Health-Related Quality of Life in Patients with Alzheimer's Disease in Different German Health Care Settings

A national survey on health-related quality of life for people with dementia in residential long-term care institutions

BACKGROUND

Health-related quality of life (HRQoL) is an essential outcome parameter in geriatric research; however, the available evidence is mixed regarding the factors associated with HRQoL among people with dementia. We aimed to identify factors that contribute to HRQoL among people with dementia in residential long-term care (LTC) institutions.

METHODS

We randomly selected 299 of 1607 registered residential LTC institutions in Taiwan. A cross-sectional survey was conducted between 2019 and 2020, including items on demographic characteristics, comorbidities, the EuroQol-5 dimensions-5 levels (EQ-5D-5L; utility and visual analog scale [VAS] scores), the Mini-Mental State Examination (MMSE), the Clinical Dementia Rating (CDR), behavioral and psychological symptoms of dementia, activities of daily living (ADL), and instrumental ADL (IADL).

RESULTS

In total, 1313 people with dementia from 267 institutions were enrolled (mean age, 76.4 ± 12.7 years). The mean EQ-5D-5L utility and VAS scores were 0.10 (standard deviation [SD] = 0.48) and 66.57 (SD = 20.67), respectively. In multivariate linear regression analysis, higher scores for ADL, IADL, and CDR sum of boxes were associated with higher utility scores. Higher VAS scores were associated with higher ADL and MMSE scores. Lower utility scores and VAS scores were associated with more frequent depressive symptoms.

CONCLUSION

ADL, dementia severity, cognitive function, and depressive symptoms influenced the HRQoL of people with dementia in residential LTC institutions. Longitudinal studies should be conducted to better understand how HRQoL changes over time among people with disabilities.

Assessing Quality of Life, Economic Burden, and Independence Across the Alzheimer's Disease Continuum Using Patient-Caregiver Dyad Surveys

Background

Alzheimer's disease (AD) and mild cognitive impairment (MCI) have negative quality of life (QoL) and economic impacts on patients and their caregivers and may increase along the disease continuum from MCI to mild, moderate, and severe AD.

Objective

To assess how patient and caregiver QoL, indirect and intangible costs are associated with MCI and AD severity.

Methods

An on-line survey of physician-identified patient-caregiver dyads living in the United States was conducted from June-October 2022 and included questions to both patients and their caregivers. Dementia Quality of Life Proxy, the Care-related Quality of Life, Work Productivity and Activity Impairment, and Dependence scale were incorporated into the survey. Regression analyses investigated the association between disease severity and QoL and cost outcomes with adjustment for baseline characteristics.

Results

One-hundred patient-caregiver dyads were assessed with the survey (MCI, n = 27; mild AD, n = 27; moderate AD, n = 25; severe AD, n = 21). Decreased QoL was found with worsening severity in patients (p < 0.01) and in unpaid (informal) caregivers (n = 79; p = 0.02). Dependence increased with disease severity (p < 0.01). Advanced disease severity was associated with higher costs to employers (p = 0.04), but not with indirect costs to caregivers. Patient and unpaid caregiver intangible costs increased with disease severity (p < 0.01). A significant trend of higher summed costs (indirect costs to caregivers, costs to employers, intangible costs to patients and caregivers) in more severe AD was observed (p < 0.01).

Conclusions

Patient QoL and functional independence and unpaid caregiver QoL decrease as AD severity increases. Intangible costs to patients and summed costs increase with disease severity and are highest in severe AD.

Health-related quality of life in subjective cognitive decline and mild cognitive impairment: a longitudinal cohort analysis

BACKGROUND

Health-related quality of life (HR-QoL) is an important outcome for patients and crucial for demonstrating the value of new treatments. Health utility estimates in subjective cognitive decline (SCD) and mild cognitive impairment (MCI) are limited, especially in biomarker-confirmed populations. Besides, little is known about the longitudinal HR-QoL trajectory. This study aims to provide health utility estimates for SCD and MCI and investigate the QoL trajectory along the disease continuum.

METHODS

Longitudinal data from 919 SCD and 1336 MCI patients from the MEMENTO cohort were included. SCD was defined as clinical dementia rating (CDR) = 0, and MCI as CDR = 0.5. HR-QoL was measured using the EQ-5D-3L patient-reported instrument. Linear mixed-effect models (LMM) were used to assess the longitudinal change in HR-QoL and identify predictors of these changes.

