Predictors of family caregiver ratings of patient quality of life in Alzheimer disease: cross-sectional results from the Canadian Alzheimer's Disease Quality of Life Study

Measuring clinically relevant change in apathy symptoms in ADMET and ADMET 2

OBJECTIVES

Among participants with Alzheimer's disease (AD) we estimated the minimal clinically important difference (MCID) in apathy symptom severity on three scales.

DESIGN

Retrospective anchor- and distribution-based analyses of change in apathy symptom scores.

SETTING

Apathy in Dementia Methylphenidate Trial (ADMET) and ADMET 2 randomized controlled trials conducted at three and ten clinics specialized in dementia care in United States and Canada, respectively.

PARTICIPANTS

Two hundred and sixty participants (60 ADMET, 200 ADMET 2) with clinically significant apathy in Alzheimer's disease.

MEASUREMENTS

The Clinical Global Impression of Change in Apathy scale was used as the anchor measure and the MCID on the Neuropsychiatric Inventory - Apathy (NPI-A), Dementia Apathy Interview and Rating (DAIR), and Apathy Evaluation Scale-Informant (AES-I) were estimated with linear mixed models across all study visits. The estimated thresholds were evaluated with performance metrics.

RESULTS

Among the MCID was a decrease of four points (95% CI: -4.0 to -4.8) on the NPI-A, 0.56 points (95% CI: -0.47 to -0.65) on the DAIR, and three points on the AES-I (95% CI: -0.9 to -5.4). Distribution-based analyses were largely consistent with the anchor-based analyses. The MCID across the three measures showed ∼60% accuracy. Sensitivity analyses found that MMSE scores and apathy severity at baseline influenced the estimated MCID.

CONCLUSIONS

MCIDs for apathy on three scales will help evaluate treatment efficacy at the individual level. However, the modest correspondence between MCID and clinical impression of change suggests the need to consider other scales.

Patient-Reported Outcome Measures for Swallowing: A Proposed Checklist

PURPOSE

Patient-reported outcome measures (PROMs) are an important tool both in clinical practice and research involving patients with swallowing disorders. There are several challenges to be overcome and methodological details to be adequately reported to ensure rigor and transparency in studies utilizing PROMs in dysphagia research. For this reason, the Framework for RigOr aNd Transparency In REseaRch on Swallowing (FRONTIERS), a critical appraisal tool developed to ensure rigor and transparency in dysphagia research, has devoted a domain to PROMs. The aim of this current article, as part of a larger forum of articles, is to present the PROM section of FRONTIERS and describe its development.

METHOD

A literature review was carried out on PROMs in the field of dysphagia by three members of the FRONTIERS collaborative to identify items that were necessary for the rigorous application and transparent reporting of PROMs utilized in research of swallowing disorders in human subjects. Framework items were then subjected to an iterative process of feedback and consensus among the three members of the working group as well as all members of the FRONTIERS collaborative. Items were flagged for review and revised as needed until consensus was achieved on the final list. The final item list was compared to existing critical appraisal tools for PROMs.

RESULTS

The final checklist for the PROMs domain included 20 "Yes/No" questions that can be broadly divided into three categories: (a) development and validation, (b) patient population, and (c) PROM administration method. Each item is presented with a rationale for its inclusion.

CONCLUSIONS

The use of the FRONTIERS Framework will serve researchers and those appraising quality of research involving PROMs. More broadly, the FRONTIERS Framework will facilitate improved rigor and transparency across dysphagia research. Special considerations and future goals are discussed.

Association Between Self- and Proxy-Reported Depression and Quality of Life in Mild-Moderate Alzheimer's Disease

OBJECTIVE

Prior studies have reported an association between depression and quality of life (QOL) in Alzheimer's disease (AD), but the effect of self- versus proxy rating of mood and QOL has not been described.

DESIGN

In this secondary analysis of data from a cohort study, the authors used a linear mixed-effects model to determine if the association between depression and QOL is affected by whether both measures are assessed by the same member of the patient-caregiver dyad.

SETTING

Participants and caregiver informants were recruited from 10 California Alzheimer Disease Centers.

PARTICIPANTS

A total of 137 participants with mild-to-moderate Alzheimer's disease and their caregivers.

MEASUREMENTS

Self- and proxy-rated scores on both the Geriatric Depression Scale (GDS) and the Quality of Life in Alzheimer's Disease scale (QoL-AD). Multivariable linear mixed-effects models were used to estimate the association between depression and QOL.

RESULTS

Results of the multivariable linear mixed-effects models showed a significant association between self-rated QoL-AD and self-rated (B = -0.49, p <0.0001) but not proxy-rated GDS (B = -0.07, p = 0.19) after adjusting for confounders. Likewise, there was a significant association between proxy-rated QoL-AD and proxy-rated GDS (B = -0.48, p <0.0001) but not self-rated GDS (B = 0.05, p = 0.36).

CONCLUSION

Depression was associated with QOL in AD over short-term longitudinal follow-up, but the association was not statistically significant if both instruments are not administered to the same member of the patient-caregiver dyad. The choice of self- versus proxy-reported QOL should be intentionally considered in future studies as it may influence reported outcomes.

Choosing the Best Instrument for Measuring Health Spillover Effect in Caregivers of Patients With Multiple Sclerosis

OBJECTIVES

To measure the health spillover effect in caregivers of patients with multiple sclerosis (MS), we aimed to select the best instrument from 2 common health-related quality of life (QoL) instruments, the 3-level EQ-5D (EQ-5D-3L) and the Health Utilities Index Mark 3 (HUI-3), by assessing them.

METHODS

Using consecutive sampling, 452 primary caregivers of patients with MS were asked to fill out a Care-related QoL instrument (CarerQol-7D), EQ-5D-3L, HUI-3, and the Center for Epidemiologic Studies Depression Scale between October 2019 and May 2020. Convergent and clinical validity were assessed to measure spillover effect in caregivers of patients with MS.

RESULTS

A strong correlation of health-utility scores between EQ-5D-3L and HUI-3 (r = 0.914, P < .01) was observed. The 95% limit of agreement (LoA) for CarerQol-7D and HUI-3 (-10.6 to 8.2) was narrower than the LoA for CarerQol-7D and EQ-5D-3L (-15.1 to 17.1). Both EQ-5D-3L and HUI-3 proved clinical validity for the QoL of caregivers. The CarerQoL-7D score was significantly lower in female (P < .001), single (P < .014), lower-educated (P < .001), parent's relatives (P < .001), and unemployed (P < .001) caregivers.

