Insight and cognitive impairment: effects on quality-of-life reports from mild cognitive impairment and Alzheimer's disease patients

Numerosity comparison, cognitive strategies, and general cognitive functioning in older people

Introduction

Studies have shown age-related differences in numerical cognition, for example, in the level of numerosity comparison ability. Moreover, some studies point out individual differences in the cognitive strategies employed during the performance of numerosity comparison tasks and reveal that they are related to the aging process. One probable cause of these differences is the level of cognitive functioning. The aim of our study was to determine the relationships among numerosity comparison ability, the cognitive strategies utilized in the performance of numerosity comparison tasks and the general cognitive functioning in older people.

Methods

Forty-seven elderly people participated in the study. The participants were examined using overall cognitive functioning scales and computerized numerosity comparison task.

Results

The results showed many correlations between the participants' level of cognitive functioning and the percent of correct responses (PCR) and response time (RT) during numerosity comparison, as well as with the cognitive strategies applied by the participants. Task correctness was positively related to the level of performance in the attention and executive function tasks. In contrast, the long-term memory resources index and visuospatial skills level were negatively correlated with RT regarding numerosity comparison task performance. The level of long-term memory resources was also positively associated with the frequency of use of more complex cognitive strategies. Series of regression analyses showed that both the level of general cognitive functioning and the cognitive strategies employed by participants in numerosity comparison can explain 9-21 percent of the variance in the obtained results.

Discussion

In summary, these results showed significant relationships between the level of cognitive functioning and proficiency in numerosity comparison measured in older people. Moreover, it has been shown that cognitive resources level is related to the strategies utilized by older people, which indicates the potential application for cognitive strategy examinations in the development of new diagnostic tools.

Self-Awareness of Cognitive Efficiency, Cognitive Status, Insight, and Financial Capacity in Patients with Mild AD, aMCI, and Healthy Controls: An Intriguing Liaison with Clinical Implications?

Objectives: This study compares objective measures of cognitive performance with subjective perception of specific performance on neuropsychological tests examining basic cognitive domains, including, for the first time, financial capacity. Additionally, differences in assessment between single- and multiple-domain aMCI, mild AD, and healthy elderly regarding insight are examined. Methods: Participants completed a number of neuropsychological tests and the Legal Capacity for Property Law Transactions Assessment Scale (LCPLTAS). After every test, participants were asked to complete the Clinical Insight Rating scale (CIR) and to self-evaluate their performance by comparing it to what they considered as average for people of their age and educational level. Results: These preliminary findings show significant differences in the self-assessment patterns of the four groups in measures of verbal memory, visuospatial perception and memory, executive functions, tests of attention, and financial capacity. Mild AD expressed the highest overestimations, followed by single- and multiple-domain aMCI as well as controls. Accuracy of self-report is not uniform across groups and functional areas. Conclusions: Unawareness of memory deficits in both MCI subtypes is contradictory to subjective memory complaints as being an important component for clinical diagnosis. Financial capacity is overestimated in MCI and mild AD, a finding that has a plethora of clinical and legal implications.

Effect of disease related biases on the subjective assessment of social functioning in Alzheimer's disease and schizophrenia patients

BACKGROUND

Questionnaires are the current hallmark for quantifying social functioning in human clinical research. In this study, we compared self- and proxy-rated (caregiver and researcher) assessments of social functioning in Schizophrenia (SZ) and Alzheimer's disease (AD) patients and evaluated if the discrepancy between the two assessments is mediated by disease-related factors such as symptom severity.

METHODS

We selected five items from the WHO Disability Assessment Schedule 2.0 (WHODAS) to assess social functioning in 53 AD and 61 SZ patients. Caregiver- and researcher-rated assessments of social functioning were used to calculate the discrepancies between self-rated and proxy-rated assessments. Furthermore, we used the number of communication events via smartphones to compare the questionnaire outcomes with an objective measure of social behaviour.

RESULTS

WHODAS results revealed that both AD (p < 0.001) and SZ (p < 0.004) patients significantly overestimate their social functioning relative to the assessment of their caregivers and/or researchers. This overestimation is mediated by the severity of cognitive impairments (MMSE; p = 0.019) in AD, and negative symptoms (PANSS; p = 0.028) in SZ. Subsequently, we showed that the proxy scores correlated more strongly with the smartphone communication events of the patient when compared to the patient-rated questionnaire scores (self; p = 0.076, caregiver; p < 0.001, researcher-rated; p = 0.046).

CONCLUSION

Here we show that the observed overestimation of WHODAS social functioning scores in AD and SZ patients is partly driven by disease-related biases such as cognitive impairments and negative symptoms, respectively. Therefore, we postulate the development and implementation of objective measures of social functioning that may be less susceptible to such biases.

Quality of Life Assessments in Individuals With Young-Onset Dementia and Their Caregivers

BACKGROUND

Quality of life (QoL) has seldom been investigated or explicitly measured in young-onset dementia (YoD). The aims of this study were (1) to investigate and compare QoL self- and proxy reports in a sample of YoD patients and caregivers using different conceptual assessments of QoL and (2) to examine the relationship between caregiver QoL and both burden and mental health.

METHODS

There were 52 participants (26 YoD patient-caregiver dyads). The design was cross-sectional and part of a larger longitudinal prospective cohort study of YoD patients and caregivers. Primary measures included generic QoL (World Health Organization Quality of Life-short version [WHOQOL-BREF]), dementia-specific QoL (Quality of Life in Alzheimer's Disease Scale [QoL-AD]), health-related QoL (EQ5D), and a single-item QoL measure. Secondary measures included caregiver burden (Zarit Burden Index), mental health (Hospital Anxiety and Depression Scale), and dementia severity (Clinical Dementia Rating).

RESULTS

Patient QoL self-reports were higher than caregiver proxy reports on the QoL-AD (P = .001). Patient QoL self-reports for the WHOQOL-BREF (P < .01) and single-item QoL (P < .05) measure were significantly higher than caregiver self-reports. Dementia severity had no relationship with QoL self-reports. Caregiver burden, anxiety, and depression were negatively correlated with QoL when measured using a generic and single-item measure, but not with the health-related measure.

DISCUSSION

Patients and caregivers show a disparity in QoL reports, with patients tending to report higher QoL. Caregiver burden, anxiety, and depression should be areas targeted for interventions when supporting caregivers.

Assessing Mental Health Difficulties of Persons With Huntington's Disease: Does Informant Presence Make a Difference?

OBJECTIVE

Persons with Huntington's disease (HD) often have communication difficulties and cognitive impairments, making mental health assessment difficult. Informants close to the patient are often included in assessments. The authors investigated effects of informant presence during assessment of persons with HD.