RESULTS

Baseline health utilities were 0.84 ± 0.16 and 0.81 ± 0.18, and visual analogue scale (VAS) were 75.8 ± 14.82 and 70.26 ± 15.77 in SCD and MCI. In amyloid-confirmed cases, health utilities were 0.85 ± 0.14 and 0.86 ± 0.12 in amyloid-negative and amyloid-positive SCD, and 0.83 ± 0.17 and 0.84 ± 0.16 in amyloid-negative and amyloid-positive MCI. LMM revealed an annual decline in health utility of - 0.015 (SE = 0.006) and - 0.09 (SE = 0.04) in moderate and severe dementia (P < 0.05). There was a negative association between clinical stage and VAS where individuals with MCI, mild, moderate, and severe dementia were on average 1.695 (SE = 0.274), 4.401 (SE = 0.676), 4.999 (SE = 0.8), and 15.386 (SE = 3.142) VAS points lower than individuals with SCD (P < 0.001). Older age, female sex, higher body mass index, diabetes, cardiovascular history, depression, and functional impairment were associated with poor HR-QoL. Amyloid positivity was associated with an annual decline of - 0.011 (SE = 0.004, P < 0.05) health utility over time.

CONCLUSIONS

Health utility estimates from this study can be used in economic evaluations of interventions targeting SCD and MCI. Health utility declines over time in moderate and severe dementia, and VAS declines with advancing clinical stages. Amyloid-positive patients show a faster decline in health utility indicating the importance of considering biomarker status in HR-QoL assessments. Future research is needed to confirm the longitudinal relationship between amyloid status and HR-QoL and to examine the level at which depression and IADL contribute to HR-QoL decline in AD.

Convergent validity of EQ-5D with core outcomes in dementia: a systematic review

Objectives

To explore through a systematic review, the convergent validity of EQ-5D (EQ-5D-3L and EQ-5D-5L (total score and dimensions)) with core outcomes in dementia and investigate how this may be impacted by rater-type; with the aim of informing researchers when choosing measures to use in dementia trials.

Methods

To identify articles relevant to the convergent validity of EQ-5D with core dementia outcomes, three databases were electronically searched to September 2022. Studies were considered eligible for inclusion within the review if they included individual level data from people with dementia of any type, collected self and/or proxy reported EQ-5D and collected at least one core dementia outcome measure. Relevant data such as study sample size, stage of dementia and administration of EQ-5D was extracted, and a narrative synthesis was adopted.

Results

The search strategy retrieved 271 unique records, of which 30 met the inclusion criteria for the review. Twelve different core outcome measures were used to capture dementia outcomes: cognition, function, and behaviour/mood across the studies. Most studies used EQ-5D-3L (n = 27). Evidence related to the relationship between EQ-5D and measures of function and behaviour/mood was the most robust, with unanimous directions of associations, and more statistically significant findings. EQ-5D dimensions exhibited associations with corresponding clinical outcomes, whereby relationships were stronger with proxy-EQ-5D (than self-report).

Conclusion

Measuring health-rated quality of life in dementia populations is a complex issue, particularly when considering balancing the challenges associated with both self and proxy report. Published evidence indicates that EQ-5D shows evidence of convergent validity with the key dementia outcomes, therefore capturing these relevant dementia outcomes. The degree of associations with clinical measures was stronger when considering proxy-reported EQ-5D and differed by EQ-5D dimension type. This review has revealed that, despite the limited targeted psychometric evidence pool and reliance on clinical and observational studies, EQ-5D exhibits convergent validity with other dementia outcome measures.

Assessing the psychometric performance of EQ-5D-5L in dementia: a systematic review

BACKGROUND

EQ-5D is widely used for valuing changes in quality of life for economic evaluation of interventions for people with dementia. There are concerns about EQ-5D-3L in terms of content validity, poor inter-rater agreement and reliability in the presence of cognitive impairment, but there is also evidence to support its use with this population. An evidence gap remains regarding the psychometric properties of EQ-5D-5L.

OBJECTIVES

To report psychometric evidence around EQ-5D-5L in people with dementia.

METHODS

A systematic review identified primary studies reporting psychometric properties of EQ-5D-5L in people with dementia. Searches were completed up to November 2020. Study selection, data extraction and quality assessment were undertaken independently by at least 2 researchers.

