Cognitively impaired spouses as primary caregivers for demented elderly people

Translation and concurrent validity, sensitivity and specificity of Chinese version of Short Orientation Memory Concentration Test in people with a first cerebral infarction

Purpose

This study aimed to translate the English version of the Short Orientation-Memory-Concentration (SOMC) test into a Chinese version, denoted the C-SOMC test, and to investigate the concurrent validity, sensitivity, and specificity of the C-SOMC test against a longer and widely used screening instrument in people with a first cerebral infarction.

Methods

An expert group translated the SOMC test into Chinese using a forward-backward procedure. Eighty-six participants (67 men and 19 women, mean age = 59.31 ± 11.57 years) with a first cerebral infarction were enrolled in this study. The validity of the C-SOMC test was determined using the Chinese version of Mini Mental State Examination (C-MMSE) as the comparator. Concurrent validity was determined using Spearman's rank correlation coefficients. Univariate linear regression was used to analyze items' abilities to predict the total score on the C-SOMC test and the C-MMSE score. The area under the receiver operating characteristic curve (AUC) was used to demonstrate the sensitivity and specificity of the C-SOMC test at various cut-off values distinguishing cognitive impairment from normal cognition.

Results

The total score for the C-SOMC test and the score for item 1 on this test exhibited moderate-to-good correlations with the C-MMSE score, with respective ρ-values of 0.636 and 0.565 (P < 0.001). The scores for each of items 2, 4, 5, 6, and 7 yielded fair correlations with C-MMSE score, with ρ-value from 0.272 to 0.495 (P < 0.05). The total score on the C-SOMC test and the item score were good predictors (adjusted R² = 0.049 to 0.615) of the C-MMSE score, and six items were good predictors (adjusted R² = 0.134 to 0.795) of the total score. The AUC was 0.92 for the C-SOMC test. A cut-off of 17/18 on the C-SOMC test gave optimal performance: correct classification of 75% of participants, with 75% sensitivity and 87.9% specificity.

Conclusion

The C-SOMC test demonstrated good concurrent validity, sensitivity and specificity in a sample of people with a first cerebral infarction, demonstrating that it could be used to screen for cognitive impairment in stroke patients.

Cognition in informal caregivers: evidence from an English population study

BACKGROUND AND OBJECTIVES

The relationship between caregiving and cognition remains unclear. We investigate this association comparing four cognitive tasks and exploring the role of potential explanatory pathways such as healthy behaviours (healthy caregiver hypothesis) and depression (stress process model).

RESEARCH DESIGN AND METHODS

Respondents were from English Longitudinal Study of Ageing (ELSA) (N = 8910). Cognitive tasks included immediate and delayed word recall, verbal fluency and serial 7 subtraction. Series of hierarchical linear regressions were performed. Adjustments included socio-demographics, health related variables, health behaviours and depression.

RESULTS

Being a caregiver was positively associated with immediate and delayed recall, verbal fluency but not with serial 7. For immediate and delayed recall, these associations were partially attenuated when adjusting for health behaviours, and depression. For verbal fluency, associations were partially attenuated when adjusting for depression but fully attenuated when adjusting for health behaviours. No associations were found for serial 7.

DISCUSSION AND IMPLICATIONS

Our findings show that caregivers have higher level of memory and executive function compared to non-caregivers. For memory, we found that although health behaviours and depression can have a role in this association, they do not fully explain it. However, health behaviours seem to have a clear role in the association with executive function. Public health and policy do not need to target specifically cognitive function but other areas as the promotion of healthy behaviours and psychological adjustment such as preventing depression and promoting physical activity in caregivers.