METHODS

Data for four subsamples from ENROLL-HD were examined: manifest for HD (N=4,109), premanifest (N=1,790), genotype negative (N=1,041), and family members with no genetic risk (N=974). Assessment interviews with and without an informant present were identified, and the subsamples were compared on three subscales of the short-form Problem Behaviors Assessment: affect, apathy, and irritability. Differences in scores between participant-only and informant-present interviews were examined via multiple regression, controlling for demographic, disease-related, and individual confounds.

RESULTS

Significant differences in apathy and irritability scores were found between participant-only and informant-present conditions for the premanifest, manifest, and genotype-negative subsamples. Affect subscale scores were not influenced by informant presence. When the analysis controlled for confounds, informant presence significantly increased irritability scores in the manifest, and genotype-negative groups and significantly increased apathy scores in the manifest group.

CONCLUSIONS

Apathy may have been systemically underreported in participant-only interviews, which supports previous findings that persons with HD underreport mental health symptoms. When an informant was present, irritability scores were higher for both HD and non-HD individuals, suggesting that underreporting via self-report may be attributable to non-HD factors. Informant contributions to apathy assessments may be particularly important for persons with HD. Clinicians should note potential underreporting regarding irritability and affect, which was not remediated by informant presence.

Validity and Reliability of the German Quality of Life-Alzheimer's Disease (QoL-AD) Self-Report Scale

BACKGROUND

The Quality of Life-Alzheimer's Disease (QoL-AD) scale is a widely used measure of quality of life (QoL) in dementia. Although the instrument has been validated in several languages, the psychometric properties of the German self-report version have not yet been analyzed.

OBJECTIVE

This study examines the internal consistency, test-retest reliability, and construct validity of the German QoL-AD self-report scale.

METHODS

The sample included 30 patients suffering from mild to moderate Alzheimer's disease or vascular dementia (19 females; mean age 77.3 years; mean Mini-Mental State Examination (MMSE) score 19.7 points). To determine test-retest reliability, the QoL-AD self-report scale was re-administered four to seven days apart. For construct validity analysis, the Dementia Quality of Life instrument (DQoL), Geriatric Depression Scale (GDS), MMSE, and an adapted short form of the Neuropsychiatric Inventory (NPI) were used.

RESULTS

The German QoL-AD self-report scale shows an internal consistency of α= 0.79 and a test-retest reliability of r = 0.75 (p < 0.01). Regarding construct validity, there was a significant positive correlation between the total scores of the QoL-AD and DQoL (r = 0.47, p < 0.05). The analysis revealed no significant correlations with the GDS or the adapted NPI. No association could be observed between the QoL-AD and the MMSE (r = 0.01), confirming divergent validity.

CONCLUSION

The results indicate that the German QoL-AD self-report scale is a suitable instrument for assessing QoL in patients suffering from mild to moderate dementia, thus supporting its use in clinical practice and research.

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.

Psychometric Validation of the Hepatitis C Symptom and Impact Questionnaire (HCV-SIQv4) in a Diverse Sample of Adults with Chronic Hepatitis C Virus Infection Treated with an Interferon-free Simeprevir-containing Regimen

BACKGROUND

Hepatitis C virus (HCV) infection and its treatments are associated with significant symptoms, side effects and impact on patients functioning. The Hepatitis C Symptom and Impact Questionnaire version 4 (HCV-SIQv4) was developed according to FDA Patient Reported Outcomes (PRO) Guidance, for evaluating chronic HCV infection and its treatment.

OBJECTIVES

This study evaluated the psychometric properties and clinically important change (CIC) thresholds of the measure.

METHODS

PRO data were pooled from three Phase IIb and III trials evaluating interferon-free simeprevir-containing regimens for treatment of chronic HCV infection. Scale range adequacy, reliability, validity, responsiveness and CIC thresholds were assessed incorporating knowledge of the appropriate measurement model.

RESULTS

Data from 437 patients were analyzed. Stage of liver disease was associated with symptom severity and functioning at baseline. Reliability was acceptable (test-retest ICC ≥0.7) for most scores except the Gastrointestinal and Integumentary domains. Convergent validity was observed between HCV-SIQv4 scores and concurrent measures of conceptual similarity. Greater symptom severity and worse impact scores were associated with liver cirrhosis, depression, severe fatigue and health limitations. Patients who achieved SVR12 had better outcomes than those failing to. HCV-SIQv4 symptom and domain scores were responsive to changes in health state (effect sizes ≥0.5). Exploratory thresholds for change in scores indicating a clinically important improvement and worsening were HCV-SIQv4 Overall Body System Score (BSS), 8 and 8; Constitutional BSS, 10 and 10; Gastrointestinal BSS, 5 and 5; Psychiatric BSS, 8 and 8; Neurocognitive BSS, 8 and 8; and Integumentary BSS, 5 and 5.

CONCLUSIONS

The HCV-SIQv4 offers reliable, responsive assessments within HCV clinical development. CIC thresholds are now available to aid score interpretation.

Predictors of the health-related quality of life of Chinese people with major neurocognitive disorders and their caregivers: The roles of self-esteem and caregiver's burden

AIM

The present research study aimed to identify and compare the clinical and non-clinical factors that predict the self-reported and proxy-reported health-related quality of life (HRQoL) of people with major neurocognitive disorder (PwND) who are living at home in a Chinese society.

METHODS

A total of 57 Chinese PwND-family caregiver dyads that were using the services of local senior centers were recruited through a cross-sectional survey with convenience sampling. Each PwND and caregiver rated the PwND's HRQoL independently by using the Quality of Life-Alzheimer's disease measure. Additional measures included the Rosenberg Self-Esteem Scale (RSES), Index for Managing Memory Loss, Geriatric Depression Scale, Cornell Scale for Depression in Dementia and Zarit Burden Inventory.

RESULTS

The results of hierarchical multiple linear regression analyses showed that the PwND's self-rated HRQoL and caregiver-rated HRQoL were found to be predicted by different clinical and non-clinical variables. In particular, the self-esteem of PwND had the highest predictive power for the self-rated HRQoL, whereas the caregiver burden is the only significant predictor for the caregiver-rated HRQoL.

CONCLUSIONS

In the present study, the self-esteem of PwND and the caregiver's burden were found to be important factors predicting self-rated HRQoL and caregiver-rated HRQoL respectively, which is probably because of the influence of traditional Chinese cultural values. Thus, it is important for non-pharmacological interventions to address these special needs to promote HRQoL for this population. Geriatr Gerontol Int 2017; 17: 2319-2328.

A Randomized Control Study on Psycho-Education Group on Improving Health-Related Quality of Life of Chinese Persons with Major Neurocognitive Disorder

OBJECTIVES

People with a major neurocognitive disorder (PwND) are found to have a lower health related quality of life (HRQoL) than those without neurocognitive disorder. This research study aims to evaluate the effectiveness of a psycho-education group in improving the HRQoL of Chinese PwND.