RESULTS

Evidence was extracted from 20 articles from 14 unique studies covering a range of dementia severity. Evidence of known group validity from 5 of 7 studies indicated that EQ-5D-5L distinguishes severity of disease measured by cognitive impairment, depression, level of dependence and pain. Convergent validity (9 studies) showed statistically significant correlations of weak and moderate strengths, between EQ-5D-5L scores and scores on other key measures. Statistically significant change was observed in only one of 6 papers that allowed this property to be examined. All seven studies showed a lack of inter-rater reliability between self and proxy reports with the former reporting higher EQ-5D-5L scores than those provided by proxies. Five of ten studies found EQ-5D-5L to be acceptable, assessed by whether the measure could be completed by the PwD and/or by the amount of missing data. As dementia severity increased, the feasibility of self-completing EQ-5D-5L decreased. Three papers reported on ceiling effects, two found some evidence in support of ceiling effects, and one did not.

CONCLUSIONS

EQ-5D-5L seems to capture the health of people with dementia on the basis of known-group validity and convergent validity, but evidence is inconclusive regarding the responsiveness of EQ-5D-5L. As disease progresses, the ability to self-complete EQ-5D-5L is diminished.

Cost-effectiveness Analysis of Combined Physical and Cognitive Exercises Programs Designed for Preventing Dementia among Community-dwelling Healthy Young-old Adults

OBJECTIVE

This study aims to estimate the cost-effectiveness of combined physical and cognitive programs designed to prevent community-dwelling healthy young-old adults from developing dementia.

METHODS

The analysis was conducted from a public healthcare and long-term care payer's perspective. Quality-adjusted life years (QALYs) and expenses for health services and long-term care services were described in terms of effectiveness and cost, respectively. A thousand community-dwelling healthy adults aged 65 years were generated through simulation and analyzed. The incremental cost-effectiveness ratio (ICER) of adults with preventive program intervention compared to those with nonintervention was simulated with a 10-year cycle Markov model. The data sources for the parameters to build the Markov models were selected with priority given to higher levels of evidence. The threshold for assessing cost-effectiveness was set as less than 5,000,000 Japanese yen/QALY.

RESULTS

The ICER was estimated as -5,740,083 Japanese yen (US$-57,400)/QALY.

CONCLUSION

A program targeting community-dwelling healthy young-old adults could be cost-effective.

Support and Empowerment for Older Adult Spousal Caregiving of People with Mild and Moderate Dementia: A Participatory Action Research

Background: Little attention has been given to the older adult caregivers of spouses with mild and moderate dementia in the caring dynamics process. The aim of this action research was to develop a program for providing support and empowerment to older adult caregivers of spouses with mild and moderate dementia in the community. Methods: The researchers acted as facilitators, with a view to empowering participants. We recruited participants from a day-care center and two community service stations. Data were collected with semi-structured, in-depth interviews with 19 dementia care dyads and from the notes, reflections, and feedback of collaborative researchers. Relevant themes for content analysis were extracted. Results: Three action cycles were completed over 18 months. The results revealed goals of three cycles: to connect the home situation and effective dialogue as a bridge to the researcher, to confirm the daily needs or expectations of the caregiver and the patient, and to enhance the interactions and quality of life of family members with resources and network. This process was cyclical and repetitive, and it also generated partnerships that built relationships among the interdisciplinary team, families, and researchers. At the same time, team workers formed a cooperative and coordinated family service mechanism to reflect the professional values and practice capabilities. Conclusions: The intervention program was based on the promotion of factors for the caregiver, linking to environmental protective factors, and the stabilization of mental and neurological symptoms of dementia patients, thereby enhancing the response capabilities of home caregivers while meeting the patient’s care needs in life. It is a tool that can effectively be used for support and empowerment in this population.

Health-related quality of life of individuals sharing a household with persons with dementia

Introduction

Previous research has found a negative effect of dementia on the health-related quality of life (HrQoL) of persons with dementia (PWD) and their primary informal caregivers. However, the impact of dementia on HrQoL of other individuals sharing a household with PWD has not been investigated to date. The current study therefore aimed to determine differences in the HrQoL between those sharing a household with PWD and those not living with PWD. In addition, factors related to the HrQoL of those sharing a household with PWD were evaluated.

Methods

The analyses were based on data from the German Socio-Economic Panel, using the SF-12 to measure HrQoL. Mixed-effects models were calculated to compare the HrQoL of those sharing a household with PWD and persons not living with PWD, as well as to determine factors related to the HrQoL of those sharing a household with PWD. Bootstrapping was used where residuals were not normally distributed.

Results

Mixed-effect models showed a significantly lower HrQoL among those sharing a household with PWD, compared to those not living with PWD. Number of diseases, number of persons in the household, marital status and educational level were significantly related to HrQoL among those sharing a household with PWD.

