Evaluation of the quality of life in dementia with a generic quality of life questionnaire: the Duke Health Profile

Cross-Culture Adaptation and Psychometric Properties of the Persian Version of Duke Health Profile

Background: Duke health profile (DHP) is a 17-item questionnaire that measures six health scales (physical, mental, social, general, perceptual, and self-confidence) and four dysfunction scales of anxiety, depression, pain, and disability. Objectives: To systematically translate DHP to Persian language and measure the validity and reliability of the translated version. Methods: We used the forward-backward method for translation of DHP from English to Persian. After linguistic matching and pilot review, a cross-sectional study was carried out on 239 individuals aged over 18 to measure the psychometric characteristics of the Persian version of DHP. The reliability of the questionnaire was assessed using Cronbach’s alpha and test-retest analysis. Content validity, face validity, and construct validity were evaluated by an expert panel, interviewing a sample of the general population, and confirmatory factor analysis, respectively. Results: Item content validity indexes (I-CVI) for relevance and clarity were between 88 and 100. Scale content validity index (S-CVI) for relevance and clarity were 96% and 94%, respectively. The calculated item content validity ratio (I-CVR) was between 0.78 and 1.0. The confirmatory factor analysis showed that the data fit the model, and the indicators of fitness were acceptable. The Cronbach’s alpha was 0.77 for the total tool and varied between 0.47 and 0.69 for different subscales. The reliability of the test-retest was 0.64 - 0.88, which was good after two weeks. Conclusions: The Persian version of DHP is a valid and reliable tool for measuring health profile.

The relationship among social support, self-esteem, affect balance and loneliness in individuals with substance use disorders in China

This study analyzed the potential mediating role of self-esteem and affect balance on the relationship between social support and loneliness. Respondents were 426 substabce use disorders from the Shifosi and Dalianshan rehab facilities in China who had completed the Multidimensional Scale of Perceived Social Support, Rosenberg Self-Esteem Scale, Positive and Negative Affect Scales, and UCLA Loneliness Scale. The results indicated that self-esteem and affect balance fully mediated the relationship between perceived social support and loneliness and all the paths, ranging from social support through self-esteem and affect balance to loneliness, were significant. Finally, we analyzed possible approaches to decreasing individuals with substance use disorders' loneliness.

Being occupied: supporting ‘meaningful activity’ in care homes for older people in England

The benefits of meaningful activity in later life are well documented. Studies show that being occupied contributes to both physical and mental health as well as quality of life. Research also suggests that activity may be beneficial to people residing in care homes, including people living with dementia. This paper presents findings from a study which used the Adult Social Care Outcomes Toolkit (ASCOT) to measure quality of life in six care homes located in the south-east of England. The study found, like previous ones, that care home residents’ days were characterised by a lack of activity. Drawing on observations, interviews and focus groups with residents and staff from these homes, this paper attempts to understand why care home residents do not engage in meaningful activities. We reject the idea that these low levels of activity are a natural part of the ageing process or that they can be explained by notions of resident choice. Instead, the findings point to both insufficient funding and working practices within care homes as more substantive explanations. These explanations inform a discussion of how the low levels of engagement in meaningful activity could be addressed and residents’ quality of life improved.

The early identification of cognitive impairment

The early and accurate identification of dementia helps to ensure the delivery of appropriate treatment and allows people with dementia and their carers to plan for the future. This article describes a research evaluation of a new screening, assessment and referral service for people with early-stage dementia and their carers who reside in one of Northern Ireland’s integrated health and social services trusts.

A total of 435 referrals were made to the service during the first 33 months; most were female (70%) with an average age of 80 (SD = 7.68) and a mild/moderate (71%) cognitive impairment (mean Mini-mental State Examination score of 20.21 (SD = 6.10)). A research interview was conducted with 20 consecutive service users and their carers ( n = 21) following their initial assessment by a community psychiatric nurse and again four months later. Users recorded an overall improvement in self-reported quality of life and their use of health and social services remained unchanged. Carers valued highly the information and support provided by the project; their QoL improved and ‘stress and strain’ (as measured by the General Health Questionnaire-30 and Carers’ Checklist) decreased.