METHODS

By adopting randomized control trial (RCT), Chinese PwND were randomly assigned to either a 10-session psycho-education group or the control group. Family caregivers of treatment group were encouraged to take part in two sessions focusing on the caring and communication skills. Control group and their family caregivers received standardized educational materials on basic information on neurocognitive disorder for them to read at home. Standardized assessment was conducted both with PwND and their caregivers independently to give the self-rated and caregiver-rated HRQoL of PwND in the pre- and post- treatment periods by a research assistant who was blind to the group assignment of the participants. Moreover, qualitative interviews were also conducted for ten participants and five family caregivers of the treatment group to identify those group elements relating to its effectiveness.

RESULTS

2 × 2 repeated measures ANCOVA demonstrated that the treatment group (n = 32) was significantly more effective than the control group (n = 32) in improving the caregiver-rated HRQoL (F[1, 61] = 4.35, p = .04 < .05) with a moderate effect size, but not self-rated HRQoL, Qualitative analysis suggested several group elements relating to its effectiveness.

CONCLUSIONS

This present RCT shows that the psycho-education group significantly improves caregiver-rated HRQoL of PwND, supporting the feasibility and effectiveness of the psycho-education group.

Self-awareness of cognitive efficiency: Differences between healthy elderly and patients with mild cognitive impairment (MCI)

INTRODUCTION

Self-estimation of performance implies the ability to understand one's own performance with relatively objective terms. Up to date, few studies have addressed this topic in mild cognitive impairment (MCI) patients. The aim of the present study was to compare objective measures of performance with subjective perception of specific performance on cognitive tests and investigate differences in assessment between MCI patients and healthy elderly.

METHOD

Thirty-five participants diagnosed with MCI (women = 16, men = 19, mean age = 65.09 years ±SD = 7.81, mean education = 12.83 years ±SD = 4.32) and 35 control subjects similar in terms of age and education (women = 20, men = 15, mean age = 62.46 years ± SD = 9.35, mean education = 14.26 ± SD = 2.84) were examined with an extended battery of neuropsychological tests. After every test they were asked to self-evaluate their performance by comparing it to what they considered as average for people of their age and educational level. This self-evaluation was reported on a scale ranging from -100 to +100.

RESULTS

Significant differences were found in the self-assessment patterns of the two groups in memory measures of verbal and visual delayed recall, visuospatial perception, and tests of attention. MCI patients overestimated their performance on every cognitive domain while control participants underestimated their performance on measures of verbal memory.

CONCLUSIONS

The present results indicate that accuracy of self-report is not uniform across groups and functional areas. The discrepancies in the MCI patients indicate unawareness of their memory deficits, which is contradictory to subjective memory complaints as being an important component for clinical diagnosis.

Use of the Xbox Kinect virtual gaming system to improve gait, postural control and cognitive awareness in an individual with Progressive Supranuclear Palsy

PURPOSE

The purpose of this report is to describe an intervention using the Xbox Kinect virtual gaming system to improve gait, postural control and cognitive awareness in order to reduce falls and improve the quality of life for an individual with Progressive Supranuclear Palsy.

METHODS

A 65-year-old woman with a five-year history of PSP and frequent falls presented for physical therapy. Her case was complicated by poor ability to visually track objects, axial rigidity, retropulsion, poor postural control with reaching and declines in cognitive awareness. Intervention was provided using the Xbox Kinect for 12 one-hour sessions over six weeks in an outpatient setting. Games were selected to challenge functional motor and cognitive tasks based on patient enjoyment.

RESULTS

The Xbox Kinect intervention may have contributed to a decline in falls and maintenance of scores on the BBS, TUG and 10 Meter Walk Tests above fall risk values. A decline in quality of life measures, PDQ-39 and FFABQ, may be attributed to an increase in cognitive awareness of deficits promoted by the intervention structure.

CONCLUSION

Implementation of a gaming intervention using the Xbox Kinect is feasible for reducing fall risk, maintaining function and improving cognitive awareness when used in an outpatient setting. Implications for Rehabilitation Progressive Supranuclear Palsy is a rare and rapidly progressive neurodegenerative disease wherethere is a lack of long-term rehabilitation options to help slow their rapid progressions. Our case demonstrates the feasibility of an intervention using a virtual gaming system to helpmaintain functional mobility, balance and independence for an individual with PSP. Collaborative interactions between game companies and physical therapists will improve theability of virtual games to address rehabilitation goals within neurodegenerative populations.

Effects of anosognosia and neuropsychiatric symptoms on the quality of life of patients with Alzheimer's disease: a 24-month follow-up study

OBJECTIVES

Neuropsychiatric symptoms and anosognosia are known to influence the perceived quality of life of patients (QoL-p) with Alzheimer's disease (AD). This study analysed their impact on patient and caregiver ratings of QoL-p and how these ratings changed in relation to the severity of dementia.

METHODS

A baseline sample of 221 patients and caregivers was followed up over 24 months. Instruments: Neuropsychiatric Inventory (NPI), Anosognosia Questionnaire-Dementia (AQ-D), Quality of life-Alzheimer's Disease (QoL-AD) and the Global Deterioration Scale (GDS). Longitudinal data were analysed using generalized linear models.

RESULTS

In the multivariate analysis, greater anosognosia was always associated with higher ratings of QoL-p among patients, especially at 24 months (p < 0.001), and with more negative ratings among caregivers, especially at baseline (p < 0.001). A higher total NPI score was associated with a more negative rating of QoL-p among caregivers (p < 0.001), and it also had a smaller negative effect on patients' self-ratings (p = 0.001). The neuropsychiatric symptoms (NPI) associated with a more negative view of QoL-p were depression, for patients' self-ratings, and apathy and agitation for caregiver ratings. The discrepancy between patient and caregiver ratings increased in line with the severity of dementia.

CONCLUSION

Neuropsychiatric symptoms had a similarly negative effect on the QoL-p ratings of both patients and caregivers, whereas the effect of anosognosia differed according to the rater (positive for patients, negative for caregivers).

Neuroanatomical correlates of awareness of illness in patients with amnestic mild cognitive impairment who will or will not convert to Alzheimer's disease

BACKGROUND

Awareness of cognitive deficits may be reduced in mild cognitive impairment (MCI). This may have a detrimental effect on illness course and may be a predictor of subsequent conversion to AD. Although neuropsychological correlates have been widely investigated, no evidence of a neuroanatomical basis of the phenomenon has been reported yet. This study was aimed at investigating the neuroanatomical correlates of deficit awareness in amnestic MCI to determine whether they constitute risk factors for conversion to AD.

METHOD

A sample of 36 first-diagnosis amnestic MCI patients were followed for five years. At the first diagnostic visit they were administered an extensive diagnostic and clinical procedure and the Memory Insight Questionnaire (MIQ), measuring a total index and four sub-indices, to investigate awareness of deficits in dementia; they also underwent a high resolution T1-weighted Magnetic Resonance Imaging (MRI) investigation. Grey matter brain volumes were analysed on a voxel-by-voxel basis using Statistical Parametric Mapping 8. Data of 10 converter patients (CONV) and those of 26 non converter patients (NOCONV) were analysed using multiple regression models.