CONCLUSIONS

We found that both, EQ-5D-3L and HUI-3, were appropriate for measuring caregivers' QoL, although HUI-3 was a better choice because of its narrower LoA. Our findings suggest researchers should use HUI-3 to measure the quality-adjusted life-year of caregivers to aggregate with the QoL of patients in the denominator of an economic evaluation equation, such as the cost-effective ratio.

Unique contributions of specific neuropsychiatric symptoms to caregiver burden in informal caregivers family members of patients with dementia

INTRODUCTION

We aimed to evaluate how the presence of individual neuropsychiatric symptoms in non-institutionalised patients with dementia is associated with caregiver burden of their informal caregivers, family members.

METHODS

We performed a cross-sectional study on a total of 131 pairs of one informal caregiver family member and non-institutionalised patient with dementia in a family medicine practices in a city of Zagreb, Croatia. Caregiver measures included Zarit Burden Interview (ZBI) whereas patient measures included Mini mental state examination (MMSE), Barthel index and Neuropsychiatric Inventory Questionnaire (NPI-Q).

RESULTS

Total NPI-Q score explained 21% of overall burden. In order of strength of the association, after adjustments for age, sex, MMSE and Barthel index, overall burden was significantly associated with higher NPI-Q scores for agitation/aggression, apathy/indifference, irritability/lability, disinhibition, motor disturbance, appetite/eating, depression/dysphoria, anxiety, elation/euphoria and nighttime behaviours. When evaluating mutually independent contribution of unique NPI-Q symptoms to caregiver burden, agitation/aggression and apathy/indifference remained only two mutually independently associated symptoms, each explaining 5% of overall burden in this context.

CONCLUSIONS

Informal caregivers who provide for family members with dementia suffering from agitation/aggression or apathy/indifference should be recognised as under special risk for the development of caregiver burden and considered as candidates for early targeted interventions.

Convergent validity of EQ-5D with core outcomes in dementia: a systematic review

Objectives

To explore through a systematic review, the convergent validity of EQ-5D (EQ-5D-3L and EQ-5D-5L (total score and dimensions)) with core outcomes in dementia and investigate how this may be impacted by rater-type; with the aim of informing researchers when choosing measures to use in dementia trials.

Methods

To identify articles relevant to the convergent validity of EQ-5D with core dementia outcomes, three databases were electronically searched to September 2022. Studies were considered eligible for inclusion within the review if they included individual level data from people with dementia of any type, collected self and/or proxy reported EQ-5D and collected at least one core dementia outcome measure. Relevant data such as study sample size, stage of dementia and administration of EQ-5D was extracted, and a narrative synthesis was adopted.

Results

The search strategy retrieved 271 unique records, of which 30 met the inclusion criteria for the review. Twelve different core outcome measures were used to capture dementia outcomes: cognition, function, and behaviour/mood across the studies. Most studies used EQ-5D-3L (n = 27). Evidence related to the relationship between EQ-5D and measures of function and behaviour/mood was the most robust, with unanimous directions of associations, and more statistically significant findings. EQ-5D dimensions exhibited associations with corresponding clinical outcomes, whereby relationships were stronger with proxy-EQ-5D (than self-report).

Conclusion

Measuring health-rated quality of life in dementia populations is a complex issue, particularly when considering balancing the challenges associated with both self and proxy report. Published evidence indicates that EQ-5D shows evidence of convergent validity with the key dementia outcomes, therefore capturing these relevant dementia outcomes. The degree of associations with clinical measures was stronger when considering proxy-reported EQ-5D and differed by EQ-5D dimension type. This review has revealed that, despite the limited targeted psychometric evidence pool and reliance on clinical and observational studies, EQ-5D exhibits convergent validity with other dementia outcome measures.

Disease modification is not all - we need symptomatic therapies for Alzheimer disease

A new study found methylphenidate to be effective in treating apathy in individuals with Alzheimer disease. At a time when the recent aducanumab approval is focusing attention on the promise of disease-modifying therapies, the new findings highlight the importance of developing better symptomatic treatment options for individuals with psychiatric disorders of Alzheimer disease.

Quality of Life Assessment in Older Adults with Dementia: A Systematic Review

INTRODUCTION

In the absence of a cure, dementia is often managed by minimizing risk factors contributing to quality of life (QOL). Attitudes to dementia in older adults may differ from those in relatively younger adults. The aim was to conduct a systematic review of the literature to determine how QOL was assessed in adults, 65 years and older with dementia, and identify factors that influence the reported scores.

METHODS

A systematic review of full-text articles addressing QOL in older adults with dementia, published in English from January 1995 to September 2020, was conducted using PubMed and PsycINFO. We included studies that assessed QOL and involved participants 65 years and older. Studies were evaluated for inclusion by 2 independent pairs of reviewers. We assessed the quality of the studies using the Joanna Briggs Institute's Critical Appraisal Checklist. Study characteristics and findings were summarized. Analysis was by narrative synthesis. We identified social and clinical factors influencing QOL scores.

RESULTS

Of the 1,010 articles identified, 19 met the inclusion criteria. These 19 studies involved 6,279 persons with dementia, with sample sizes from 32 to 1,366. Mean age of participants ranged from 77.1 to 86.6 years. Five measurement tools were identified; Quality of Life in Alzheimer Disease (QOL-AD), Alzheimer Disease-Related Quality of Life (ADRQL), Quality of Life in Late-Stage Dementia (QUALID), QUALIDEM (a dementia-specific QOL tool), and DEMQOL (health-related QOL for people with dementia). Self-ratings of QOL were higher than proxy ratings. Factors commonly influencing self-ratings of QOL included depression, functional impairment, and polypharmacy. Common factors that influenced proxy ratings included functional impairment, presence of neuropsychiatric symptoms, cognitive impairment, and caregiver burden.

CONCLUSION

In evaluating QOL in dementia, self- and proxy reports may complement each other to ensure that all perspectives are addressed.

Quality of Life and Caregiver Burden of Alzheimer's Disease Among Community Dwelling Patients in Europe: Variation by Disease Severity and Progression

Background:

Alzheimer’s disease (AD) is a significant burden on patients and caregivers. How this burden increases as disease progresses has not been well researched.

Objective:

To assess the association of caregiver burden and quality of life with Alzheimer’s disease severity and disease progression in community-dwelling patients in Germany, Spain, and the UK.