Discussion

The HrQoL of those sharing a household with PWD was reduced compared to persons not living with PWD. Further, those living with PWD in small households, or those with multi-morbidities had a lower HrQoL. Further research focusing on HrQoL in the social environment of PWD is needed.

Impact of the Severity of Alzheimer's Disease on the Quality of Life, Activities of Daily Living, and Caregiving Costs for Institutionalized Patients on Anti-Alzheimer Medications in Japan

Background:

Alzheimer’s disease (AD) increases societal costs and decreases the activities of daily living (ADL) and quality of life (QoL) of the affected individuals.

Objective:

We assess the impact of AD severity on ADL, QoL, and caregiving costs in Japanese facilities for the elderly.

Methods:

Patients with AD in facilities for the elderly were included (47 facilities, N = 3,461). The QoL, ADL, and disease severity of patients were assessed using Barthel Index (BI), EuroQoL-5D-5L (EQ-5D-5L), and Mini-Mental State Examination (MMSE), respectively. Annual caregiving costs were estimated using patients’ claims data. The patients were subcategorized into the following three groups according to the MMSE score: mild (21≤MMSE≤30), moderate (11≤MMSE≤20), and severe (0≤MMSE≤10). Changes among the three groups were evaluated using the Jonckheere-Terpstra test.

Results:

Four hundred and one participants were on anti-AD medicines, of whom 287 (age: 86.1±6.4 years, 76.7% women) in the mild (n = 53, 84.0±6.9 years, 71.7%), moderate (n = 118, 86.6±5.9 years, 76.3%), and severe (n = 116, 86.6±6.5 years, 79.3%) groups completed the study questionnaires. The mean BI and EQ-5D-5L scores for each group were 83.6, 65.1, and 32.8 and 0.801, 0.662, and 0.436, respectively. The mean annual caregiving costs were 2.111, 2.470, and 2.809 million JPY, respectively. As AD worsened, the BI and EQ-5D-5L scores decreased and annual caregiving costs increased significantly.

Conclusion:

AD severity has an impact on QoL, ADL, and caregiving costs.

The impact of multimorbidity patterns on health-related quality of life in the general population: results of the Belgian Health Interview Survey

BACKGROUND

Chronic diseases and multimorbidity are a major cause of disease burden-for patients, caregivers, and society. Little is known however about potential interaction effects between specific disease combinations. Besides an additive effect, the presence of multiple conditions could also act synergistically or antagonistically regarding the impact on patients' health-related quality of life (HRQoL). The aim was to estimate the impact of coexisting chronic diseases on HRQoL of the adult general Belgian population.

METHODS

The Belgian Health Interview Survey 2018 provided data on self-reported chronic conditions and HRQoL (EQ-5D-5L) for a nationally representative sample. Linear mixed models were used to analyze two-way and three-way interactions of disease combinations on HRQoL.

RESULTS

Multimorbidity had a prevalence of 46.7% (≥ 2 conditions) and 29.7% (≥ 3 conditions). HRQoL decreased considerably with the presence of multiple chronic diseases. 14 out of 41 dyad combinations and 5 out of 13 triad combinations showed significant interactions, with a dominant presence of negative/synergistic effects. Positive/antagonistic effects were found in more subjective chronic diseases such as depression and chronic fatigue. Conditions appearing the most frequently in significant disease pair interactions were dorsopathies, respiratory diseases, and arthropathies.

CONCLUSIONS

Diverse multimorbidity patterns, both dyads and triads, were synergistically or antagonistically associated with lower HRQoL. Tackling the burden of multimorbidity is needed, especially because most disease combinations affect each other synergistically, resulting in a greater reduction in HRQoL. Further knowledge about those multimorbidity patterns with a greater impact on HRQoL is needed to better understand disease burden beyond mortality and morbidity data.

[The psychological process and its longitudinal of family caregivers involved in associations for families of dementia patients]

AIM

This study aimed to explore the psychological and dynamic process of modification and evaluate its time-series peculiarity in family caregivers involved in associations for the families of dementia patients.

METHODS

The current study included 39 family caregivers involved in two associations for the families of dementia patients. Five-year free group conversations in the family caregivers were recorded and converted into a verbatim record. The KJ method was then used to encode and group the verbatim record. After analyzing grouped terms and structuring the psychological and dynamic process of modification, time periods of the psychological status were determined based on the psychological process and the time-oriented perspective. The verbatim record extracted by the KJ method was analyzed by text-mining and a cluster analysis in order to assess validity of the psychological process and its time division. In addition, the appearance ratio of the texts extracted in each time period were analyzed to determine the longitudinal peculiarity in the psychological and dynamic process.