RESULTS

At baseline, self-awareness of memory deficits was poorer in CONV compared to NOCONV. Furthermore, reduced awareness of cognitive deficits in CONV correlated with reduced grey matter volume of the anterior cingulate (memory deficit awareness), right pars triangularis of the inferior frontal cortex (memory deficit awareness) and cerebellar vermis (total awareness), whereas in NOCONV it correlated with reduced grey matter volume of left superior (total awareness) and middle (language deficit awareness) temporal areas. Further, at baseline self-awareness of memory deficits were poorer in CONV than in NOCONV.

CONCLUSIONS

Defective awareness of cognitive deficits is underpinned by different mechanisms in CONV and NOCONV amnestic MCI patients. Our data support the hypothesis that poor awareness of cognitive deficit is a predictor of subsequent conversion to AD.

Linguistic validation and reliability properties are weak investigated of most dementia-specific quality of life measurements-a systematic review

OBJECTIVE

For people with dementia, the concept of quality of life (Qol) reflects the disease's impact on the whole person. Thus, Qol is an increasingly used outcome measure in dementia research. This systematic review was performed to identify available dementia-specific Qol measurements and to assess the quality of linguistic validations and reliability studies of these measurements (PROSPERO 2013: CRD42014008725).

STUDY DESIGN AND SETTING

The MEDLINE, CINAHL, EMBASE, PsycINFO, and Cochrane Methodology Register databases were systematically searched without any date restrictions. Forward and backward citation tracking were performed on the basis of selected articles.

RESULTS

A total of 70 articles addressing 19 dementia-specific Qol measurements were identified; nine measurements were adapted to nonorigin countries. The quality of the linguistic validations varied from insufficient to good. Internal consistency was the most frequently tested reliability property. Most of the reliability studies lacked internal validity.

CONCLUSION

Qol measurements for dementia are insufficiently linguistic validated and not well tested for reliability. None of the identified measurements can be recommended without further research. The application of international guidelines and quality criteria is strongly recommended for the performance of linguistic validations and reliability studies of dementia-specific Qol measurements.

Predictors of self- and caregiver-rated quality of life for people with dementia living in the community and in nursing homes in northern Taiwan

BACKGROUND

Factors affecting quality of life (QOL) ratings for people with dementia (PWD) have been well studied, but few studies have examined the effect of residence on PWD- and caregiver-rated QOL for PWDs. We designed this study to determine the factors related to PWD- and caregiver-rated QOL in dementia as well as factors related to the discrepancy in these ratings.

METHODS

For this cross-sectional study, we analyzed data from a convenience sample of 106 PWD-family caregiver dyads (58 community-dwelling dyads and 48 nursing-home dyads). PWDs' data included socio-demographic variables, QOL (assessed by the Quality of Life-Alzheimer's Disease [QOL-AD] scale), cognition, dementia severity, depression, comorbidities, and quality of the dyadic relationship. Caregivers' data included socio-demographic variables, depressive symptoms, and mutuality of the dyadic relationship.

RESULTS

QOL-AD scores were lower when rated by caregivers than by PWDs. The key factors positively related to both PWD- and caregiver-rated QOL for PWDs were fewer PWD depressive symptoms and higher quality of the PWD-caregiver relationship. The key factors related to the discrepancy in PWD- and caregiver-rated QOL in dementia were PWD residence in a nursing home and lower dementia severity, as well as higher caregiver depression, being an adult child caregiver, and lower caregiver-PWD mutuality.

CONCLUSION

Caregiver-rated QOL for PWDs and the discrepancy in rated QOL were significantly associated with PWD residence. If caregiver-rated QOL is needed, the effect of residence of PWD should be taken into consideration. Caregivers' depressive status and mutuality with PWD must be also carefully assessed.

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.

Quality of life in dementia: a systematically conducted narrative review of dementia-specific measurement scales

OBJECTIVES

Ascertaining the quality of life (QoL) in people with dementia is important for evaluating service outcomes and cost-effectiveness. This paper identifies QoL measures for people with dementia and assesses their properties.

METHOD

A systematic narrative review identified articles using dementia QoL measures. Electronic databases searched were AMED, CINAHL, EMBASE, Index to Theses, IBSS, MEDLINE, PsycINFO, Sociological Abstracts, and Web of Science. All available years and languages (if with an English language abstract) were included.

RESULTS

Searches yielded 6806 citations; 3043 were multiple duplicates (759 being true duplicates). Abstracts were read; 182 full papers were selected/obtained, of which 126 were included as relevant. Few measures were based on rigorous conceptual frameworks. Some referenced Lawton's model (Dementia Quality of Life [DQOL] and Quality of Life in Alzheimer's Disease [QOL-AD]), though these tapped part of this only; others claimed relationship to a health-related QoL concept (e.g. DEMQOL), though had less social relevance; others were based on limited domains (e.g. activity, affect) or clinical opinions (Quality of Life in Late-Stage Dementia [QUALID]). Many measures were based on proxy assessments or observations of people with dementia's QoL, rather than their own ratings. The Bath Assessment of Subjective Quality of Life in Dementia (BASQID) was developed involving people with dementia and caregivers, but excluded some of their main themes. All measures were tested on selective samples only (ranging from community to hospital clinics, or subsamples/waves of existing population surveys), in a few sites. Their general applicability remains unknown, and predictive validity remains largely untested.

CONCLUSION

The lack of consensus on measuring QoL in dementia suggests a need for a broader, more rigorously tested QoL measure.

Self and carer perspectives of quality of life in dementia using the QoL-AD

OBJECTIVE

Quality of life (QoL) is one of the most important outcomes in improving well-being in people with dementia (PwD). The primary aim of the present study was to compare self and carer ratings of QoL in PwD and to identify the most important factors influencing self and carer ratings.

METHODS

We conducted a cross-sectional analytic study of 488 dyads using the Quality of Life in Alzheimer's Disease scale, demographics, data on self-rated health, and clinical characteristics.

RESULTS

Higher levels of self-rated health in PwD were associated with higher self-rated QoL after controlling for depression and activities of daily living. When the carer experienced less stress related to caregiving, the PwD reported better QoL. Higher carer-rated QoL was associated with less carer stress, better health for the family carer, and the PwD being of younger age. When carers lived with the PwD, and reported lower levels of depression and better functional ability for their relative, carer-rated QoL was higher.

CONCLUSIONS

The self-rated health of PwD and carers influences the ratings they make of the QoL of the PwD indicating that it is an important influence on QoL in this population.

