Development of an international schedule for the assessment and staging of care for dementia

Introduction to living with advanced dementia series

This is the introductory article in a six-part series in Nursing Older People exploring the nursing care of people living with advanced dementia. It discusses the complex and progressive array of nursing required to meet the needs of individuals, the provision of personal care, learning and leadership, meaningful activity, and palliative and end of life care. A main theme of the series is the exceptional nursing skills and knowledge required to deliver evidence-informed care with compassion and respect for people living with advanced dementia. This introductory article provides background information to contextualise advanced dementia and identify the main challenges facing nurses, nurse educators and nurse leaders.

What is new within staging of care for people with dementia? The IDEAL schedule and other recent work

PURPOSE OF REVIEW

This review provides an overview of recent progress within work centred around the 'International schedule for the integrated assessment and staging of care for dementia' (IDEAL schedule), and places it within the context of recent work around other staging models for dementia.

RECENT FINDINGS

The IDEAL schedule assesses the severity of dementia across seven dimensions. A 'Menu of care options' of recommended priorities for interventions accompanies the schedule. A user manual for the schedule has just been published. Other staging models for dementia include those based on biomarkers, such as in the recently published research framework for Alzheimer's disease by the National Institute on Aging and Alzheimer's Association (NIA-AA), or those based on specific aspects of dementia, principally cognitive impairment.

SUMMARY

The IDEAL schedule is a global staging model to guide the organization of dementia care. The schedule covers a range of domains that extend beyond cognitive functioning and include care needs; it is applicable to all types and stages of dementia; and can be used by any healthcare professional, both within clinical practice and research. The schedule is not in opposition to, or is even complementary to, other staging models for dementia.

Reliability and validity of the Spanish version of the IDEAL Schedule for assessing care needs in dementia: Cross-sectional, multicenter study

OBJECTIVE

The IDEAL Schedule was developed for staging "care needs" in patients with dementia. We here aim to validate the Spanish version, further test its psychometric properties and explore a latent construct for "care needs".

METHODS

A multicenter study was done in 8 dementia care facilities across Spain. Patients referred with a reliable ICD-10 diagnosis of dementia (n = 151) were assessed with the IDEAL Schedule by pairs of raters. Inter-rater reliability (intra-class correlation [ICC] coefficients), internal consistency (Cronbach's alpha), and factor analysis were calculated. Convergent validity for individual items was tested against validated Spanish versions of international instruments.

RESULTS

Pilot testing with numerical scales supported the feasibility, face, and content validity of the schedule. The psychometric coefficients were good/clinically acceptable: inter-rater reliability (mean ICC = 0.861; 85% of the ICCs > 0.8), internal consistency (global alpha coefficient = 0.74 in 5 nuclear items), and concurrent validity (global score against the Clinical Dementia Rating schedule, r = 0.63; coefficients for individual items ranging from 0.40 to 0.84, all statistically significant, p < 0.05). Internal consistency was low for the "nonprofessional care" and "social support" dimensions. Factor analysis supported a unidimensional solution, suggesting a latent "care needs" construct.

CONCLUSION

The Spanish version of the IDEAL Schedule confirms the main psychometric properties of the original version and documents for the first time the convergent validity of individual items. Factor analysis identified a latent construct consistent with the concept "care needs" although 2 dimensions need further psychometric research.

Reliability and validity of the international dementia alliance schedule for the assessment and staging of care in China

BACKGROUND

Clinical and social services both are important for dementia care. The International Dementia Alliance (IDEAL) Schedule for the Assessment and Staging of Care was developed to guide clinical and social care for dementia. Our study aimed to assess the validity and reliability of the IDEAL schedule in China.

METHODS

Two hundred eighty-two dementia patients and their caregivers were recruited from 15 hospitals in China. Each patient-caregiver dyad was assessed with the IDEAL schedule by a rater and an observer simultaneously. The Clinical Dementia Rating (CDR), Mini-Mental Status Examination (MMSE), and Caregiver Burden Inventory (CBI) were assessed for criterion validity. IDEAL repeated assessment was conducted 7-10 days after the initial interview for 62 dyads.

RESULTS

Two hundred seventy-seven patient-caregiver dyads completed the IDEAL assessment. Inter-rater reliability for the total score of the IDEAL schedule was 0.93 (95%CI = 0.92-0.95). The inter-class coefficient for the total score of IDEAL was 0.95 for the interviewers and 0.93 for the silent raters. The IDEAL total score correlated with the global CDR score (ρ = 0.72, p < 0.001), the CDR-sum of box (CDR-SOB, ρ = 0.74, p < 0.001), the total score of MMSE (ρ = -0.65, p < 0.001) and CBI (ρ = 0.70, p < 0.001). All item scores of the IDEAL schedule were associated with the CDR-SOB (ρ = 0.17 ~ 0.79, all p < 0.05).