RESULTS

The psychological process of family caregivers was classified broadly into four components: (1) recognizing and identifying problems, (2) seeking help and dealing with problems, (3) remedying and evaluating problems, and (4) feeling effective and empowering oneself to overcome problems. The validity of the psychological process and its time division was supported by text-mining and a cluster analysis. The appearance ratio of the texts extracted in each time period was quasi-periodic and recursive rather than transient.

CONCLUSIONS

The psychological and dynamic process elucidated in the current study consists of four major components participants experience when involved in associations for the families of dementia patients. Although this process may not have originated in associations for the families of dementia patients, a quasi-periodic and recursive tendency in the appearance ratio of extracted texts is a notable feature. In dementia care, it is vital to foresee emerging challenges on a constant basis and attempt precedent, forecasting-type care. Being involved in associations for the families of dementia patients facilitates the administration of forecasting-type care.

Health utility in preclinical and prodromal Alzheimer's disease for establishing the value of new disease-modifying treatments-EQ-5D data from the Swedish BioFINDER study

Quality of life and health utility are important outcomes for patients with Alzheimer's disease (AD) and central for demonstrating the value of new treatments. Estimates in biomarker-confirmed AD populations are missing, potentially delaying payer approval of treatment. We examined whether health utility, assessed with the EuroQoL-5 3-level version (EQ-5D-3L), differed between individuals with a positive or negative amyloid beta (Aβ) biomarker in patients with mild cognitive impairment (MCI) and cognitively unimpaired (CU) participants from the Swedish BioFINDER study (n = 578). Participants with prodromal AD (Aβ-positive MCI) reported better health utility (n = 79, mean = 0.81, 95% confidence interval [CI] 0.77-0.85) than Aβ-negative MCI (mean = 0.71, 95% CI 0.64-0.78), but worse than controls (Aβ-negative CU, mean = 0.87, 95% CI 0.86-0.89). Health utility in preclinical AD (Aβ-positive CU; mean = 0.86, 95% CI 0.83-0.89) was similar to controls. This relatively good health utility in prodromal AD suggests a larger value of delaying progression to dementia than previously anticipated and a great value of delaying clinical progression in preclinical AD.

Tip of the Iceberg: Assessing the Global Socioeconomic Costs of Alzheimer's Disease and Related Dementias and Strategic Implications for Stakeholders

While it is generally understood that Alzheimer’s disease (AD) and related dementias (ADRD) is one of the costliest diseases to society, there is widespread concern that researchers and policymakers are not comprehensively capturing and describing the full scope and magnitude of the socioeconomic burden of ADRD. This review aimed to 1) catalogue the different types of AD-related socioeconomic costs described in the literature; 2) assess the challenges and gaps of existing approaches to measuring these costs; and 3) analyze and discuss the implications for stakeholders including policymakers, healthcare systems, associations, advocacy groups, clinicians, and researchers looking to improve the ability to generate reliable data that can guide evidence-based decision making. A centrally emergent theme from this review is that it is challenging to gauge the true value of policies, programs, or interventions in the ADRD arena given the long-term, progressive nature of the disease, its insidious socioeconomic impact beyond the patient and the formal healthcare system, and the complexities and current deficiencies (in measures and real-world data) in accurately calculating the full costs to society. There is therefore an urgent need for all stakeholders to establish a common understanding of the challenges in evaluating the full cost of ADRD and define approaches that allow us to measure these costs more accurately, with a view to prioritizing evidence-based solutions to mitigate this looming public health crisis.

Health-Related Quality of Life in Community-Dwelling Older People with Cognitive Impairment: EQ-5D-3L Measurement Properties

BACKGROUND

Assessing quality of life (QoL) in older people with cognitive impairment is a challenge. There is no consensus on the best tool, but a short, user-friendly scale is advised.

OBJECTIVE

This study aimed to assess the psychometric properties of the self-reported and generic EQ-5D (including the EQ index and EQ visual analog scale [VAS]) in community-dwelling older adults with cognitive impairment.

METHODS

Cross-sectional study analyzing the feasibility, acceptability, reliability, and validity of the EQ-5D based on 188 self-administered questionnaires in a sample of community-dwelling older adults with Mini-Mental State Examination (MMSE) scores of 10 to 24 points.