Generally, stakeholders such as referral agents reported that the new service made an important contribution to dementia care, although some professionals thought that the service needed to be better ‘networked’ in order to avoid duplication of resources. Overall, the findings from this evaluation help to address the lack of available information about ways in which to organize and deliver early-stage dementia care.

Comparison of QoL-AD and DQoL in elderly with Alzheimer's disease

OBJECTIVE

The Dementia Quality of Life (DQoL) and the Quality of Life in Alzheimer's Disease (QoL-AD) are the two most widely used dementia-specific QoL instruments in the world. We aimed to compare the psychometric properties of these two instruments and identify which is most adapted to use in geriatric consultations.

METHODS

To evaluate the psychometric properties of the French language validation of DQoL and QoL-AD, 123 patients aged 65 years and over suffering from AD (Mini Mental State Examination score ≥10) were recruited in seven French hospitals and one Switzerland hospital. The DQoL comprises 29 items, ranked on a five-point Likert scale and measuring five QoL domains: self-esteem, positive affect, negative affect, feeling of belonging and sense of aesthetics. The QoL-AD contains 13 items giving an overall score ranging from 13 to 52 and evaluating the domains of interpersonal relationships, financial difficulties, physical condition, memory, mood and overall health.

RESULTS

Both questionnaires showed adequate reproducibility at 2 weeks interval (intra-class correlation coefficient >0.80), good internal consistency (Cronbach's alpha coefficient >0.70) and good convergent validity with the general health dimension of the Duke Health Profile. The time required to complete the QoL-AD was significantly shorter (p < 0.0001). DQoL had better discriminant capacity (with at least one dimension significant for each subgroup of severity of cognitive decline, dependency, presence of depression or behavioural disorders).

CONCLUSIONS

For quick evaluation of QoL during consultations in geriatric care, the QoL-AD is preferable, whereas for the purposes of research and more in-depth evaluation, the DQoL is more suitable.

Health-related quality of life after stroke: reliability and validity of the Duke Health Profile for use in Vietnam

INTRODUCTION

Health-related quality of life (HRQoL) is commonly used to assess outcomes after stroke. The Duke Health Profile (DHP) has been translated and culturally adapted for use in Vietnam, but its reliability and validity for use with stroke patients in Vietnam or elsewhere have not been assessed.

METHODS

First-ever stroke patients (n = 108) who were admitted to 115 People's Hospital between February and September 2012 and survived for 3 months after stroke had HRQoL assessed using the DHP and a comparison instrument (EQ-5D). Caregivers of 94 patients completed these questionnaires as a proxy. After 1 week, these questionnaires were re-administered to patients and proxies.

RESULTS

The mean differences between test and retest assessments of HRQoL by patients were small and not clinically meaningful and were not consistently associated with sex, age, type of stroke or severity of impairment or disability. Direct assessments by the patient were on average greater than those obtained from the proxy. The ICCs ranged from 0.60 to 0.86 (patient test-retest) and from 0.55 to 0.98 (patient-proxy agreement). The ICCs were greatest for physical functioning components (patient test-retest 0.63-0.86, patient-proxy 0.69-0.98). The correlations between the DHP dimensions and EQ-5D were generally stronger when they measured similar constructs (r = 0.53-0.66) and were lower for less related constructs (r = 0.11-0.43).

CONCLUSION

The DHP has moderate reliability and validity for use with stroke patients in Vietnam even when information is obtained from proxy respondents.

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.

Health Status in Patients with Alzheimer’s Disease: An Investigation of Inter-rater Agreement

OBJECTIVE

The purpose of the present study was to examine the level of agreement between health status ratings provided by patients with Alzheimer's disease and by their proxies.

BACKGROUND

Because proxy-completed responses are often necessary in assessing health outcomes for the elderly, it is necessary to determine the feasibility and potential limitations of using proxies as a patient substitutes.

METHODS

To assess the potential utility of proxy responses on health status when subjects present a cognitive impairment, this study compared the responses of 70 subjects with Alzheimer's disease and those of their family and/or care provider proxy using the SF-36. Agreement between proxies and patients was measured by intraclass correlation coefficients (ICCs).

RESULTS

The proportion of exact agreement between patients and proxies on the 36 items ranged from 3.3 to 41.7%. Results reveal poor to moderate agreement between patient and proxy reports. Proxy reliability varied according to the relationship of the proxy to the index subject. Agreement decreased significantly with increasing severity of dementia and with increasing severity of Physical status (Katz ADL). Agreement was better for measures of functions that are directly observable and relatively poor for more subjective measures.