Methods:

This was a prospective observational longitudinal study of mild-to-moderate AD patients (assessed by Mini-Mental State Examination, MMSE), and their caregivers. The humanistic burden was assessed using these instruments: [Rapid Assessment of Physical Activity (RAPA), EuroQoL-5-Dimension Level (EQ-5D-5L)] and caregiver-reported [Dependence Scale (DS), EQ-5D-5L, Zarit Burden Interview (ZBI)]. Caregiver-reported healthcare resource use was assessed using the Resource Use in Dementia (RUD) and ad-hoc questions.

Results:

Of 616 patients recruited, 338 and 99 were followed-up at 12 and 18 months, respectively. The caregiver-reported EQ-5D-5L scores of patients’ health-related quality of life (HRQoL) showed a negative trend over time (baseline: 0.76; 18 months: 0.67) while patient-reported HRQoL remained at 0.85. DS scores tended to worsen. Disease progression was an independent predictor of HRQoL and increased dependence.

Mean ZBI score increased over time reflecting an increase in caregiver burden; MMSE being an independent predictor for caregiver burden. Patient resource utilization and caregiver time for caregiving tended to increase over time.

Conclusion:

We found significant association between disease progression and caregiver and patient burden. Independently, both disease-specific outcomes and disease burden measures increased over time, but as disease progresses, we also found incremental burden associated with it.

Quality of life and caregiver burden in familial frontotemporal lobar degeneration: Analyses of symptomatic and asymptomatic individuals within the LEFFTDS cohort

OBJECTIVE

The Longitudinal Evaluation of Familial Frontotemporal Dementia Subjects evaluates familial frontotemporal lobar degeneration (FTLD) kindreds with MAPT, GRN, or C9orf72 mutations. Objectives were to examine whether health-related quality of life (HRQoL) correlates with clinical symptoms and caregiver burden, and whether self-rated and informant-rated HRQoL would correlate with each other.

METHODS

Individuals were classified using the Clinical Dementia Rating (CDR® ) Scale plus National Alzheimer's Coordinating Center (NACC) FTLD. HRQoL was measured with DEMQOL and DEMQOL-proxy; caregiver burden with the Zarit Burden Interview (ZBI). For analysis, Pearson correlations and weighted kappa statistics were calculated.

RESULTS

The cohort of 312 individuals included symptomatic and asymptomatic individuals. CDR® plus NACC FTLD was negatively correlated with DEMQOL (r = -0.20, P = .001), as were ZBI and DEMQOL (r = -0.22, P = .0009). There was fair agreement between subject and informant DEMQOL (κ = 0.36, P <.0001).

CONCLUSION

Lower HRQoL was associated with higher cognitive/behavior impairment and higher caregiver burden. These findings demonstrate the negative impact of FTLD on individuals and caregivers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spaced Retrieval and Episodic Memory Training in Alzheimer's Disease

Introduction

This study replicated and extended the findings from the author's previous pilot study to further explore how a spaced retrieval (SR) memory training program might be effectively applied to help persons with Alzheimer’s disease (AD)  improve both short- and long-term recall of recent episodic events.

Methods

A quasi-experimental within-subject group study was conducted with 15 participants with a diagnosis of AD.

Results

Compared to a control condition, all participants were able to spontaneously recall significantly more specific details about trained events, and their recall was significantly enhanced when they were provided with cues. Although the findings indicated that people with AD were able to encode information during training, recall gains diminished by the end of the maintenance period.

Discussion

This study provides evidence that individuals with mild to moderate AD can learn and recall new episodic information through SR training. These findings support the use of SR as an intervention tool to help individuals maintain their functioning in episodic recent memory. However, more research into maintaining the long-term recall of recent episodic events is warranted.

Quality of care reported by proxies – Does resident cognition count?

Resident self-reports are considered the primary source of quality of care information, but proxy reports by family or staff can also be used to supplement or substitute resident reports. This study analyses how the results of proxy reports vary according to residents’ cognition level. The data set used covers proxy reports of family ( n = 558) and staff ( n = 801), divided by the availability of resident self-reports (family yes n = 289, no n = 269; staff yes 393, no = 408). Family and staff proxies assessed residents’ quality of care as better when resident self-reports were also available, and quality of care tended to be assessed as poorer among those with higher cognitive decline. The results of this methodological study indicate the importance of using several proxy evaluations; however, these can only supplement resident self-reports, not replace them. The interpretation rules acknowledging dependency between residents’ cognition and proxy assessments could be used as a basis for future comparisons of quality improvement in long-term care and for painting a more comprehensive picture of service quality.

The relationship between perceived functional difficulties and the ability to live well with mild-to-moderate dementia: Findings from the IDEAL programme

OBJECTIVES

The objectives of the study are to investigate how different levels of functional ability relate to quality of life, well-being, and satisfaction with life, conceptualised as reflecting capability to "live well" in people with dementia.

METHODS/DESIGN

Participants were 1496 people with mild-to-moderate dementia and 1188 informants who completed baseline assessments in the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study. Total self-rated and informant-rated scores on the Functional Activities Questionnaire were split into six ability levels to monitor how poorer functioning impacts the ability to live well. We also investigated the potential influence of sociodemographic and diagnostic variables, depression, cognition, and carer stress.

RESULTS

Multivariate multiple regression models found that people with dementia who had the greatest functional impairment according to self-ratings and informant ratings had poorer living well scores than those with the least functional impairment. Sociodemographic and diagnostic factors and cognition had little impact on effect sizes. For self-ratings, depression attenuated the relationship between functional ability and living well, whereas carer stress attenuated informant ratings.

CONCLUSIONS

People with dementia with the least functional impairments had greater capability to live well than those with the most functional impairment. Even subtle perceived difficulties in functional ability had a detrimental effect on the ability of people with dementia to live well. Depression in people with dementia and carer stress in informants influenced these associations, and therefore, these factors should be routinely included in future research studies and clinical assessments.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The hidden patient: chronic physical morbidity, psychological distress, and quality of life in caregivers of older adults

AIM

Increasing demands for care provision to older adults require good physical and mental health among caregivers. Few studies have examined the health status and correlates of quality of life among caregivers of older adults. The present study therefore sought to examine the prevalence of chronic physical conditions, psychological distress, and correlates of physical and mental quality of life among caregivers of older adults (≥60 years) in Singapore.

METHODS

Participants were 285 informal caregivers who were providing care to an older relative. Participants were recruited at the Institute of Mental Health, Singapore, and they completed self-report measures on chronic physical morbidity, psychological distress, and physical and mental quality of life. Multiple regression models were constructed to examine correlates of physical and mental quality of life.