Mild cognitive dysfunction of caregivers and its association with care recipients' end-of-life plans and preferences

Little is known about the association between cognitive dysfunction among informal caregivers and patients’ plans and preferences for patients’ end of life care. We report on the frequency of cognitive dysfunction among both patients and caregivers and examine associations between caregivers’ cognitive screening scores and end of life plans and preferences of patients with advanced cancer. The current sample was derived from a National Cancer Institute- and National Institute of Mental Health-funded study of patients with distant metastasis who had disease progression on at least first-line chemotherapy, and their informal caregivers (n = 550 pairs). The Pfeiffer Short Portable Mental Status, a validated cognitive screen, was administered to patients and caregivers. Patients were interviewed about their end of life plans and preferences. Logistic regression models regressed patients’ advance care planning and treatment preferences on caregivers’ cognitive screen scores. Patients’ cognitive screen scores were included as covariates. Most caregivers (55%) were spouses. Almost 30% of patients scored worse on the cognitive screen than their caregivers and 12% of caregivers scored worse than the patients. For each additional error that caregivers made on the cognitive screen, patients were more likely (AOR = 1.59, p = 0.002) to report that they preferred that everything possible be done to keep them alive and were less likely (AOR = 0.75, p = 0.04) to have a living will or a health care proxy/durable power of attorney. Worse caregiver cognitive screening scores were associated with higher likelihood of patients’ reporting that they wanted everything done to save their lives and a lower likelihood of having a living will or other type of advanced care plan. Future studies should confirm these findings in other populations and determine the mechanisms that may underlie the identified relationships.

A systematic review of medication non-adherence in persons with dementia or cognitive impairment

Background

Adherence to medication is vital for disease management while simultaneously reducing healthcare expenditure. Older persons with cognitive impairment (CI) are at risk for non-adherence as cognitive processes are needed to manage medications. This systematic review focuses on the relationship between medication non-adherence and specific cognitive domains in persons with CI, and explores determinants of medication non-adherence. When available, relationships and factors are compared with cognitively intact populations.

Methods

A seven database systematic search of studies published between 1 January 1949–31 December 2015 examining medication non-adherence in community dwelling persons with CI or dementia was conducted. Articles reporting medication non-adherence in people with CI or dementia in the community, with or without caregiver supports were eligible for inclusion. Papers reporting adherence to treatments in cognitively intact populations, populations from hospital or institutional settings, for non-prescribed medication or those describing dementia as a factor predicting medication non-adherence were excluded. Data on study and population characteristics, research design, data sources and analysis, specific cognitive domains, non-adherence prevalence, measurement of adherence, salient findings, factors associated with adherence and strategies to improve medication adherence were extracted. Study limitations included inconsistencies between data sources and definitions, resulting in a loss of fidelity in the value and comprehensiveness of data, as well as exclusion of non-pharmacological treatments and regimens.

Findings

Fifteen studies met inclusion criteria. Adherence among CI subjects ranged from 10.7%-38% with better rates of adherence in non-CI individuals. Medication non-adherence definitions varied considerably. New-learning, memory and executive functioning were associated with improved adherence and formed the focus of most studies. Multiple factors were identified as modulators of non-adherence.

Conclusion

This review highlights a gap in knowledge on how specific cognitive domains contribute to medication non-adherence amongst CI populations, and demonstrates the current focus is limited to two domains: memory and executive functioning.

Risk of Cognitive and Functional Impairment in Spouses of People With Dementia: Evidence From the Health and Retirement Study

Caring for a spouse with dementia is a chronic stressor that may compromise caregivers' own cognitive functioning and capacity to provide adequate care. We examined whether having (i) a spouse with dementia and (ii) a spouse who requires assistance with activities of daily living predicted cognitive and functional impairments in respondents to the Health and Retirement Study (n = 7965). Respondents who had a spouse who requires care had poorer cognitive functioning, whereby this relationship was significantly stronger for male respondents. Having a spouse with dementia moderated the relationship between income and cognition and predicted caregiver functional impairment, though not when depression was controlled. Although we found no significant differences on any individual cognitive domains between 179 dementia caregivers and sociodemographically matched noncaregivers, our findings suggest that caregivers, especially men, and low-income individuals who have a spouse with dementia are more vulnerable to adverse cognitive outcomes. Targeting depression in spouses of people with dementia may help to prevent functional impairments.