CONCLUSIONS

Our results confirm the importance of the information source used for patient health status.

Using the WHOQOL-BREF in persons with dementia: a validation study

Increasing evidence suggests that persons with early dementia can give reliable and valid assessments about their own quality of life (QOL), thereby improving accuracy, and reducing the need for proxy informants. The objective of this study was to examine QOL in persons diagnosed with dementia (Diagnostic and Statistical Manual of Mental Disorder-IV) using a battery of subjective assessments including the new World Health Organization Quality of Life (WHOQOL-BREF). Persons with mild-to-moderate dementia (n=104) were recruited and interviewed at 6 Spanish centers to obtain sociodemographic information, health perceptions, depressive symptoms (Geriatric Depression Scale 15-item version), functional ability (Barthel Index), generic QOL (WHOQOL-BREF), and specific QOL (DEMQOL-28). Analysis was performed using classical psychometric methods. Internal consistency reliability for the WHOQOL-BREF domains ranged from moderate (0.54 for social) to good (0.79 for psychological). Test-retest reliability (intraclass correlation) ranged from moderate (0.51 for psychological) to good (0.70 for physical). Associations were confirmed between WHOQOL-BREF domains with DEMQOL-28, Geriatric Depression Scale 15-item version, and Barthel dimensions. With regard to contrasting groups' differences, WHOQOL-BREF scores significantly differentiated between healthy and unhealthy and depressed and nondepressed participants. This study is the first to report on the use of the WHOQOL-BREF in persons with mild-to-moderate dementia. These results indicate that it is a useful tool in assessing these groups, as it includes important dimensions commonly omitted from other dementia measures.

Feasibility and accuracy of fall reports in persons with dementia: a prospective observational study

BACKGROUND

The feasibility, test-retest reliability, and accuracy of different fall recording methods have not been studied in older persons with dementia.

METHODS

This was a prospective observational study, nested within a randomized controlled trial on motor training, in which 110 participants were monitored for falls over 12 months. Seven methods of fall recording were compared: face-to-face interviews; phone interviews: weekly for three months, monthly for 9 months, a final interview after 12 months; prospective calendar method; interviews with a proxy and the general practitioner (GP). Summing the count of falls and removing duplicate reporting of the same fall was found to provide the best approximation of the actual number of falls and was chosen as the criterion-standard.

RESULTS

The combination of calendar method and phone interviews showed the highest accuracy (74% of falls, 93% of fallers). As a single measure, weekly phone calls were superior to calendars or proxy-report. Monthly phone calls recorded only half the falls that were picked up by weekly calls (p = 0.002) and were inferior to the calendars (p<0.001) and proxy-report (p = 0.015). GPs knew of only 14% of falls and 19% of fallers. In addition, 49% of subjects who documented a fall prospectively did not recall a fall after 12 months.

CONCLUSION

The combination of fall calendars with regular telephone interviews can be recommended for persons with mild to moderate stage dementia. If feasible, recall periods should be as short as one week; additional information by care-givers increases accuracy of reports. Retrospective recall of falling with long recall periods is not recommended.

Health-related quality of life in French adolescents and adults: norms for the DUKE Health Profile

BACKGROUND

The continual monitoring of population health-related quality of life (HRQoL) with validated instruments helps public health agencies assess, protect, and promote population health. This study aimed to determine norms for the French adolescent and adult general population for the Duke Health Profile (DUKE) questionnaire in a large representative community sample.

METHODS

We randomly selected 17,733 French people aged 12 to 75 years old in 2 steps, by households and individuals, from the National Health Barometer 2005, a periodic population study by the French National Institute for Prevention and Health Education. Quality of life and other data were collected by computer-assisted telephone interview.

RESULTS

Normative data for the French population were analyzed by age, gender and self-reported chronic disease. Globally, function scores (best HRQoL=100) for physical, mental, social, and general health, as well as perceived health and self-esteem, were 72.3 (SEM 0.2), 74.6 (0.2), 66.8 (0.1), 71.3 (0.1), 71.3 (0.3), 76.5 (0.1), respectively. Dysfunction scores (worst HRQoL=100) for anxiety, depression, pain and disability domains were 30.9 (0.1), 27.6 (0.2), 34.3 (0.3), 3.1 (0.1), respectively.