RESULTS

More than half of the caregivers had at least one chronic physical condition (58.6%) and psychological distress (52.6%). Chronic physical morbidity, psychological distress, and secondary education status were associated with lower physical quality of life. Psychological distress, younger age, primary education status, and more time spent caregiving were associated with lower mental quality of life.

CONCLUSION

Poor physical and mental health among caregivers may impair their ability to provide adequate care to older adults with progressive medical needs. It is important for medical practitioners not to neglect the physical and mental health of caregivers through continued assessment of chronic physical morbidity, psychological distress, and quality of life.

Duchenne muscular dystrophy and caregiver burden: a systematic review

AIM

To conduct a systematic literature review of caregiver burden in Duchenne muscular dystrophy (DMD).

METHOD

We searched Embase, Web of Science, and PubMed for full-text articles reporting results from studies of caregiver burden in DMD.

RESULTS

We identified 483 unique publications. Of these, 450 were excluded after title and abstract screening, and 12 after full-text review. A total of 21 articles were included for data synthesis. Results encompassing more than 15 aspects of caregiver burden, investigated through surveys and/or interviews across 15 countries, were identified in the literature. Caregiving in DMD was frequently associated with impaired health-related quality of life, poor sleep quality, reduced family function, depression, pain, stress, sexual dysfunction, and/or lower self-esteem, as well as a considerable impact on work life and productivity.

INTERPRETATION

Providing informal care to a patient with DMD can be associated with a substantial burden. Yet, more research is needed to better understand the clinical implications of caregiving in DMD and the relationship between caregiver burden and the progression of the disease. Our data synthesis should be helpful in informing clinical and social support programmes directed to families caring for a patient with DMD.

WHAT THIS PAPER ADDS

A substantial body of evidence describes caregiver burden in Duchenne muscular dystrophy. Little is known of the family burden beyond caregivers' self-assessments.

Cognitive functioning and quality of life: Diverging views of older adults with Alzheimer and professional care staff

OBJECTIVE

Staff ratings of quality of life (QOL) in dementia are often lower and more strongly related to the cognitive functioning of the person with dementia than self-ratings. However, cognition-related items in QOL measures and limited cognitive screening measures hamper a clear understanding of the relationship, 2 issues we addressed in the current study.

METHODS

We collected data of 88 pairs of older adults with Alzheimer disease and their professional caregivers in 9 residential care settings. Both self-report and staff report of the QOL of residents were assessed with the Quality of Life in Alzheimer's Disease. Cognitive functioning was assessed with the Mini-Mental State Examination and a battery of specific cognitive measures.

RESULTS

Intraclass correlations and a paired sample t test confirmed a discrepancy between self-rating and staff rating, with staff significantly underestimating QOL as experienced by the resident. After removing the possibly confounding memory item of the Quality of Life in Alzheimer's Disease, Mini-Mental State Examination score remained a significant predictor of staff ratings but not self-ratings in regression analyses. Exploratory analyses of specific cognitive measures showed a significant contribution of a memory test of intentional visual association learning in the prediction of staff-rated QOL.

CONCLUSIONS

Staff reports cannot simply substitute reports of the subjective experience of residents with Alzheimer, so both judgments should be taken into account to form an adequate picture of QOL. Staff might be guided more strongly by a cognitive point of view when evaluating QOL of residents with Alzheimer disease, while the latter might have shifted their evaluation standards to cope adequately with the challenges posed by their disease.

How Different are Quality of Life Ratings for People with Dementia Reported by Their Family Caregivers from Those Reported by the Patients Themselves?

BACKGROUND

Measurements of patient quality of life (QoL) play a major role in the management of dementia.

OBJECTIVE

We investigated the self-proxy discrepancy of QoL ratings in the elderly and the impact of dementia severity on the discrepancy.

METHODS

QoL of 718 patients with dementia and 651 non-demented elderly were rated by themselves and their caregivers (CG) using the Quality of Life-Alzheimer's Disease (QoL-AD). The impact of the rater on the total and item scores of QoL-AD was analyzed using repeated measures ANOVA and differential response patterns between self and proxy were analyzed using differential item functioning (DIF) analysis.

RESULTS

Self-rated scores were higher than CG-rated scores in all diagnostic groups. The interaction between rater and diagnostic group was significant in total QoL-AD score and 5 item scores ('memory', 'marriage', 'chores around the house', 'do things for fun', and 'life as a whole'). The strength of the DIF increased with advancing dementia in these items.

CONCLUSION

Self-proxy rating discrepancy of QoL was influenced by the presence and severity of dementia only in five items.

A Computer-Assisted Personal Interview App in Research Electronic Data Capture for Administering Time Trade-off Surveys (REDCap): Development and Pretest

Background

The time trade-off (TTO) task is a method of eliciting health utility scores, which range from 0 (equivalent to death) to 1 (equivalent to perfect health). These scores numerically represent a person’s health-related quality of life. Software apps exist to administer the TTO task; however, most of these apps are poorly documented and unavailable to researchers.

Objective

To fill the void, we developed an online app to administer the TTO task for a research study that is examining general public proxy health-related quality of life estimates for persons with Alzheimer’s disease. This manuscript describes the development and pretest of the app.

Methods

We used Research Electronic Data Capture (REDCap) to build the TTO app. The app’s modular structure and REDCap’s object-oriented environment facilitated development. After the TTO app was built, we recruited a purposive sample of 11 members of the general public to pretest its functionality and ease of use.

Results

Feedback from the pretest group was positive. Minor modifications included clarity enhancements, such as rearranging some paragraph text into bullet points, labeling the app to delineate different question sections, and revising or deleting text. We also added a research question to enable the identification of respondents who know someone with Alzheimer’s disease.

Conclusions

We developed an online app to administer the TTO task. Other researchers may access and customize the app for their own research purposes.