What contributes to a good quality of life in early dementia? Awareness and the QoL-AD: a cross-sectional study

Background

Self-report quality of life (QoL) measures for people with dementia are widely used as outcome measures in trials of dementia care interventions. Depressed mood, relationship quality and neuropsychiatric symptoms predict scores on these measures, whereas cognitive impairment and functional abilities typically do not. This study examines whether these self-reports are influenced by personality and by the person’s awareness of his/her impairments. A strong negative association between QoL and awareness of deficits would have implications for the validity of self-report in this context and for therapeutic interventions aiming to increase adjustment and coping.

Methods

Participants were 101 individuals with early‒stage dementia and their family carers participating in the Memory Impairment and Dementia Awareness (MIDAS) Study. QoL was assessed using the QoL-AD scale, and awareness was assessed in relation to memory, activities of daily living and social functioning. Self-concept, conscientiousness, quality of relationship and mood were assessed and a brief neuropsychological battery administered. Carers rated their own stress and well-being and reported on neuropsychiatric symptoms. A series of regression analyses predicting QoL-AD were carried out, identifying key variables in each domain of assessment to take forward to an overall model.

Results

Cognitive impairment was not related to QoL. The final model accounted for 57% of the variance in QoL-AD scores, with significant contributions from depressed mood, severity of irritability shown by the person with dementia, self-concept, quality of relationship (rated by the person with dementia) and male gender. The bivariate relationships of QoL-AD with awareness of memory function, awareness of functional abilities and conscientiousness were mediated by both depressed mood and self-concept.

Conclusions

This study reports the most comprehensive approach to evaluation of awareness to date. Most of the indices of awareness used are not related to self-reported QoL. Discrepancies in evaluative judgements of memory function and functional abilities between people with dementia and carers are related to QoL, but this relationship is mediated by both depressed mood and self-concept, which have a much stronger relationship with QoL. The validity of self-report measures of QoL in people with early stage dementia is supported by these results.

Dialogue on Ideal End-of-Life Care for Those With Dementia

PURPOSE

To identify both meanings and perceptions of delivery of end-of-life (EoL) care for the person experiencing dementia.

DESIGN/METHODS

As part of a larger cross-sectional mixed methods study examining quality of life in dementia, perspectives of EoL care were sought from 136 seniors using open-ended questions administered at interview.

RESULTS

Seniors living in various settings identified obligatory requisites of care as time when the finality of death needed to be accepted, comfort was prioritized, family presence was valued, appearance remained important, and solitude or time "to be with God" was stressed. Skilled nursing care, honesty, and engaged family were also necessary.

IMPLICATIONS

Understanding EoL preferences of those with dementia is critical for advocacy and service delivery.

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.

Quality of life in dementia: impact of cognition and insight on applicability of the SF-36

OBJECTIVES

Comparability of measures of quality of life in dementia and in other diagnostic groups, such as mild cognitive impairment, normal aging, or other diseases, is highly desirable. However, the impact of cognitive deficits and impaired insight on applicability and validity of generic instruments is sparsely studied.

PARTICIPANTS AND MEASUREMENTS

Sixty patients with dementia [38 women; age: mean (SD) = 78.7 (6.4) years; Mini-Mental State Examination (MMSE): mean (SD) = 20.2 (6.0)] recruited as part of the start-modem study, a multicenter care research study in Germany, completed the generic instrument SF-36 and the specific instrument Quality of Life-Alzheimer's Disease (QOL-AD).

RESULTS

QOL-AD self-rating scores [mean (SD) = 32.8 (5.9)] and SF-36 subscales indicated moderate to good quality of life in the total group. Reliability and validity of five subdomains of the SF-36 were poor in subgroups of patients with impaired insight or with MMSE scores less than 17 (Cronbach's α <0.7, no significant correlation to the QOL-AD). In contrast, for patients with both adequate insight and MMSE score greater than 16 (n = 33; 55%) Cronbach's α of the subdomains of the SF-36 ranged between 0.920 and 0.676. Seven of the eight subdomains correlated significantly with the QOL-AD self-rating and composite score in this group of patients (0.355 ≤ r ≤ 0.709).

CONCLUSIONS

Despite the impact of insight and cognition on self-rated quality of life, we found reliable and valid data for a broad spectrum of patients with dementia. According to the present data, the SF-36 is suitable for dementia patients with both insight into their deficits and an MMSE score greater than 16.

Multidisciplinary team meetings (MDTM) in detection of Alzheimer's disease: data from the IDEM study

INTRODUCTION

The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom, the Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWIG) in Germany and the Haute Autorité de Santé (HAS) in France have recently set out guidelines on prescription of anti-dementia medication. The HAS proposes in particular that continuation of these drugs for longer than one year should be decided in multidisciplinary team meetings (MDTM).

OBJECTIVE

To assess the feasibility of MDTM and the satisfaction of coordinating physicians from institutions for the dependent elderly (nursing home, NH) and expert physicians from memory clinics who have participated in the meetings.

METHODS

Survey carried out among physicians who had participated in the MDTM held as part of the IDEM study (Interest of systematic tracking of dementia cases in NH: analysing the contribution of MDTM in Alzheimer's disease and related diseases; PHRC National 2009, Code 0910701). The survey evaluated the organization of MDTM and the physicians' opinion of these meetings.

RESULTS

The cases of 574 patients were discussed in MDTM involving 133 healthcare professionals (32 coordinating physicians, 48 expert physicians, 4 general practitioners and 49 other health professionals). The mean number of participants was 4.2±1.6. About 16 minutes were spent discussing the case of each resident. About 90% of physicians considered that the meetings were useful. Overall assessment of their efficacy was 11.5/20 for the coordinating physicians and 14.1/20 for the expert physicians. The benefits of MDTM in relation to the work entailed were considered important by 60% of expert physicians and 33% of coordinating physicians.

CONCLUSIONS

Our survey confirmed the feasibility of MDTM in the field of Alzheimer's disease. The overall benefit/workload ratio of the meetings was considered to be favorable for the expert physicians. The benefits of MDTM were turned out to be less appreciated by the coordinating physicians according to high workload involved.

Quality of life and the effect of memantine in dementia with lewy bodies and Parkinson's disease dementia

AIM

To investigate quality of life (QOL) and the effect of memantine treatment in patients with Lewy body dementias.

METHODS

A secondary analysis of a randomized controlled study in 70 patients with Parkinson's disease dementia (PDD) or dementia with Lewy bodies (DLB) over 24 weeks using caregiver-rated QOL-Alzheimer's disease (AD) in domains according to the WHO's classification of health.

RESULTS

Baseline QOL shows lower ratings for body functions over environmental factors in DLB/PDD. Treatment with memantine significantly improves life as a whole compared to placebo and improves total QOL, body function and structure.

