The influence of neuropsychiatric and functional changes on quality of life in Alzheimer's disease

IMOVE: Protocol for a randomized, controlled 2x2 factorial trial of improvisational movement and social engagement interventions in older adults with early Alzheimer's disease

Background

In addition to cognitive impairment, people with Alzheimer's disease (PWAD) experience neuropsychiatric symptoms (e.g., apathy, depression), altered gait, and poor balance that further diminish their quality of life (QoL). Here, we describe a unique, randomized, controlled trial to test the hypothesis that both movement and social engagement aspects of a group dance intervention alter the connectivity of key brain networks involved in motor and social-emotional functioning and lead to improved QoL in PWAD.

Methods

IMOVE (NCT03333837) was a single-center, randomized, controlled 2x2 factorial trial that assigned PWAD/caregiver dyads to one of 4 study conditions (Movement Group, Movement Alone, Social Group, or Usual Care control). The Movement Group participated in twice-weekly group improvisational dance (IMPROVment® Method) classes for 12 weeks. The Movement Alone intervention captured the same dance movement and auditory stimuli as the group class without social interaction, and the Social Group used improvisational party games to recapitulate the fun and playfulness of the Movement Group without the movement. The primary outcome was change in QoL among PWAD. Key secondary outcomes were functional brain network measures assessed using graph-theory analysis of resting-state functional magnetic resonance imaging scans, as well as neuropsychiatric symptoms, gait, and balance.

Results

A total of 111 dyads were randomized; 89 completed the study, despite interruption and modification of the protocol due to COVID-19 restrictions (see companion paper by Fanning et al.). The data are being analyzed and will be submitted for publication in 2023.

Validation of the Adapted German Versions of the Dementia Knowledge Assessment Tool 2, the Dementia Attitude Scale, and the Confidence in Dementia Scale for the General Population

Background: There are almost no validated tools in German that assess dementia knowledge, attitude toward dementia, and confidence in the general population. Objective: Translation and validation of the German version of the Dementia Knowledge Assessment Tool 2 (DKAT2), the Dementia Attitude Scale (DAS), and the Confidence in Dementia Scale (CODE). Methods: Instruments were translated into German and adapted for the general public. A convenience sample of 263 persons was recruited via an online platform. Validation of the tools’ psychometric properties consisted of an assessment of its reliability (internal consistency and 4-week test-retest reliability of a subgroup with n = 110), an analysis of its construct validity through principal component analysis and known-group analysis, convergent validity, and an item analysis for DKAT2-D. This study used the STROBE checklist for reporting. Results: Acceptable to excellent internal reliability was found for DAS-D (α= 0.90), DKAT2-D (α= 0.78), and CODE-D (α= 0.93). The principal component analysis confirmed the two-factor model for the DAS-D as well as the one-factor solution for CODE-D. Intra-class correlation coefficient between the first and the 4-week retest was good (CODE-D: 0.897; 0.849–0.929) to excellent (DKAT2-D: 0.918; 0.879–0.945 and DAS-D: 0.940; 0.910–0.960). Known-group analysis revealed that DAS-D, DKAT-D, and CODE-D could distinguish between individuals with or without experience with people with dementia and with or without participation in a dementia course. Conclusion: The German versions DAS-D, DKAT2-D, and CODE-D are reliable and valid tools to measure knowledge, attitude, and confidence in dementia in the German-speaking general population.

Factors Related to the Quality of Life in Family Carers of People With Dementia: A Meta-Analysis

OBJECTIVES

This meta-analysis aimed to (1) quantitatively synthesize evidence of factors related to the quality of life (QoL) of family carers of people with dementia and (2) explore moderating factors that may influence the strength of the relationship between such potential predictive factors and carer QoL.

METHODS

Studies that investigated correlations between patient/carer factors and QoL in unpaid family carers of people with dementia and were published in English, Spanish, Portuguese, or Japanese were included.

RESULTS

Thirty-three studies were identified. The pooled correlations with carer QoL (effect size) were significantly large for depression (-0.58), significantly moderate for subjective burden (-0.47), and significantly small for people with dementia's neuropsychiatric symptoms (-0.24). These results indicated to be robust in the context of publication bias. The results of subgroup analyses demonstrated the social and economic development status of the country where study participants resided did not moderate these effects.

CONCLUSION

Carer depression, subjective burden, and people with dementia's neuropsychiatric symptoms may play a critical role in maintaining QoL of family carers regardless of the social and economic circumstances.

Optimizing Quality of Life With Cognitive Impairment: A Study of End-of-Life Care in Assisted Living

OBJECTIVES

Assisted living (AL) is an expanding site of end-of-life (EOL) care in the United States. Understanding determinants of quality of life (QoL) for AL residents near EOL is vital to optimize care for this growing population, most of whom have some degree of cognitive impairment (CI). This analysis aimed to identify factors associated with QoL in a diverse sample of AL residents with CI approaching EOL.

DESIGN

Observational cross-section design.

SETTING AND PARTICIPANTS

Data are from a 5-year study funded by the National Institute on Aging examining EOL care of residents in 7 diverse AL communities in metropolitan Atlanta (n = 67).