Fatores associados a uma pior avaliação da qualidade de vida entre familiares cuidadores de usuários de Centros de Atenção Psicossocial

Resumo Introdução A identificação dos fatores associados a uma pior avaliação da qualidade de vida dos familiares cuidadores em saúde mental pode constituir uma estratégia importante para o estabelecimento de ações de acompanhamento e de suporte desses sujeitos. Objetivo Este estudo buscou identificar quais os fatores associados a uma pior avaliação da qualidade de vida entre 1.242 familiares cuidadores de usuários de 40 Centros de Atenção Psicossocial (CAPS) localizados no Sul do Brasil. Métodos Para análise, munindo-se de um modelo teórico hierarquizado, utilizou-se a regressão logística com o cálculo das razões de odds ajustadas. Resultados Os fatores associados a uma pior avaliação da qualidade de vida foram: escolaridade, facilidade de acesso aos CAPS, eficácia dos CAPS, apoio dos CAPS na sobrecarga, divisão das atividades do cuidado, problema de saúde, relação com a família e sentimento de sobrecarga. Conclusão Ao considerar a gama de aspectos relacionados ao serviço que estiveram associados ao desfecho, este estudo entende que os CAPS exercem um papel importante na vida dos familiares cuidadores a eles vinculados, influenciando significativamente em sua qualidade de vida.

Development of a core outcome set for disease modification trials in mild to moderate dementia: a systematic review, patient and public consultation and consensus recommendations

BACKGROUND

There is currently no disease-modifying treatment available to halt or delay the progression of the disease pathology in dementia. An agreed core set of the best-available and most appropriate outcomes for disease modification would facilitate the design of trials and ensure consistency across disease modification trials, as well as making results comparable and meta-analysable in future trials.

OBJECTIVES

To agree a set of core outcomes for disease modification trials for mild to moderate dementia with the UK dementia research community and patient and public involvement (PPI).

DATA SOURCES

We included disease modification trials with quantitative outcomes of efficacy from (1) references from related systematic reviews in workstream 1; (2) searches of the Cochrane Dementia and Cognitive Improvement Group study register, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Latin American and Caribbean Health Sciences Literature and PsycINFO on 11 December 2015, and clinical trial registries [International Standard Randomised Controlled Trial Number (ISRCTN) and clinicaltrials.gov] on 22 and 29 January 2016; and (3) hand-searches of reference lists of relevant systematic reviews from database searches.

REVIEW METHODS

The project consisted of four workstreams. (1) We obtained related core outcome sets and work from co-applicants. (2) We systematically reviewed published and ongoing disease modification trials to identify the outcomes used in different domains. We extracted outcomes used in each trial, recording how many used each outcome and with how many participants. We divided outcomes into the domains measured and searched for validation data. (3) We consulted with PPI participants about recommended outcomes. (4) We presented all the synthesised information at a conference attended by the wider body of National Institute for Health Research (NIHR) dementia researchers to reach consensus on a core set of outcomes.

RESULTS

We included 149 papers from the 22,918 papers screened, referring to 125 individual trials. Eighty-one outcomes were used across trials, including 72 scales [31 cognitive, 12 activities of daily living (ADLs), 10 global, 16 neuropsychiatric and three quality of life] and nine biological techniques. We consulted with 18 people for PPI. The conference decided that only cognition and biological markers are core measures of disease modification. Cognition should be measured by the Mini Mental State Examination (MMSE) or the Alzheimer's Disease Assessment Scale - Cognitive subscale (ADAS-Cog), and brain changes through structural magnetic resonance imaging (MRI) in a subset of participants. All other domains are important but not core. We recommend using the Neuropsychiatric Inventory for neuropsychiatric symptoms: the Disability Assessment for Dementia for ADLs, the Dementia Quality of Life Measure for quality of life and the Clinical Dementia Rating scale to measure dementia globally.

LIMITATIONS

Most of the trials included participants with Alzheimer's disease, so recommendations may not apply to other types of dementia. We did not conduct economic analyses. The PPI consultation was limited to members of the Alzheimer's Society Research Network.

CONCLUSIONS

Cognitive outcomes and biological markers form the core outcome set for future disease modification trials, measured by the MMSE or ADAS-Cog, and structural MRI in a subset of participants.

FUTURE WORK

We envisage that the core set may be superseded in the future, particularly for other types of dementia. There is a need to develop an algorithm to compare scores on the MMSE and ADAS-Cog.

STUDY REGISTRATION

The project was registered with Core Outcome Measures in Effectiveness Trials [ www.comet-initiative.org/studies/details/819?result=true (accessed 7 April 2016)]. The systematic review protocol is registered as PROSPERO CRD42015027346.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The mediating role of depression in the association between disability and quality of life in Alzheimer's disease

BACKGROUND

An understanding of the determinants of quality of life in Alzheimer's disease (AD) is required in order to develop effective interventions to promote patients' well-being. Most studies have pointed out depression, functional ability and environmental factors. However, unmeasured confounders can jeopardize the interpretation of the results.

OBJECTIVES

To explore the mediating role of depression in the association between functional status and QoL, and establish a procedure to detect confounding variables.

METHODS

A sample of 192 AD patients and their respective caregivers were recruited from day centers and health care centers in the region of Murcia (Spain). The mediating effect was evaluated using causal mediation analysis. Covariates were introduced into the model in a stepwise fashion and sensitivity analyses were performed to assess the influence of potential confounders.

RESULTS

Self-rated depression acted as a partial mediator between functional status and quality of life. The mediating effect was positive and significant even after including both patient- and caregiver-related covariates. Only if confounders explained more than 80% of the residual variance in the mediator or in the outcome, the mediating effects would not be positive.

CONCLUSIONS

The effect of lack of autonomy on the QoL is mostly explained by the negative consequences on mood status. The sensitivity analysis confirms the robustness of this finding.

Development of Clinical Vignettes to Describe Alzheimer's Disease Health States: A Qualitative Study

Aims

To develop clinical descriptions (vignettes) of life with Alzheimer’s disease (AD), we conducted focus groups of persons with AD (n = 14), family caregivers of persons with AD (n = 20), and clinicians who see persons with AD in their practices (n = 5).

Methods

Group participants read existing descriptions of AD and commented on the realism and comprehensibility of the descriptions. We used thematic framework analysis to code the comments into themes and develop three new vignettes to describe mild, moderate, and severe AD.

Results

Themes included the types of symptoms to mention in the new vignettes, plus the manner in which the vignettes should be written. Since the vignette descriptions were based on focus group participants’ first-hand knowledge of AD, the descriptions can be said to demonstrate content validity.

Conclusion

Members of the general public can read the vignettes and estimate their health-related quality-of-life (HRQoL) as if they had AD based on the vignette descriptions. This is especially important for economic evaluations of new AD medications, which require HRQoL to be assessed in a manner that persons with AD often find difficult to undertake. The vignettes will allow the general public to serve as a proxy and provide HRQoL estimates in place of persons with AD.