RESULTS

The EQ index was 0.69 (±0.27) and the EQ VAS was 63.8 (±28.54). Adequate measurement properties were found in acceptability and feasibility. Cronbach's alpha was 0.69. Good validity was observed in the correlation of each dimension of the EQ-5D with geriatric assessment scales. Higher validity was observed for the EQ index compared to the EQ VAS.

CONCLUSION

The EQ-5D scale could be a good tool for assessing health-related QoL in community-dwelling older adults with cognitive impairment, though it is necessary to assess the dimensions and the EQ index.

Association between periodontitis and Alzheimer's disease and its impact on the self-perceived oral health status: a case-control study

PURPOSE

To test the hypothesis that periodontitis is associated with AD and search whether periodontal and other variables would negatively impact the oral health-related quality of life (OHRQoL) perception.

MATERIALS AND METHODS

Oral examinations and interview on self-perceived oral health status (Geriatric Oral Health Assessment Index (GOHAI) questionnaire (higher score corresponds to better perceived oral status)) were carried out and socio-demographic data were collected from outpatients with mild to moderate AD (cases, n = 50) and from their age- and sex-matched family caregivers (controls, n = 52). Full-mouth periodontal examination was performed. Significance of differences between groups was sought by chi-square, Student's t, or the Mann-Whitney test. The association between the variables periodontitis, probing depth (PD) ≥ 5 mm, and clinical attachment loss (CAL) ≥ 5 mm with the variable group was tested in binary logistic regression models (LRMs). LRMs were used to test the association of oral findings, demographics, and group with GOHAI.

RESULTS

Cases had fewer teeth and greater CAL than controls. Cases had a superior percentage of sites with plaque, calculus, and bleeding on probing than controls. Cases had greater GOHAI scores than controls. Periodontitis was a variable most likely associated with AD (OR = 11.08, p < 0.001). None of the oral findings or demographics, but group, was associated with GOHAI (OR = 14.45, p < 0.001).

CONCLUSION

Periodontitis is associated with AD, but not with patients' OHRQoL.

CLINICAL RELEVANCE

Health care professionals must be aware that AD patients should have a periodic thorough oral examination and preventive intervention aiming at their welfare and maintenance of a pain-free functional dentition.

Determinants of self- and carer-rated quality of life and caregiver burden in Alzheimer disease

OBJECTIVE

We aimed to investigate factors associated with self- and carer-rated quality of life (QoL) and caregiver burden related to very mild to severe clinical Alzheimer disease (AD).

METHODS

One hundred patient-carer dyads were recruited, and assessments of relevant outcomes were performed, including sociodemographic characteristics, QoL, activities of daily living (ADL), cognitive performance, behavioural and psychological symptoms of dementia (BPSD), caregiver burden, and health resource utilisation.

RESULTS

There was a strong correlation between carer- and self-rated QoL, with patients consistently rating their QoL higher than caregivers. Duration of illness did not affect the QoL ratings. There was an inverse association between both self- and carer-rated QoL with age, age at symptom onset, impairment of ADL, time spent on assisting the patient, and depression. Both self- and carer-rated QoL ratings were higher if the caregiver was a spouse vs a child. Carer-rated QoL was inversely associated with severity of dementia, BPSD, caregiver burden, and requirement to supervise the patient. The variables age at symptom onset, ADL, and living together with the primary caregiver explained 34.50% of the variance in self-rated QoL, whereas age at symptom onset, ADL, and BPSD explained 48.20% of the variance in carer-rated QoL. For caregiver burden, 26% of the variance was explained by the variables ADL, living together with the primary caregiver, and agitation.

CONCLUSION

Our study highlights the need for a stronger focus on QoL in clinical AD research by providing further pieces of evidence on the key determinants, including the important aspect of caregiver burden.

Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018

OBJECTIVE

It is useful for reviewers of economic evaluations to assess quality in a manner that is consistent and comprehensive. Checklists can allow this, but there are concerns about their reliability and how they are used in practice. We aimed to describe how checklists have been used in systematic reviews of health economic evaluations.

METHODS

Meta-review with snowball sampling. We compiled a list of checklists for health economic evaluations and searched for the checklists' use in systematic reviews from January 2010 to February 2018. We extracted data regarding checklists used, stated checklist function, subject area, number of reviewers, and issues expressed about checklists.

RESULTS

We found 346 systematic reviews since 2010 that used checklists to assess economic evaluations. The most common checklist in use was developed in 1996 by Drummond and Jefferson, and the most common stated use of a checklist was quality assessment. Checklists and their use varied within subject areas; 223 reviews had more than one reviewer who used the checklist.