CONCLUSION

The French norms for adolescents and adults for the DUKE could be used as a reference for other studies assessing HRQoL, for specific illnesses, in France and for international comparisons.

Which generic health related Quality of Life questionnaire should be used in older inpatients: comparison of the Duke Health Profile and the MOS Short-Form SF-36?

OBJECTIVES

The objective of our study was to compare advantages and limitations of two generic Quality of Life questionnaires administered in older inpatients.

DESIGN

Two validated generic health-related Quality of Life instruments : the MOS Short-Form 36 (9 dimensions, 36 items) and the Duke Health Profile (6 dimensions, 4 dysfunctions, 17 items) were administered to inpatients over 65 years.

SETTING AND PARTICIPANTS

The sample was drawn from the CliniQualVie program that assessed systematically Quality of Life among hospitalized inpatients (18-79 years) in 10 medical and surgical wards at Nancy University Hospital.

RESULTS

The two self-administered questionnaires were completed by 701 patients over 65 years at admission (mean age 71 +/- 4, 63% men). The proportion of patients who completed all items were 72.5% for the Duke and 66.9% for the SF-36 (p < .001). The Duke's internal consistency was low as compared with the SF-36, but other psychometric properties were comparable. Good correlations (Spearman) were observed between the two questionnaires for physical health (0.59, p < .0001), mental health (0.68, p < .0001) and health perception (0.56, p < .0001) scores. Low correlations were observed for the social score.

CONCLUSIONS

This is the first study to our knowledge to assess the interest of using the Duke Health Profile in a general elderly inpatients population as compared with the SF-36 questionnaire. Although these two questionnaires have four comparable dimensions, they differ in their content and psychometric properties. The Duke questionnaire, due to its better completion rate and despite some psychometric limitations may be useful in this population, particularly in the more frail patients.

How can we get access to the experiences of people with dementia?

This paper suggests and discusses a methodological approach that aims to facilitate the inclusion of people with dementia in research where the ambition is to better understand their experiences. People with dementia have commonly not been included as informants in research as their cognitive deficits have been regarded as a hindrance. Moreover, in the qualitative research tradition, most inquiries rely on data obtained from interviews, thereby requiring communication and verbal skills, which are skills that are affected early in the cause of dementia. Consequently, the considerably under-researched area of how dementia is experienced and managed from the perspective of those afflicted has long been put aside. This paper suggests that a combination of qualitative observations and adapted interviews may make it possible for people with dementia to participate as research informants. Issues concerned with creating a relationship with informants with dementia and helping them to elicit their experiences are elaborated and discussed. Some suggestions are made concerning how the context can be used for this intent, and how the observations and interviews can be adapted to the informants with dementia.

Use of questionnaire infeasibility in order to detect cognitive disorders: example of the Center for Epidemiologic Studies Depression Scale in psychiatry settings

AIM

To examine the extent to which cognitive disorders influenced the feasibility and accuracy of both the 20-item and the 10-item Center for Epidemiologic Studies Depression Scale (CES-D).

METHODS

Cross-sectional analyses of 223 first-visit patients in a psychiatric clinic and 108 patients in a psychiatric department in a general hospital were conducted. To assess the influence of age, gender, and the presence of cognitive disorders on the feasibility of both versions of the CES-D, multiple logistic regression was performed with feasibility per se as the dummy dependent variable. In order to assess the accuracy of the CES-D, receiver operating characteristic (ROC) analysis was performed.

RESULTS

The infeasibility of both types of CES-D were so strongly associated with the presence of cognitive disorders that it can be used as an indicator of cognitive impairment. Moreover, the 10-item CES-D had almost as acceptable an internal consistency reliability as the 20-item CES-D in the study settings.

CONCLUSIONS

Information obtained from both versions of the CES-D could be utilized fully, using infeasibility as an indicator of cognitive disorders, in psychiatry settings. Other screening instruments with as heavy a cognitive load as the CES-D can also be used in the same manner as an indicator of cognitive disorders to save the need for instruments specifically designed for dementia. Such usage can decrease the burden on both the respondent and the clinician in clinical practice.

