the previous year. The care-giver's poor health-related QoL significantly influenced rates of nursing-home admission of patients in their care.