CONCLUSIONS

Use of checklists is inconsistent. Eighteen individual checklists have been used since 2010, many of which have been used in ways different from those originally intended, often without justification. Different systematic reviews in the same subject areas would benefit from using one checklist exclusively, using checklists as intended, and having 2 reviewers complete the checklist. This would increase the likelihood that results are transparent and comparable over time.

Prevalence of Depression, Anxiety and PTSD in People with Dementia: a Systematic Review and Meta-Analysis

There appears to be a link between depression/anxiety/PTSD and dementia, although the evidence is incomplete and the reason is unclear. Mental illness may cause dementia or may be prodromal or comorbid with dementia, or dementia may trigger a relapse of symptoms in individuals with a history of mental illness. This study examined the link between depression/anxiety/PTSD and dementia by evaluating the prevalence of these disorders in people with dementia, relative to their healthy peers. Existing meta-analyses have examined the prevalence of clinically-significant depression and anxiety in Alzheimer's disease (AD), and depression in frontotemporal dementia (FTD), but have not considered vascular dementia (VaD), dementia with Lewy bodies (DLB), PTSD, or anxiety in FTD. The current meta-analysis compared the prevalence of clinically-significant depression, anxiety and PTSD in the four most common types of dementia (AD, VaD, DLB, FTD) and in unspecified dementia to that of healthy controls (PROSPERO number: CRD42017082086). PubMed, EMBASE, PsycINFO and CINAHL database searches identified 120 eligible studies. Prevalence rates were calculated for depression and anxiety in AD, VaD, DLB, FTD, unspecified dementia, and controls. PTSD data were only available for unspecified dementia. Subgroup analyses indicated that depression, but not anxiety, was more prevalent in people with dementia compared to controls; however, the anxiety analyses were probably under-powered. The results support a link between depression and dementia; however, the link between anxiety or PTSD and dementia remains unclear due to insufficient data. Longitudinal data is now needed to clarify whether depression/anxiety/PTSD may be risk factors for dementia.

Comparing assessment of diabetes-related quality of life between patients and their physicians

Background

Health-related quality of life (QoL) is a comprehensive, multidimensional construct encompassing physical and psychosocial wellbeing. Physicians frequently assess QoL as part of their decision making process without specifically asking their patients. This study examined the degree and predictors of concordance between physician and patient assessments of QoL among patients with diabetes in primary care and in multi-disciplinary diabetes clinics.

Methods

Patients completed a questionnaire regarding overall and diabetes-specific QoL before entering their physician’s office. After the visit, the physician completed the same questionnaire in order to evaluate how he/she perceived that patient’s QoL. In addition, medical data relating to the patient’s health status were collected from the medical records. The concordance between patient-reported QoL and physician-estimated QoL was evaluated. Stepwise regression analysis was conducted to determine which factors contributed to the difference between physicians’ and patients’ assessment of QoL.

Results

A total of 136 patients and 39 treating physicians were surveyed. Patients’ response rate was 95%. A strong concordance was found between patients’ and physicians’ ratings of current health status (r = 0.79, p < 0. 01); however, physicians perceived their patients’ QoL as worse than the QoL assessed by the patients themselves. Primary care physicians were better at assessing their patients’ overall wellbeing while diabetes-specialists were better at assessing their patients’ diabetes-specific QoL. In addition, the longer the duration of diabetes, the more difficult is was for the physicians to accurately assess QoL. When entered in the regression analysis, familiarity did not explain physicians’ ability to assess health-related QoL or diabetes-specific QoL.

Conclusions

Physicians make reasonable assessments of their patients’ QoL, however as the patients’ disease progresses, it becomes harder for physicians to assess QoL. Primary care physicians are better at assessing overall well-being whereas diabetes specialists are better at assessing diabetes-specific QoL.

Trial registration number

Not registered. Assuta Medical Center institutional review board approval number 2009103.

Effect of passive finger exercises on grip strength and the ability to perform activities of daily living for older people with dementia: a 12-week randomized controlled trial

Background

Dementia adds burden to society. As it is not curable, physical exercise activities are optimal to improve the physical strength and quality-of-life of people with dementia.

Aim

Design, implementation, and examination of a set of passive finger exercises and their effects on improving grip strength and activities of daily living (ADL) for older people with dementia.