Depressed mood mediates decline in cognitive processing speed in caregivers

PURPOSE

Very few studies have examined cognitive decline in caregivers versus noncaregivers, and only 1 study has examined mediators of such decline. We evaluated the relationship between caregiver status and decline on the digit symbol test (DST; a measure of processing speed, attention, cognitive-motor translation, and visual scanning) and whether this relationship was mediated by depressed mood.

DESIGN AND METHODS

Caregivers for spouses with Alzheimer's disease (n = 122) were compared with demographically similar noncaregiver spouses (n = 117) at study entry (Time 1 = T1), T2 (1 year later), and T3 (2 years after T1).

RESULTS

Caregivers had lower DST scores and higher Hamilton depression scores at T1, T2, and T3 than noncaregivers (all p < .05). Hierarchical linear modeling revealed that although caregivers started well below noncaregivers, they experienced a more rapid rate of decline than noncaregivers (p = .047). Caregivers declined 4.5 times faster than noncaregivers. Greater depressed mood at T1 (p < .01) and T2 (p < .01) predicted DST decline and mediated DST decline in caregivers vs. noncaregivers.

IMPLICATIONS

Depressed mood in caregivers relative to noncaregivers may influence their greater risk for DST decline. This is important because the DST predicts problem solving and everyday functions necessary for independent living and the potential well-being of their care recipients.

Cognitive functioning in spousal caregivers of dementia patients: findings from the prospective MAASBED study

BACKGROUND

Spousal caregivers are usually of the same age as the dementia patient and therefore at risk of age-related cognitive decline. Suboptimal cognitive functioning in caregivers may have profound implications.

METHODS

Fifty-four spousal caregivers of dementia patients from the Memory Clinic of the Academic Hospital Maastricht and the Regional Institute for Community Mental Health Care in the Netherlands were compared with 108 non-caregiving controls. Data were collected on patient and caregiver characteristics and caregiver cognitive functioning. Repeated measures statistical analyses were carried out to investigate the relationship between caregiver cognitive functioning at baseline and patient behavioural problems and caregiver competence during 1 year of follow-up.

RESULTS

Caregivers performed significantly worse on several cognitive domains compared with control subjects. Low performance on a verbal memory task was related to a decrease in caregiver subjective competence and an increase in patient hyperactivity.

CONCLUSION

The results indicate that screening for cognitive impairment of spousal caregivers may be helpful, because suboptimal cognitive functioning may affect the ability to provide adequate care.

Galantamine prolonged-release formulation in the treatment of mild to moderate Alzheimer's disease

The primary objective of this study was to evaluate the efficacy and tolerability of a flexible dosing regimen (16 or 24 mg/day) of galantamine prolonged-release capsule (PRC) compared with placebo in subjects with mild to moderate Alzheimer's disease (AD). This phase III, double-blind, placebo- and active-controlled, parallel-group trial randomized 971 patients to treatment for 6 months. Efficacy endpoints included change in the 11-item cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog/11), Clinician's Interview-Based Impression of Change plus caregiver input (CIBIC-plus), Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL), and Neuropsychiatric Inventory (NPI) scores. Galantamine was associated with significant improvements in the ADAS-cog/11 score but not in the CIBIC-plus or NPI scores. Galantamine PRC was associated with significant improvement in ADCS-ADL scores. Galantamine PRC had similar tolerability and safety profiles compared with twice-daily galantamine, and when administered as a once-daily flexible dosing regimen of 16 or 24 mg/day, was demonstrated to be as safe and effective for the treatment of mild to moderate AD.

Trial of a disease management program to reduce hospital readmissions of the chronically critically ill

BACKGROUND

Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. They are prone to continued morbidity and mortality after hospital discharge and are at high risk for hospital readmission. Disease management (DM) programs have been shown to be effective in improving both coordination and efficiency of care after hospital discharge for populations with single-disease diagnoses, but have not been tested with patients with multiple-disease diagnoses, such as the chronically critically ill.

STUDY OBJECTIVES

To test the effect of a DM program on hospital readmission patterns of chronically critically ill patients during the first 2 months after hospital discharge and to estimate the cost-effectiveness of the DM program.

DESIGN

Randomized, controlled trial.

SETTING

Academic medical center, extended care facilities, and participant homes.