CONCLUSION

The IDEAL schedule is a valid and reliable tool for the staging of care for dementia in the Chinese population.

Staging cognitive impairment and incidence of dementia

AIMS

In a background of interest in staging models in psychiatry, we tested the validity of a simple staging model of cognitive impairment to predict incident dementia.

METHOD

A large community sample of adults aged ≥55 years (N = 4803) was assessed in the baseline of a longitudinal, four-wave epidemiological enquiry. A two-phase assessment was implemented in each wave, and the instruments used included the Mini-Mental Status Examination (MMSE); the History and Aetiology Schedule and the Geriatric Mental State-AGECAT. For the standardised degree of cognitive impairment Perneczky et al's MMSE criteria were applied. A panel of psychiatrists diagnosed cases of dementia according to DSM-IV criteria, and cases and sub-cases of dementia were excluded for the follow-up waves. Competing risk regression models, adjusted by potential confounders, were used to test the hypothesised association between MMSE levels and dementia risk.

RESULTS

Out of the 4057 participants followed up, 607 (14.9%) were classified as 'normal' (no cognitive impairment), 2672 (65.8%) as 'questionable' cognitive impairment, 732 (18.0%) had 'mild' cognitive impairment, 38 (0.9%) had 'moderate' cognitive impairment and eight (0.2%) had 'severe' impairment. Cognitive impairment was associated with risk of dementia, the risk increasing in parallel with the level of impairment (hazard ratio: 2.72, 4.78 and 8.38 in the 'questionable', 'mild' and 'moderate' level of cognitive impairment, respectively).

CONCLUSIONS

The documented gradient of increased risk of dementia associated with the severity level of cognitive impairment supports the validity of the simple staging model based on the MMSE assessment.

The International Dementia Alliance Instrument for Feasible and Valid Staging of Individuals with Dementia by Informal Caregivers

OBJECTIVES

To assess the feasibility and validity of the International Dementia Alliance (IDEAL) instrument for Informal Caregivers (IDEAL-IC), which is based on the IDEAL instrument for professionals (IDEAL-P), for staging individuals with dementia.

DESIGN

Cross-sectional.

SETTING

Memory clinic of a university hospital.

PARTICIPANTS

Informal caregivers of 73 community-dwelling elderly adults referred to a memory clinic and six geriatric registrars.

MEASUREMENTS

Caregivers completed the IDEAL-IC; physicians completed the original IDEAL-P and the Clinical Dementia Rating sum of boxes (CDR-SB). Missing items and floor and ceiling effects were reviewed to assess feasibility. To test construct validity, a priori hypotheses were defined for expected correlations between IDEAL-IC, IDEAL-P, and CDR-SB scores.

RESULTS

Seventy-three IDEAL-IC instruments were completed, 86% of which had no missing items. Three percent of all 730 individual items were missing. No floor or ceiling effects were detected. CDR scores were 0 7%, 0.5 in 33%, 1 in 27%, 2 in 10%, and unknown in 23%. IDEAL-IC scores correlated highly with IDEAL-P scores (correlation coefficient (r) = 0.70) and with CDR-SB scores (r = 0.65) as expected; the difference between these two correlations was smaller than expected. Agreement between IDEAL-IC and IDEAL-P scores was 34% within a range of 1 point difference on 36-point scales, 57% within a range of two points, and 81% within a range of five points. Correlation between IDEAL-P and CDR-SB was very high (r = 0.85).

CONCLUSION

Results of this study indicate good feasibility and high validity of staging dementia by informal caregivers using the IDEAL-IC.

Reliability and Validity of the International Dementia Alliance Schedule for the Assessment and Staging of Care in Ireland

OBJECTIVE

To independently assess the inter-rater reliability of the International Dementia Alliance (IDEAL) schedule in Ireland and to examine criterion validity for cognitive functioning and caregiver distress.

METHODS

Two raters independently completed the IDEAL schedule based on an interview with persons diagnosed with dementia and their informal caregivers. The Clinical Dementia Rating (CDR) scale and the Zarit Burden Interview were used as reference standards for criterion validity. Intraclass coefficients (ICCs) and correlations (Spearman's ρ) were derived.

RESULTS

ICCs for the IDEAL subdomains ranged from 0.77 to 1.00, indicating robust agreement between raters. Strong correlations between the CDR and the IDEAL cognitive functioning domain (ρ = 0.82) and overall summary score (ρ = 0.77) were observed. The Zarit Burden Interview and the IDEAL carer distress subdomain were moderately correlated (ρ = 0.56).

CONCLUSION

This study confirmed that the IDEAL schedule is a valid and reliable instrument in the Irish population and further supports the international use of the IDEAL schedule.