Quantifying the burden of caregiving in Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a rare pediatric neuromuscular disease associated with progressive muscle degeneration and extensive care needs. Our objective was to estimate the caregiver burden associated with DMD. We made cross-sectional assessments of caregiver health-related quality of life (HRQL) and burden using the EuroQol EQ-5D, a Visual Analogue Scale (VAS), the SF-12 Health Survey, and the Zarit Caregiver Burden Interview (ZBI) administered online. Results were stratified by disease stage (early/late ambulatory/non-ambulatory) and caregivers’ rating of patients’ health and mental status. In total, caregivers to 770 patients participated. Mean EQ-5D utility ranged between 0.85 (95 % CI 0.82–0.88) and 0.77 (0.74–0.80) across ambulatory classes and 0.88 (0.85–0.90) and 0.57 (0.39–0.74) across caregivers’ rating of patients’ health and mental status. Mean VAS score was 0.74 (0.73–0.75), mean SF-12 Mental Health Component Summary score 44 (43–45), and mean ZBI score 29 (28–30). Anxiety and depression, recorded in up to 70 % of caregivers depending on patients’ health and mental status, was significantly associated with annual household cost burden (>$5000 vs. <$1000, odds ratio 1.76, 95 % CI 1.18–2.63) and hours of leisure time devoted to informal care per week (25–50 vs. <25 h 2.01, 1.37–2.94; >50 vs. <25 h 3.35, 2.32–4.83) (p < 0.007). We show that caring for a person with DMD can be associated with a substantial burden and impaired HRQL. Our findings suggest that caregivers to patients with DMD should be screened for depression and emphasize the need for a holistic approach to family mental health in the context of chronic childhood disease.

Can the general public use vignettes to discriminate between Alzheimer's disease health states?

BACKGROUND

Valid estimates of health-related quality-of-life (HRQoL) are often difficult to obtain from persons with Alzheimer's disease (AD) and family caregiver proxies. To help assess whether the general public can serve as an alternate source of proxy HRQoL estimates in AD, we examined whether the general public can use vignettes to discriminate between AD health states.

METHODS

We administered a telephone survey to randomly recruited participants from the general public who were aged 18 years or older. Interviewers read vignettes describing the mild, moderate, and severe AD health states to the participants, who answered the EQ-5D-5L and Quality of Life-Alzheimer's Disease (QoL-AD) scales as if they had AD based on the vignette descriptions. Participants also answered the EQ-5D-5L for their current health states. We converted EQ-5D-5L responses into health utility scores using Canadian preference weights. We employed the Wilcoxon signed rank test to examine whether mean health utility scores and mean QoL-AD scores differed between health states. We used Pearson's r to assess correlations between health utility and QoL-AD scores.

RESULTS

Forty-eight participants (median age = 53 years; 25 female) completed the telephone interview; health utility and QoL-AD scores decreased as AD severity increased (p <0.0001). Mean health utility scores were 0.65 (mild), 0.51 (moderate), and 0.25 (severe). Mean QoL-AD scores were 26.7 (mild), 23.0 (moderate), and 17.4 (severe). The correlations between health utility and QoL-AD scores were moderate to strong (r ≥ 0.62).

CONCLUSIONS

Using the vignettes, the general public provided HRQoL estimates that discriminated between the three AD health states. This finding suggests the general public may be a promising source of proxy HRQoL estimates in place of persons with AD.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Multiple perspectives on quality of life for residents with dementia in long term care facilities: protocol for a comprehensive Australian study

BACKGROUND

Dementia is a chronic illness without cure or effective treatment, which results in declining mental and physical function and assistance from others to manage activities of daily living. Many people with dementia live in long term care facilities, yet research into their quality of life (QoL) was rare until the last decade. Previous studies failed to incorporate important variables related to the facility and care provision or to look closely at the daily lives of residents. This paper presents a protocol for a comprehensive, multi-perspective assessment of QoL of residents with dementia living in long term care in Australia. A secondary aim is investigating the effectiveness of self-report instruments for measuring QoL.

METHODS

The study utilizes a descriptive, mixed methods design to examine how facility, care staff, and resident factors impact QoL. Over 500 residents with dementia from a stratified, random sample of 53 facilities are being recruited. A sub-sample of 12 residents is also taking part in qualitative interviews and observations.

CONCLUSIONS

This national study will provide a broad understanding of factors underlying QoL for residents with dementia in long term care. The present study uses a similar methodology to the US-based Collaborative Studies of Long Term Care (CS-LTC) Dementia Care Study, applying it to the Australian setting.

Addressing the bias problem in the assessment of the quality of life of patients with dementia: determinants of the accuracy and precision of the proxy ratings

OBJECTIVES

We aimed to examine the discrepancy between patients and caregivers' ratings of quality of life in terms of accuracy and precision, and identify factors associated with it, in order to facilitate the use of this scale as dementia progresses.

DESIGN

Cross-sectional analytic study.

SETTING

Day care centres.

PARTICIPANTS

Community-living patients with Alzheimer's disease in early or moderate stage and their principal caregivers.

MEASUREMENTS

PARTICIPANTS rated patients' quality of life using DEMQOL. The discrepancy was assessed using the individual difference score and the residuals for each domain of DEMQOL. The scores on Mini-Mental State Examination, Geriatric Depression Scale, Neuropsychiatric Inventory, Clinical Insight Rating Scale, Cumulative Illness Rating Scale, Health Utilities Index Mark 3 and Zarit Burden Interview were considered as possible predictors of the discrepancy.

RESULTS

A total of 276 subjects participated in the study (138 patients with Alzheimer's disease and their caregivers). Discrepancy measured by individual difference score was lower than that measured by the residuals. Burden and mood-related symptoms explained the positive differences and residuals, while pain, self-perceived depression and cognition determined the negative ones.

CONCLUSIONS

Differences exist between patients and caregivers' perceptions about subjective states. The evaluations of each informant seem to be influenced by their own emotional state and the inner experience of the effects of the disease. Caregivers' ratings on DEMQOL could be useful to monitor the efficacy of any treatment whenever burden is low and patients have no great physical or emotional suffering.

A scale of socioemotional dysfunction in frontotemporal dementia

Early social dysfunction is a hallmark symptom of behavioral variant frontotemporal dementia (bvFTD); however, validated measures for assessing social deficits in dementia are needed. The purpose of the current study was to examine the utility of a novel informant-based measure of social impairment, the Socioemotional Dysfunction Scale (SDS) in early-onset dementia. Sixteen bvFTD and 18 early-onset Alzheimer's disease (EOAD) participants received standard clinical neuropsychological measures and neuroimaging. Caregiver informants were administered the SDS. Individuals with bvFTD exhibited greater social dysfunction on the SDS compared with the EOAD group; t(32) = 6.32, p < .001. The scale demonstrated preliminary evidence for discriminating these frequently misdiagnosed groups (area under the curve = 0.920, p = <.001) and internal consistency α = 0.977. The SDS demonstrated initial evidence as an effective measure for detecting abnormal social behavior and discriminating bvFTD from EOAD. Future validation is recommended in larger and more diverse patient groups.