CONCLUSION

This study shows that memantine improves QOL in Lewy body dementias. We also demonstrate important QOL patterns which can be used in clinical practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Caregiver burden and depression in mild cognitive impairment

Little is known about contributors to burden and depression in caregivers of patients with mild cognitive impairment (MCI) even though these patients experience cognitive, emotional, and behavioral changes. We examined caregiver burden and depression in 43 caregivers for patients with MCI as well as their associations with patients' neuropsychological status and behavioral symptoms. Almost 30% of caregivers reported clinically significant burden, whereas <5% reported significant depression. Increased caregiver burden was associated with greater disinhibited behaviors by patients, whereas increased caregiver depressive symptoms were associated with greater disinhibited behaviors as well as instrumental activity of daily living (ADL) impairments. Caregiver burden and depression were not associated with patients' neuropsychological performance. Results suggest these caregivers would benefit from interventions addressing both practical methods to provide ADL assistance and behavioral methods to address inappropriate behaviors in patients in the predementia stages.

Multidimensional assessment of awareness in early-stage dementia: a cluster analytic approach

BACKGROUND/AIMS

Research on awareness in dementia has yielded variable and inconsistent associations between awareness and other factors. This study examined awareness using a multidimensional approach and applied cluster analytic techniques to identify associations between the level of awareness and other variables.

METHODS

Participants were 101 individuals with early-stage dementia (PwD) and their carers. Explicit awareness was assessed at 3 levels: performance monitoring in relation to memory, evaluative judgement in relation to memory, everyday activities and socio-emotional functioning, and metacognitive reflection in relation to the experience and impact of the condition. Implicit awareness was assessed with an emotional Stroop task.

RESULTS

Different measures of explicit awareness scores were related only to a limited extent. Cluster analysis yielded 3 groups with differing degrees of explicit awareness. These groups showed no differences in implicit awareness. Lower explicit awareness was associated with greater age, lower MMSE scores, poorer recall and naming scores, lower anxiety and greater carer stress.

CONCLUSION

Multidimensional assessment offers a more robust approach to classifying PwD according to level of awareness and hence to examining correlates and predictors of awareness.

Awareness of social and emotional functioning in people with early-stage dementia and implications for carers

OBJECTIVES

This study explores the extent to which awareness of social and emotional function is reduced in early-stage dementia and whether this relates to the quality of life of the person with dementia (PwD), the quality of the relationship between the PwD and carer and carer stress.

METHOD

Ninety-seven participants with a diagnosis of Alzheimer's, vascular or mixed dementia rated their social functioning using the Socio-Emotional Questionnaire (SEQ). Carers provided parallel ratings, allowing calculation of discrepancy scores used to index awareness. Neuropsychiatric symptoms, PwD quality of life, the perceived quality of the relationship for both partners and carer stress were also measured.

RESULTS

Factor analysis of the SEQ indicated three domains of social functioning: emotional recognition and empathy (ERE), social relationships (SR) and prosocial behaviour (PB). For PwD unawareness was related to cognitive dysfunction and psychiatric disturbance, but not to quality of life or quality of relationship. Lower awareness was associated with greater carer stress and poorer perceived quality of relationship.

CONCLUSION

Lack of awareness of social functioning had important implications for relationship quality and levels of carer stress.

Quality of life in early dementia: Comparison of rural patient and caregiver ratings at baseline and one year

This study examined change in patient and caregiver ratings of patient quality of life (QOL) over one year in individuals with dementia living in rural and remote settings. The sample was selected from non-institutionalized patients who were assessed at an interprofessional memory clinic. Measures of QOL, cognitive function, depression, and functional ability were completed by the patient. Caregivers completed measures of patient QOL and behavior, and their own burden and distress. At baseline (clinic day) 119 patients and family caregivers were assessed. Thirty-two families had complete data at clinic day and one-year follow-up. There was no significant change in either patient or caregiver-rated QOL over one year. Significant predictors of patient self-rated QOL were patient symptoms of depressed mood and functional ability at clinic day, and symptoms of depressed mood and clinic day QOL at one year. Significant predictors of caregiver-rated patient QOL were caregiver burden, patient functional ability, and symptom severity at clinic day, and caregiver burden at one year. Patient and caregiver ratings of patient QOL were moderately associated, but neither patients nor their caregivers reported a significant change in patient QOL. Changes in QOL over time remain a unique individual experience that cannot be entirely predicted by analytical models.

Family triad perceptions of mild cognitive impairment

OBJECTIVES

We examined subjective perceptions of memory loss among older adults with mild cognitive impairment (MCI) and two other relatives in order to improve understanding of family coping. We also investigated contextual conditions associated with perceptions of family dynamics and relationships.

METHOD

We conducted interviews with 56 family triads (the elder with MCI, the primary care partner, and a secondary care partner). Guided by Pearlin and colleagues' caregiving stress process framework, questions addressed perceptions of memory changes and interpretation of the effects of MCI on family interaction patterns.

RESULTS

Analyses of family triads revealed four degrees of the extent to which family members similarly acknowledged elders' MCI. The acknowledgment groups differed on history of family dynamics, experience with dementia, and perceived extent of memory change in the elder. Families characterized by full acknowledgment coped better with perceived changes in the elder's functioning than those in which members' perceptions of MCI were incongruent.

DISCUSSION

Pursuing family-level data on responses to MCI uncovered more nuanced reactions, often differing across triad members, than individual-based research has found. Family perceptions about changes in elders' memory have important implications for within-family interactions and support that can help families cope successfully with MCI.

Unawareness of memory impairment and behavioral abnormalities in patients with Alzheimer's disease: relation to professional health care burden

OBJECTIVES

The present study investigates the impact of unawareness of deficit (anosognosia) in patients with Alzheimer's disease upon professional health care burden.

DESIGN

Cross-sectional study with a consecutive clinical sample from an Alzheimer day-care hospital in France.

SUBJECTS

65 patients with probable AD, aged from 75 to 94 years old, consecutively admitted at the Alzheimer Day Hospital to complete a program of cognitive stimulation and psychosocial rehabilitation.

MEASUREMENTS

Each patient was submitted to a standardized evaluation including clinical investigation, cerebral imagery, and neuropsychological assessment. Anosognosia of memory deficit and anosognosia of behavioral disturbances were measured as the "discrepancy scores" between patients' self-reports and family member ratings of patient memory performance and behavioral disturbances. Professional health care burden was assessed with the Professional Health Care Dementia Burden Index (PCDBI; maximal score: 12), designed for this study. Multiple linear regressions were used to examine the correlations between the PCDBI and the severity of anosognosia.

RESULTS

The findings showed a significant positive correlation between the PCDBI and both anosognosia of memory impairment and behavioral abnormalities (both p at least less than 0.05). However, there was no significant correlation between the severity of the burden and the severity of cognitive decline or functional impairment (both p at least>0.05).

CONCLUSION

Anosognosia in Alzheimer disease patients has a negative impact upon the professional caregivers' burden over and above the cognitive deficit and the functional impairments.

Neuropsychiatric symptoms and quality of life in patients with very mild and mild Alzheimer's disease

BACKGROUND

Neuropsychiatric symptoms (NPS) are common manifestations of Alzheimer' s disease (AD).