PARTICIPANTS

Three hundred thirty-four consenting adults from one academic medical center who underwent > 3 days of mechanical ventilation and survived to hospital discharge.

INTERVENTION

Two hundred thirty-one patients in the experimental group received care coordination, family support, teaching, and monitoring of therapies from a team of advanced-practice nurses, a geriatrician, and a pulmonologist for 2 months post-hospital discharge.

MEASUREMENTS

Rehospitalization rate, time-to-first rehospitalization, duration of rehospitalization, mortality during rehospitalization, and associated costs.

RESULTS

Patients who received DM services had significantly fewer mean days of rehospitalization (11.4; 95% confidence interval [CI], 9.3 to 12.6) compared with the control group (16.7 days; 95% CI, 12.5 to 21.0; p = 0.03). There were no other significant differences between experimental and control groups, although all measures of rehospitalization risk for the experimental group were in a positive direction. Total cost savings associated with the intervention were approximately $481,811 for the 93 subjects who were readmitted to the hospital.

CONCLUSIONS

Chronic critical illness may have a natural trajectory of continued morbidity following hospital discharge that is not affected by the provision of additional care coordination services. Nevertheless, given the high cost of rehospitalization and the additional burden it imposes on patients and families, interventions that can reduce the duration of rehospitalization are cost-effective and merit continued testing.

Stress in caregivers of hospitalized oldest-old patients

BACKGROUND

Stress in caregivers of elderly patients is a well-recognized health care problem. However, little has been published about the stress in caregivers of the oldest-old patients, the most rapidly growing segment of our population.

METHODS

A prospective cohort study was conducted in four teaching hospitals. Questionnaires were administered to patients 80 years of age and older and their surrogates (the person who would make decisions if the patient were unable to-usually a family member) who identified themselves as the primary caregivers for the patients. Data were abstracted from medical records.

RESULTS

Caregivers tended to be female and 50 years of age or older. About one in five described her own health as fair or poor; nearly half of them lived with the patient. About one quarter spent at least 8 h/d caring for the patient, and they had few persons available to help them with care. Most of the caregivers reported mild-to-moderate levels of stress. After adjustment, higher stress scores were associated with female caregivers, poorer caregiver health, more hours per day spent caring for the patient, and the presence of patient depression and hearing impairment.

CONCLUSION

Stress is common in caregivers of the hospitalized oldest-old patients. Women who are in poor health and spend 8 or more hours every day caring for relatives aged 80 and over are at high risk for caregiver stress. Treatment of patient depression and hearing impairment may ameliorate caregiver stress.

The Short Orientation-Memory-Concentration Test: a study of its reliability and validity

OBJECTIVE

To establish the limits of intra-observer test-retest reliability of the Short Orientation-Memory-Concentration Test (SOMC), and to investigate the relationship of performance on the SOMC with a test of verbal memory.

DESIGN

Each patient was assessed twice by the same assessor over an interval of 3-7 days.

SETTING

Two specialist rehabilitation units concerned with patients with severe and/or complex disability arising from neurological disease.

SUBJECTS

Thirty-eight patients aged 17-63 years, 25 being men, with a variety of neurological diseases. The Barthel Activities of Daily Living Index score ranged from 0 to 20, median 10.5.

MEASURES

The Short Orientation-Memory-Concentration Test, the Barthel Activities of Daily Living Index and the paragraph recall subtest of the Rivermead Behavioural Memory Test (RBMT).

RESULTS

There was a slight but statistically significant (p <0.01) improvement in the score of 2 points (out of 28) between the two test occasions, but this was not related to the interval between testing or to the mean score of the two tests. The scores differed by as much as +10 to -8, but most patients (n = 35; 92%) showed a difference between -2 and +6 points. The SOMC scores were correlated with the RBMT paragraph recall immediate and delayed scores (r = 0.74) but the scatterplot showed considerable variation.

CONCLUSION

If used by the same observer, changes in the SOMC score are likely to reflect a real difference if it increases by more than 6 points or decreases by more than 2 points. The SOMC does seem to reflect verbal memory.