Calidad de vida y demencia

Dementia and Alzheimer disease (AD) are an important public health problem with devastating consequences for the patient and they impose a great burden on the families. However, the concept and emphasis on quality of life (QoL) in dementia and AD has appeared in the last decade. Given that there is not treatment for the disease, the main objective is to preserve the patients' quality of life. QoL is an outcome measure in the assessment of different treatments and health and social interventions. The measurement of QoL allows patients and caregivers to express the impact produced by the treatment and the interventions; also, the measurement of QoL offers to professionals the opportunity to incorporate the value systems of patients and their caregivers in their assessments. The existing specific QoL scales for dementia have been developed mainly in the US and UK. There is a lack of these scales in our culture.

Using the Nottingham Health Profile (NHP) among older adult inpatients with varying cognitive function

BACKGROUND

High rates of missing, non-applicable items and insufficient reliability have been frequently reported as limitations of the generic Quality of Life questionnaires for older patients. The Nottingham Health Profile (NHP) might be more suitable as it contains easy to respond (yes/no) items covering moderate-to-severe health deterioration.

OBJECTIVES

To assess feasibility, reliability and validity of the NHP in disabled, older patients.

DESIGN

Cross-sectional study.

SETTING

Acute care hospital.

SUBJECTS

134 inpatients aged >or=65 with severe disability, abnormal cognitive function, or other persistent health problems precluding their discharge.

METHODS

The (interviewer-administered) NHP, Mini-Mental State Examination (MMSE), Barthel Index, and diagnostic information were recorded.

RESULTS

Completion rates varied from 98% of the 49 patients with normal cognition (MMSE >or=21) and 86.3% of the 51 with moderate cognitive impairment (MMSE 10-20), to 5.9% of the 34 with severe cognitive impairment (MMSE<10). Cronbach's alpha of the total NHP score was near 0.9 (0.82 and 0.87 for patients with MMSE >or= 21 and 10-20, respectively; p = 0.291). The correlation between 'Physical Mobility' of the NHP and Barthel Index was also similar in both cognitive groups (0.39 and 0.40).

CONCLUSION

Interviewer-administered NHP is suitable, reliable and valid, even in patients with moderate cognitive function.

A review of quality of life instruments used in dementia

OBJECTIVE

To provide an overview of QOL measures applicable for research in dementia, the scale content, method of data collection, and their psychometric properties.

METHOD

Literature research.

RESULTS

Six dementia-specific QOL measures were identified, eight generic measures were used in a demented population, and three dementia-specific measures related to QOL are described as well. Measures vary considerably in scale content, and method of data collection. Reliability indexes were always available, support of instrument validity was often reported, but reports of responsiveness to change were found only for two dementia-specific QOL measures.

CONCLUSION

When the interest is primarily on people with dementia, a dementia-specific instrument is to be preferred. Further clarification of the concept of QOL and particularly its relation to disease severity is required.

Assessment of Adult Psychopathology: Meta-Analyses and Implications of Cross-Informant Correlations

Assessment of adult psychopathology relies heavily on self-reports. To determine how well self-reports agree with reports by "informants" who know the person being assessed, the authors examined 51,000 articles published over 10 years in 52 peer-reviewed journals for correlations between self-reports and "informants" reports. Qualifying correlations were found in 108 (0.2%) of the articles. When self-reports and informant reports were obtained with parallel instruments, mean cross-informant correlations were .681 for substance use, .428 for internalizing, and .438 for externalizing problems. When based on different instruments, the mean cross-informant correlation was .304. The moderate sizes of the correlations argue for systematically obtaining multi-informant data. National survey findings were used to illustrate practical ways to obtain and use such data.

Agreement between dementia patient report and proxy reports using the Nottingham Health Profile

OBJECTIVE

The aim of the study was to examine the agreement between patient reports and their proxy reports (family and care provider proxies) on Health Status in a sample of patients with dementia.

METHOD

Ninety-nine patients with mild to moderate dementia and proxies completed the 38-item Nottingham Health Profile (NHP) questionnaire.