METHODS

CI was assessed with the Montreal Cognitive Assessment (scores ≤ 26) and QoL was determined with the self-reported QoL in Alzheimer's disease survey adapted for use in AL. Psychological distress was assessed using the Patient Health Questionnaire-4 and fatigue was assessed using the 13-item Functional Assessment of Chronic Illness Therapy Fatigue Scale. Initial descriptive analyses were followed by backward stepwise regression analyses to select a best-fitting model of QoL.

RESULTS

The final model predicted 27% of the variance in QoL. CI was not significantly correlated with QoL and was not retained in the final model. Pain and functional limitation also did not meet inclusion criteria (P ≤ .10) and were sequentially removed, producing a final model of QoL in terms of psychological distress (β = -0.28, P = .032), fatigue (β = -0.26, P = .048), and race (β = 0.21, P = .063).

CONCLUSIONS AND IMPLICATIONS

The lack of a significant correlation between degree of CI and self-reported QoL suggests that AL residents have the potential to experience high QoL, despite CI. Interventions to reduce psychological distress and manage fatigue could be implemented during EOL care to attempt to improve QoL for AL residents with CI. The correlation between race and QoL warrants investigation into possible racial disparities in AL and EOL care.

Living well with dementia: a systematic review and correlational meta-analysis of factors associated with quality of life, well-being and life satisfaction in people with dementia

Current policy emphasises the importance of 'living well' with dementia, but there has been no comprehensive synthesis of the factors related to quality of life (QoL), subjective well-being or life satisfaction in people with dementia. We examined the available evidence in a systematic review and meta-analysis. We searched electronic databases until 7 January 2016 for observational studies investigating factors associated with QoL, well-being and life satisfaction in people with dementia. Articles had to provide quantitative data and include ⩾75% people with dementia of any type or severity. We included 198 QoL studies taken from 272 articles in the meta-analysis. The analysis focused on 43 factors with sufficient data, relating to 37639 people with dementia. Generally, these factors were significantly associated with QoL, but effect sizes were often small (0.1-0.29) or negligible (<0.09). Factors reflecting relationships, social engagement and functional ability were associated with better QoL. Factors indicative of poorer physical and mental health (including depression and other neuropsychiatric symptoms) and poorer carer well-being were associated with poorer QoL. Longitudinal evidence about predictors of QoL was limited. There was a considerable between-study heterogeneity. The pattern of numerous predominantly small associations with QoL suggests a need to reconsider approaches to understanding and assessing living well with dementia.

Cross-cultural adaptation to Brazilian Portuguese of the Dementia Knowledge Assessment Tool Version Two: DKAT2

ABSTRACT The Dementia Knowledge Assessment Tool Version Two (DKAT2) was developed to measure caregivers’ knowledge about the trajectory of dementia and assess changes in the knowledge before and after educational programs. The DKAT2 is a 21-item tool with questions about several aspects of dementia. The possible answers for each question are “yes”, “no” or “don't know”. The maximum score is 21. Objective: The aim of the study was to cross-culturally adapt the DKAT2 to Brazilian Portuguese. Methods: The essential steps to cross-culturally adapt were conducted and the final version administered to 30 caregivers of older people with dementia, sampled by convenience. Results: In the sample assessed, the mean age was 55.7 (± 12.5) years, 93.3% were female, 56.7% were sons/daughters and 23.3% were spouses of the older adults with dementia. The mean time caring for the elder was 4.7 (± 3.3) years and 70% of the caregivers had some level of burden. The mean age of the older people was 82.4 (± 6.7) years, 19 (63.3%) had a diagnosis of Alzheimer's disease, 100% were dependent for instrumental activities of daily living and 70% had some degree of dependence for basic activities of daily living. The mean score for the caregivers’ knowledge level was 15.0 (± 2.5) correct answers. Conclusions: The Brazilian Portuguese version was developed and the final version is suitable for use in Brazil.

Cognitive Domains and Health-Related Quality of Life in Alzheimer's Disease

OBJECTIVES

The nature of the association between the cognitive decline and quality of life (QoL) during the course of Alzheimer's disease (AD) has not been studied in detail. We designed this study to determine if the association between cognitive domains in AD and health-related quality of life (HRQoL) changed over 18 months.

METHODS

We recruited 80 community-dwelling older adults with mild to moderate AD and 61 healthy elderly controls as well as their next-of-kin. The primary outcome measure was the QoL-AD. Specific cognitive functions were assessed with a broad range of neuropsychological measures, which were later grouped into cognitive domains following factor analyses at the baseline and 18-month assessments. Other explanatory variables included demographics, psychopathology, burden of care, and use of medication.

RESULTS

Self-reported QoL-AD scores were not associated with any of the identified cognitive domains at either assessment. The cognitive domains of people with AD changed between baseline and the 18-month assessment, as did the association of these factors with carer-rated HRQoL. The HRQoL scores assigned by the next-of-kin declined alongside a general measure of cognitive function.

DISCUSSION

These results indicate that HRQoL is not consistently associated with specific cognitive domains in AD and that cognitive-enhancing focused therapies may fail to affect the HRQoL of people with AD.