OBJECTIVE

To examine the prevalence and significance of NPS in very mild and mild AD patients with emphasis on their influence on the well-being of the patients and their caregivers.

METHODS

The participants were 240 patient-caregiver dyads who participated in a prospective, controlled rehabilitation study (ALSOVA). Three Quality of Life (QoL) instruments were used; generic 15D, disease-specific QoL-AD and Visual Analog Scale (VAS). The disease-specific QoL-AD was both self-rated and caregiver rated. Other scales used were Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), ADCS-ADL, Neuropsychiatric Inventory (NPI) and Beck Depression Inventory (BDI).

RESULTS

NPS were present in 76.5% of patients with very mild AD (CDR 0.5) and in 84.9% of patients with mild to moderate AD (CDR 1). The most frequent symptoms were apathy, depression, irritability, and agitation. The strongest predictor of self-reported QoL-AD scores was depressive symptoms whereas functional decline and presence of NPS predicted poor caregiver ratings of patients' QoL. However, caregiver depression also influenced significantly their ratings.

CONCLUSION

NPS are common even in the early stages of AD. NPS were significantly associated with caregiver assessment of the patient's QoL but not with patients' self-assessed QoL. Depression decreases QoL, but may remain unrecognized in AD patients, emphasizing the need for careful and structured assessment of NPS before deciding on the appropriate treatment.

Self-Rated Quality of Life in Mild Cognitive Impairment and Alzheimer’s Disease

Background: Cognitively impaired or demented patients may have difficulty performing the complex and multidimensional appraisal required by self-ratings (SR) of quality of life (QoL). Even healthy subjects often refer to their current mood state for QoL self-assessment. Therefore, it is hypothesized that patients rely on current mood state as a reference point for QoL SR, and that the degree of reliance increases with the level of cognitive impairment. Methods: Two consecutive samples of 14 patients with mild cognitive impairment (MCI) and 16 patients with Alzheimer’s disease (AD) were examined using the self-rated Dementia-Quality of Life (DEMQoL), a multidimensional mood state questionnaire (MDBF-A, Mehrdimensionaler Befindlichkeitsfragebogen), and the Mini-Mental State Examination (MMSE; MCI: mean = 25.1, SD = 2.1; AD: mean = 20.3, SD = 2.7). Results: As expected, correlations between current mood state and QoL SR (DEMQoL) were highly significant in AD patients but not in MCI patients. The degree of association for all significant correlations was also significantly higher in AD than in MCI patients. Conclusions: The results indicate that SR of QoL are more affectively distorted in AD than MCI. Mood state questionnaires may be an alternative to QoL questionnaires for AD patients, in particular if mood state ratings can be averaged across several points of assessment thus enhancing their validity.

Generic quality of life assessment in dementia patients: a prospective cohort study

BACKGROUND

Quality of life (QoL) is increasingly used to characterize the impact of disease and the efficacy of interventions.

METHODS

Prospective cohort study in patients' and proxies' homes with 137 patients with dementia (age 52 to 88; Mini-Mental Status Examination (MMSE) 3 to 28) and their proxies (age 43 to 90). MMSE, Behave-AD, Geriatric Depression Scale (GDS), and Bayer-ADL scale (B-ADL), and the Euroqol (EQ-5D; patient self-rating, proxy self-rating, and proxy-rating of patient).

RESULTS

B-ADL impairment and Behave-AD total score increased with dementia severity (Kruskal-Wallis p < 0.001 and p = 0.023, respectively). Patients' self-rated QoL and proxies' self-rated QoL were unrelated to dementia severity (p = 0.148 and p = 0.414, respectively). The difference between patients' self- and proxies'-rating of the patient's QoL correlated with the patient's MMSE (Spearman's rho = -0.434; p < 0.001), even if analysis was constrained to patients with mild AD (rho = -0.328; p = 0.019). The proxies' rating of the patients QoL was not only correlated with cognitive and behavioral symptoms of the patient but also with mood (GDS-score; rho = 0.317; p < 0.001) and cognitive abilities (verbal fluency; rho = 0.209; p < 0.018) of the proxy.

CONCLUSION

Proxies' assessment of the patients' QoL is related to the proxies' health, and the difference of patient's and proxie's QoL-rating is correlated with dementia severity even in mild dementia stages. QOL measures use ratings of the individual to assess the impact of symptoms and disorders on everyday life. In dementia patients, however, this impact is not captured since patients' and proxies' self-assessment of their own QoL do not reflect severity of disease whatsoever. Patients' and proxies' influencing variables render the score obtained with generic quality of life assessment meaningless in capturing the impact of dementia. Decisions on initiation or discontinuation of treatment or allocation of other resources for patients with dementia therefore need not depend on generic assessment of quality of life.

Health economics and the value of therapy in Alzheimer's disease

In increasingly aging societies throughout the developed and developing world, Alzheimer's disease and related dementias are fast becoming a critical public health issue, exacting an enormous toll on individuals and healthcare systems. Over the past 10 years, five drugs have been developed and approved for the symptomatic treatment of Alzheimer's dementia, and several disease-modifying drugs are in various stages of clinical development. While symptomatic medications were consistently shown to have clinical benefit in numerous efficacy studies, the cost effectiveness of antidementia therapies and their value to healthcare systems remain unclear. The pharmacoeconomics of antidementia therapies is an evolving field, with several unanswered questions. This poses many challenges for biopharmaceutical companies developing these therapies, regulatory agencies responsible for their approval, and payers responsible for ensuring their availability to patients. The challenge partly relates to the unique nature of dementia as a disease of impaired cognition, behavior, and function. Thus, the selection of appropriate outcome measures that directly relate to healthcare utilization, quality of life, caregiver burden, and pharmacoeconomic analysis has been difficult. The development of meaningful and widely acceptable outcome measures, as well as novel clinical-study designs, is needed to better evaluate cost effectiveness and to demonstrate the value of therapeutics for Alzheimer's disease. Providing the decision-makers in healthcare systems with a body of evidence that demonstrates a positive relationship between clinical outcomes and the economic and humanistic benefits of antidementia therapeutics will improve patient access to novel drugs as they become available.

Factors related to perceived quality of life in patients with Alzheimer's disease: the patient's perception compared with that of caregivers

AIMS

To compare care recipient and caregiver perceptions of quality of life in patients (QoL-p) with Alzheimer's disease (AD). To identify associated factors, and the concordances-discrepancies.

METHOD

Cross-sectional analytic study of 236 patients and their carers using the Quality of Life in Alzheimer's Disease (QoL-AD) scale, socio-demographic data and clinical examination.