Improving the experience of dementia and enhancing active life--living well with dementia: study protocol for the IDEAL study

BACKGROUND

Enabling people with dementia and carers to 'live well' with the condition is a key United Kingdom policy objective. The aim of this project is to identify what helps people to live well or makes it difficult to live well in the context of having dementia or caring for a person with dementia, and to understand what 'living well' means from the perspective of people with dementia and carers.

METHODS/DESIGN

Over a two-year period, 1500 people with early-stage dementia throughout Great Britain will be recruited to the study, together with a carer wherever possible. All the participants will be visited at home initially and again 12 months and 24 months later. This will provide information about the way in which well-being, life satisfaction and quality of life are affected by social capitals, assets and resources, the challenges posed by dementia, and the ways in which people adjust to and cope with these challenges. A smaller group will be interviewed in more depth.

DISCUSSION

The findings will lead to recommendations about what can be done by individuals, communities, health and social care practitioners, care providers and policy-makers to improve the likelihood of living well with dementia.

Improving the experience of dementia and enhancing active life--living well with dementia: study protocol for the IDEAL study

BACKGROUND

Enabling people with dementia and carers to 'live well' with the condition is a key United Kingdom policy objective. The aim of this project is to identify what helps people to live well or makes it difficult to live well in the context of having dementia or caring for a person with dementia, and to understand what 'living well' means from the perspective of people with dementia and carers.

METHODS/DESIGN

Over a two-year period, 1500 people with early-stage dementia throughout Great Britain will be recruited to the study, together with a carer wherever possible. All the participants will be visited at home initially and again 12 months and 24 months later. This will provide information about the way in which well-being, life satisfaction and quality of life are affected by social capitals, assets and resources, the challenges posed by dementia, and the ways in which people adjust to and cope with these challenges. A smaller group will be interviewed in more depth.

DISCUSSION

The findings will lead to recommendations about what can be done by individuals, communities, health and social care practitioners, care providers and policy-makers to improve the likelihood of living well with dementia.

Study protocol: Randomised controlled trial to evaluate the impact of an educational programme on Alzheimer's disease patients' quality of life

Introduction

Therapeutic education is expanding in the management of Alzheimer’s disease (AD) patients. Several studies have revealed a positive impact of therapeutic educational programmes on the caregiver’s burden and/or quality of life. However, to date, no study has evaluated its impact on the quality of life of the AD patient.

Methods

The THERAD study (THerapeutic Education in Alzheimer’s Disease) is a 12-month randomised controlled trial that started in January 2013. This paper describes the study protocol. THERAD plans to enroll 170 dyads (AD patient and caregiver) on the basis of the following criteria: patient at a mild to moderately severe stage of AD, living at home, receiving support from a family caregiver. The main outcome is the patient’s quality of life assessed by the Logsdon QoL-AD scale at 2 months, reported by the caregiver. The study is being led by geriatricians trained in therapeutic education at Toulouse University Hospital in France. To date, 107 caregiver/patient dyads have been recruited.

Conclusion

This is the first trial designed to assess the specific impact of a therapeutic educational programme on the AD patient’s quality of life. The final results will be available in 2015.

Trial registration

[ClinicalTrials.gov: NCT01796314] Registered 19 February 2013

Trajectories of quality of life in early-stage dementia: individual variations and predictors of change

BACKGROUND

Little evidence is available about how quality of life (QoL) changes as dementia progresses.

OBJECTIVES

We explored QoL trajectories over a 20-month period and examined what predicted change in QoL.

METHOD

Fifty-one individuals with a diagnosis of Alzheimer's, vascular or mixed dementia (people with dementia (PwD)) participating in the Memory Impairment and Dementia Awareness Study rated their QoL using the QoL-Alzheimer's Disease Scale at baseline and at 20-month follow-up. PwD also rated their mood and quality of relationship with the carer. In each case, the carer rated his or her level of stress and perceived quality of relationship with the PwD.

RESULTS

There was no change in mean QoL score. Nearly one-third of PwD rated QoL more positively at 20-month follow-up and nearly one-third rated QoL more negatively. These changes could be regarded as reliable in one-quarter of the sample. Participants taking acetylcholinesterase-inhibiting medication at baseline were more likely to show a decline in QoL score. There were no other significant differences between those whose scores increased, decreased or stayed the same on any demographic or disease-related variables, or in mood or perceived quality of relationship with the carer. Whereas baseline QoL score was the strongest predictor of QoL at 20 months, the quality of relationship with the carer as perceived by the PwD was also independently a significant predictor.

CONCLUSIONS

There is a degree of individual variation in QoL trajectories. Use of acetylcholinesterase-inhibiting medication appears linked to decline in QoL score, whereas positive relationships with carers play an important role in maintaining QoL in early-stage dementia.

Addressing Everyday Challenges: Feasibility of a Family Caregiver Training Program for People With Dementia

OBJECTIVE. The purpose of this study was to examine the feasibility and efficacy of the Family Caregiver Training Program for assisting with the basic activities of daily living of people with dementia.

METHOD. A one-group pretest–posttest research design with a 3-mo follow-up was used to examine the efficacy of a manualized education program for caregivers. The 6-hr training was delivered to 72 family caregivers over 3 consecutive weeks (2 hr/wk) by trained clinicians.

RESULTS. Caregivers showed a significant gain in knowledge of how to effectively assist with communication and nutrition, t(52) = 7.05, p &lt; .000; transfers and toileting, t(45) = 3.10, p &lt; .003; and bathing and dressing, t(44) = 2.71, p &lt; .01, of their care recipients.

CONCLUSION. Our findings demonstrate that this manualized intervention protocol is a promising method of equipping family members with the skills needed to face their everyday challenges in caring for people with dementia.

Evaluation of emotional blunting in behavioral variant frontotemporal dementia compared to Alzheimer's disease

BACKGROUND

Emotional blunting is a major clinical feature of behavioral variant frontotemporal dementia (bvFTD). Assessing the change in emotional blunting may facilitate the differential diagnosis of this disorder and can quantify a major source of distress for the patients' caregivers and families.