RESULTS

Completion rates for the different NHP dimensions ranged from 78 to 90% for the dementia subjects. Inter-rater agreement between different proxies and subject was from moderate to good for physical assessment (ICCs from 0.54 to 0.78 for physical mobility scales). Patient/family proxy concordance was moderate to good for five out of six dimensions (physical mobility, social isolation, pain, energy, sleep) and poor for emotional reaction. Family proxies systematically reported lower functioning than did patients in the four subscales assessing: physical mobility (p <0.0001), energy (p <0.005), social isolation (p <0.01) and sleep (p <0.03). Care provider proxies only estimated physical mobility as lower (p <0.0001).

CONCLUSION

Age and physical status of the patient significantly affected agreement in patient-care provider proxy ratings. Thus, caution is appropriate when resorting to proxies to estimate the Health Status of a dementia patient.

Dementia Care Mapping as a research tool for measuring quality of life in care settings: psychometric properties

BACKGROUND

There are a paucity of validated measures focusing on quality of life for people with dementia in care facilities.

METHOD

The current study evaluated the internal consistency of Dementia Care Mapping (DCM) in a group of 123 people with dementia residing in care facilities and further evaluated the test retest reliability and concurrent validity of key DCM constructs in an additional group of 54 residents.

RESULTS

The results show good internal consistency. Well-ill being score was significantly correlated with an informant rated quality of life measure (r = 0.73, p < 0.0001) and showed good test retest reliability (r = 0.55, p < 0.0001). An abbreviated assessment period focusing on the hour before lunch showed significant correlation with the total assessment period (well-ill being score r = 0.5, p = 0.02).

CONCLUSION

The current study indicates that DCM is a valid tool for the longitudinal evaluation of quality of life in people with dementia in care settings and that some abbreviation of the method may facilitate its use more widely.

Benefit-risk considerations in the treatment of dementia with Lewy bodies

Dementia with Lewy bodies (DLB) is a relatively recently characterised syndrome with clinical and pathological features that distinguish it from classical Alzheimer's disease. These characteristics include more rapid decline, spontaneous features of parkinsonism, visual hallucinations and fluctuating cognition. This article reviews the clinical syndrome of DLB and the agents used to treat its cognitive, motor and behavioural manifestations. Benefit-risk issues regarding the treatment of DLB are discussed based upon limited randomised, controlled clinical trials with some speculative conclusions being drawn from case reports and case series. We conclude that patients with DLB may respond better to cholinesterase inhibitors than patients with Alzheimer's disease on both cognitive and behavioural measures. Cholinesterase inhibitor therapy may result in reduced caregiver burden and less time institutionalised. These agents are well tolerated with the majority of adverse effects being gastrointestinal in nature. Although neuropsychiatric manifestations are numerous in patients with DLB, antipsychotics should be used infrequently and with caution, although atypical antipsychotics are better tolerated than conventional antipsychotics. Physicians should exhibit caution when prescribing these agents because of the increased risk of extrapyramidal adverse effects. Limited data suggest that the use of levodopa or other dopaminergic agents may be of benefit for the treatment of the parkinsonism that is associated with DLB. However, the increased risk of hallucinations and neuropsychiatric symptoms may negate the potential benefits of increased mobility. There is insufficient evidence to draw conclusions about the use of antidepressants; however, selective serotonin reuptake inhibitors may be of benefit.

Agreement between patients' and proxies' reports of quality of life in Alzheimer's disease

Agreement between self reports and proxy reports of health-related quality of life (H RQoL) was examined in a sample of 76 patients with mild to moderate Alzheimer's disease and their proxies. Patients and proxies completed an '17-item Duke health profile'. The items were rephrased for the proxy. The proportion of exact agreement between patients and proxies on the 17 items ranged from 26.3 to 52.6%. Results reveal poor to moderate agreement (intraclass correlation coefficients (ICCs) from 0.00 to 0.61 for 10 subscales) between patients' and proxies' reports. Agreement was higher for measures of function that are directly observable (physical health, disability) and relatively poor for more subjective measures. Proxy reliability varied according to the relationship of the proxy to the index subject. Spouses and nurses agreed more closely with index subjects than did children or nurses' aides. Agreement decreased with increasing severity of dementia. Statistically significant differences in mean scores were noted for several dimensions, with proxies tending to rate the patients as having a lower quality of life than the patients themselves. This study indicates the importance of considering the information source of a patient's HRQoL. However, assessments by proxies should be used with caution.