RESULTS

Patients scored the QoL-AD more favourably than did caregivers (34.4 vs 31.3, p < 0.001). Cognitive deterioration did not affect the perception of QoL-AD (rho = -0.05, p = 0.394). The neuropsychiatric symptoms was associated with a negative perception of the QOL-AD in both patients (rho = -0.22, p < 0.01) and caregivers (rho = -0.47, p < 0.001). Greater functional autonomy was associated with a better perception of the QOL-AD in patients (rho = 0.17, p < 0.01) and even more so in caregivers (rho = 0.56, p < 0.001). In carers, burden (rho = -0.56, p < 0.001) and mental health (rho = 0.31, p < 0.001) were inversely associated with the QoL-AD. QoL-AD scores of both patients and caregivers were higher for men, married subjects, those who lived with their spouse and those living in their own home. When the carer was a spouse both patients and caregivers scored the QoL-AD higher than when the carer was a son or daughter (35.5 vs 33.4 and 33.7; 32.9 vs 30.5 and 27.7, p < 0.001).

CONCLUSIONS

Patients have a better perception of QoL-p. Caregivers give a more negative evaluation of neuropsychiatric symptoms, but have a more positive view of functional autonomy. Carers who are spouses have a better perception of QoL-p than do carers who are sons or daughters.

Critical evaluation of self-rated quality of life in mild cognitive impairment and Alzheimer's disease--further evidence for the impact of anosognosia and global cognitive impairment

OBJECTIVES

The present study investigates the effect of anosognosia (impaired insight for an illness) and cognitive deficits on the reliability and validity of self-rated Quality of Life (QoL) in Mild Cognitive Impairment (MCI) and Alzheimer's Disease (AD).

DESIGN

Cross-sectional study.

SETTING

Cross-sectional study with a consecutive clinical sample from a memory clinic in Leipzig (Germany).

SUBJECTS

27 patients (aged 65 years or above) with a diagnosis of either MCI (N=12) or AD (N=15), each together with a caregiver.

MEASUREMENTS

The patients' QoL was measured using the Dementia Quality of Life self and proxy ratings (DEMQoL and DEMQoLproxy). The degree of anosognosia was rated by means of the Clinical Insight Rating Scale (CIR). In addition the Mini-Mental-State Examination (MMSE), and for diagnostic purposes the Bayer Activities of Daily Living Scale (B-ADL) and the Consortium to Establish a Registry of Alzheimer;s Disease (CERAD) word list were applied.

RESULTS

In accordance with the results of Ready et al. (1), patients with impaired insight were found to produce less reliable QoL ratings than those with unimpaired insight. The validity (concordance between self- and proxy QoL ratings) is influenced by cognitive deficits, anosognosia and the interaction between these factors.

CONCLUSIONS

Data which are based on dementia patients' QoL self-ratings need to be interpreted with caution when anosognosia is present.

Personal perspectives of persons with Alzheimer's disease and their carers: a global survey

BACKGROUND

Alzheimer's disease (AD) impacts on persons with AD as well their families. This survey aimed to identify information/communication gaps, and quality of life and other issues, from both perspectives.

METHODS

Persons with AD and their families or other carers from Europe, Brazil, and North America completed telephone interviews. Responses were analyzed by country.

RESULTS

Five hundred two persons with AD and 614 carers were included. Issues important to persons with AD were treatment that helps control symptoms; feeling safe and supported at home; and ability to enjoy life. Most felt well-respected by family members. Families/carers considered a wider range of issues important, including detailed information about AD, regimens that are easier to comply with, and medication in a form that is easier to take. This reflects the fact that carers very often manage medications.

CONCLUSIONS

This is the first global survey to include persons with AD themselves. Differences between responses from persons with AD and their caregivers highlight the importance of considering both viewpoints.

The patient with dementia, the caregiver and the doctor: cognition, depression and quality of life from three perspectives

BACKGROUND

For comprehensive information about the situation of patients with dementia or mild cognitive impairment (MCI), clinicians have to rely on information from different sources, e.g. caregivers or the patients themselves, which may differ from each other. In addition to the assessment of cognitive impairment, the importance of evaluating not only depressive symptoms but also health related quality of life (HRQOL) in clinical research and practice in dementia has increased.

OBJECTIVE

To examine about how the ratings of patients, caregivers and clinicians regarding the patients' cognitive impairment, depression and HRQOL relate to each other by comparing these three perspectives by using self- and proxy-rating measures.

METHOD

One hundred outpatients with mild to moderate dementia or MCI and their family caregivers participated in this study. Depression and cognitive impairment were examined with self- and proxy-ratings as well as the Mini-Mental Status Examination (MMSE); HRQOL was assessed with the SF-12 Health Survey and the EUROHIS quality of life index.

RESULTS

We found high correspondence between caregivers' assessment of cognitive function and MMSE scores, while patients' self-rating did not correlate with MMSE. HRQOL was underestimated by caregivers compared to self-rating. Concerning depression, the patients' assessment was in good accordance with the clinician's evaluation.

CONCLUSION

The study suggests that patients with mild to moderate dementia and MCI are important informants of their HRQOL and depressive symptoms, but they underestimate their cognitive deficits. Assessing different perspectives of the patients' HRQOL is relevant in order to obtain a comprehensive understanding of the patients' well-being.

Effects of a goal-oriented rehabilitation program in mild cognitive impairment: a pilot study

BACKGROUND

Memory disturbance, deficient concentration, and fatigue are symptoms seen in amnestic mild cognitive impairment (MCI) as well as in mild traumatic brain injury (TBI). The aim of this study was to assess if an established rehabilitation program commonly used in TBI can aid MCI patients to develop compensatory memory strategies that can improve their cognition, occupational performance, and quality of life (QoL).

METHODS

Fifteen patients with MCI participated in the program 2 days per week for 8 weeks. Cognitive function, occupational performance, and self-perceived QoL were assessed at baseline, at the end of the intervention, and at follow-up after 6 months.

RESULTS

Significant improvements were seen in cognitive processing speed, occupational performance, and in some of the QoL domains.

CONCLUSION

As this goal-oriented rehabilitation program in MCI resulted in some improvements in cognition, occupational performance, and QoL, further randomized controlled studies are warranted.

Integrating patient and informant reports on the Cornell-Brown Quality-of-Life Scale

Patients with mild cognitive impairment and mild to moderate Alzheimer's disease can provide information about their quality of life. This study determined whether aggregating patient and informant quality-of-life reports on the Cornell-Brown Scale for Quality of Life in Dementia can provide a broader perspective on the quality of life relative to patient or informant reports separately. Aggregated Cornell-Brown Scale for Quality of Life in Dementia scores were hypothesized to correlate more strongly with both patient and informant perspectives of patient's memory, function, and neuropsychiatric symptoms than the unaggregated measures. Results indicated that aggregated Cornell-Brown Scale for Quality of Life in Dementia scores reflected a blend of patient and informant perspectives on patient function. This study contributes to a growing line of research that recommends integrating patient and informant perspectives to achieve the most complete assessment of quality of life.