METHODS

We evaluated investigator ratings on the Scale for Emotional Blunting (SEB) for 13 patients with bvFTD versus 18 patients with early-onset Alzheimer's disease (AD). The caregivers also performed SEB ratings for both the patients' premorbid behavior (before dementia onset) and the patients' behavior on clinical presentation (after dementia onset).

RESULTS

Before the onset of dementia, the caregivers reported normal SEB scores for both dementia groups. After the onset of dementia, both caregivers and investigators reported greater SEB scores for the bvFTD patients compared to the AD patients. The patients were rated to be much more emotionally blunted by the bvFTD caregivers than by the investigators. A change of ≥15 in the caregiver SEB ratings suggests bvFTD. The change in caregiver SEB ratings was positively correlated with bifrontal hypometabolism on FDG-PET scans.

CONCLUSIONS

Changes in the caregiver assessment of emotional blunting with dementia onset can distinguish patients with bvFTD from those with AD, and they may better reflect the impact of emotional blunting than similar assessments made by clinicians/investigators.

Severity of dementia, anosognosia, and depression in relation to the quality of life of patients with Alzheimer disease: discrepancies between patients and caregivers

OBJECTIVE

To investigate the factors associated with discrepancies between patient and caregiver reports of the quality of life of patients (QoLp) with Alzheimer disease.

METHODS

Cross-sectional analytic study of 141 patients and their caregivers. The instruments used were the Quality of Life in AD, the Global Deterioration Scale (GDS), the Geriatric Depression Scale, and the Anosognosia Questionnaire-Dementia. Differences were analyzed according to GDS stage. A linear regression analysis was conducted using the difference between the absolute QoLp scores of patients and caregivers. A cluster analysis involving patient variables was then performed.

RESULTS

The discrepancy between patient and caregiver QoLp ratings increased in line with GDS stages (χ(2) (2) = 8.7, p = 0.013). In the regression model (F [7,133] = 16.6, p <0.001; R(2) = 0.477), discrepancies in QoLp reports were associated with greater anosognosia, less depression, and a better cognitive status in patients and with female gender among caregivers. The cluster analysis showed that patients with the lowest ratings of QoLp had a better cognitive status, more depression, and less anosognosia. Conversely, the highest ratings were given by patients with a poorer cognitive status, less depression, and greater anosognosia.

CONCLUSIONS

The factors associated with greater discrepancies between patient and caregiver ratings of QoLp were severity of dementia, anosognosia, depression, and cognitive status in patients and female gender in caregivers. In patients with advanced dementia, greater anosognosia leads to more positive ratings in QoLp and complementary observations are required.

Depressive Symptoms in Clinical and Incipient Alzheimer's Disease

The updated diagnostic criteria for Alzheimer's disease (AD) distinguish three stages: dementia, symptomatic pre-dementia [i.e. mild cognitive impairment (MCI)], and asymptomatic pre-dementia. Although AD is primarily associated with cognitive deficits, co-morbid depressive symptoms frequently occur at each stage. Depression in AD dementia is qualitatively different from depression in cognitively intact and/or younger populations, and may be less responsive to established interventions. In MCI, depressive symptoms are associated with higher rates of progression to dementia, and may identify a subset of individuals that are more responsive to acetylcholinesterase inhibitor treatment. Clinical and subsyndromal depressive symptoms in cognitively normal elderly represent a risk factor and/or prodrome for dementia due to AD, but sustained antidepressant therapy may be able to modulate this risk.

Reduced quality-of-life ratings in mild cognitive impairment: analyses of subject and informant responses

OBJECTIVES

To determine whether quality-of-life (QOL) ratings are reduced in mild cognitive impairment (MCI) and analyze correlations between QOL ratings and cognitive, neuropsychiatric, and functional indices in MCI.

DESIGN

Cross-sectional.

SETTING

The Easton Center for Alzheimer's Disease Research at the University of California, Los Angeles.

PARTICIPANTS

A total of 205 individuals who met criteria for normal cognition (n = 97) or MCI (n = 108). The MCI group included amnestic (n = 72) and nonamnestic (n = 36) MCI.

MEASUREMENTS

QOL was assessed using subject and informant ratings on the Quality of Life-Alzheimer's Disease (QOL-AD) scale. Cognitive performance was assessed with the National Alzheimer's Disease Coordinating Center Uniform Data Set neuropsychological battery. Neuropsychiatric symptoms were assessed with the Geriatric Depression Scale (GDS) and the Neuropsychiatric Inventory. Functional abilities were assessed with the Functional Activities Questionnaire (FAQ).

RESULTS

The normal cognition group had significantly higher QOL-AD scores than the MCI group on both subject and informant assessments. Individual item analyses indicated that the largest group differences were seen on the mood and memory items. Similar QOL-AD scores were seen in the amnestic and nonamnestic MCI subgroups. Multiple regression analyses within the MCI group indicated that QOL-AD ratings were not correlated with neuropsychological performance. Subject QOL-AD ratings were inversely correlated with GDS scores and informant QOL-AD ratings were inversely correlated with GDS, Neuropsychiatric Inventory, and FAQ scores.

CONCLUSIONS

Significant declines in QOL are seen in MCI and are associated with neuropsychiatric symptoms and functional decline. Interventions targeting mood symptoms and/or instrumental activities of daily living may improve QOL in MCI.

Frailty and quality of life for people with Alzheimer's dementia and mild cognitive impairment

BACKGROUND

Our aim was to investigate the relationship between frailty and health-related quality of life (HR-QOL) in cognitively impaired elderly individuals.

METHODS

A cross-sectional observational study of a convenience sample of 115 patients with a diagnosis of Alzheimer's dementia or mild cognitive impairment. Frailty was measured using the biological syndrome model and HR-QOL was measured using the DEMQOL-Proxy. Regression models were constructed to establish the factors associated with HR-QOL.

RESULTS

Frailty and neuropsychiatric symptoms were associated with HR-QOL, with Mini-Mental State Examination (MMSE) scores ≥21 (P = .037, P ≤ .001, and R (2) = .362). Functional limitation was associated with HR-QOL, with MMSE scores ≤20 (P = .017 and R (2) = .377).

CONCLUSION

Frailty and neuropsychiatric symptoms were the determinants of HR-QOL in the earlier stages of cognitive impairment. Functional limitation predicted HR-QOL in the later stages of cognitive impairment. Frailty may represent a novel modifiable target in early dementia to improve HR-QOL for patients.