Methods

Forty older people with dementia were recruited and randomly allocated into an experimental group and a control group, each with 20 people. The control group received routine nursing care. In addition to this, the experimental group received 25-minutes of passive finger exercises every day for 12 weeks. The health outcomes measured were grip strength and ADL, before and after the intervention. Grip strength was assessed by electrical hand muscle dynamometer. ADL were assessed with Barthel index.

Results

Although there was no effect on grip strength, passive finger exercises led to significant improvements in urinary control, defecation function, and overall ADL in comparison with the control group.

Implications for practice

Passive finger exercises can be integrated into physical exercise programs for older people with dementia to improve their urinary control, defecation function, and ADL.

Differences between patient- and proxy-reported HRQoL using the Wound-QoL

The purpose of this study was to examine the patient- and proxy-report agreement on the Wound-quality of life (QoL) questionnaire to assess health-related QoL in patients with chronic wounds. Patients and their proxies (in this case, relatives) were recruited via different nursing services in Germany and asked to complete the Wound-QoL. Intraclass correlation coefficients were calculated for each Wound-QoL scale and the total score, and weighted Cohen's Kappa coefficients for individual items. Proxies tended to report lower health-related QoL in the Wound-QoL than their relatives with chronic wounds. Agreement between the two perspectives was moderate on single-item level and excellent on scale level. Proxy-reports can be helpful, if patients are unable to provide information, although caution remains when interpreting the results. However, the patient's own perspective remains preferable.

Antipsychotic treatment of community-dwelling and institutionalised patients with dementia in Germany

OBJECTIVE

A restrictive use of antipsychotic drugs in patients with Alzheimer's disease (AD) is recommended due to an increased risk of cerebrovascular events and mortality. We hypothesise that the prescription of antipsychotics is associated with the patients' socio-demographic and clinical status (e.g., dementia severity).

METHODS

The prescription of antipsychotics was cross-sectionally evaluated in 272 community-dwelling and 123 institutionalised patients with AD across all severity stages of dementia. The patients' clinical characteristics covered the cognitive status, neuropsychiatric symptoms, daily activities, and quality of life (HrQoL). To determine associations with the use of antipsychotics bivariate and logistic regression analyses were conducted.

RESULTS

Totally, 25% of the patients were treated with antipsychotics. significantly less frequently than nursing home inhabitants (15.1% vs. 45.5%). Severely demented patients (MMSE 0-9) received antipsychotics most often (51.5%). Additionally, multiple regression analyses revealed a higher chance of prescription for participants with depressive symptoms (OR 2.3, 95% CI: 1.019-5.160) and those treated by neuropsychiatric specialists (OR 3.4, 95% CI: 1.408-8.328).

CONCLUSIONS

Further longitudinal studies are required to assess the appropriateness of indications for antipsychotics and the reasons for a higher use in nursing home inhabitants and patients with severe dementia and depression.

Alzheimer's disease severity and its association with patient and caregiver quality of life in Japan: results of a community-based survey

BACKGROUND

Alzheimer's disease (AD) dementia, a progressive neurodegenerative disease, exerts significant burden upon patients, caregivers, and healthcare systems globally. The current study investigated the associations between AD dementia patient disease severity and health-related quality of life (HRQoL) of both patients (proxy report) and their caregivers living in Japan, as well as caregiving-related comorbidities such as depression.

METHODS

This cross-sectional study used self-reported data from caregivers of people diagnosed with AD dementia by a healthcare provider in Japan. Caregivers were identified via online panels and invited to participate in an online survey between 2014 and 2015. Caregivers completed survey items for themselves, in addition to providing proxy measures for patients with AD dementia for whom they were caring. Patient and caregiver HRQoL was measured using the EuroQoL 5-Dimension (EQ-5D). Additional outcomes for caregivers of AD dementia patients included the Patient Health Questionnaire (PHQ-9) of depressive symptomology, as well as comorbidities experienced since initiating caregiving for their AD dementia patients. These outcomes were examined as a function of AD dementia severity, as measured by long-term care insurance (LTCI) categories. Bivariate analyses between LTCI and outcomes were conducted using independent t-tests and chi-square tests. Multivariable analyses, controlling for potential confounders, were conducted using generalized linear models (GLMs) specifying a normal distribution.

RESULTS

Across 300 caregiver respondents, multivariable results revealed that increasing AD dementia severity was significantly associated with poorer patient and caregiver EQ-5D scores and a high proportion of caregivers (30.0%) reported PHQ-9 scores indicative of major depressive disorder (MDD). The most frequent comorbidities experienced after becoming caregivers of AD dementia patients included hypertension (12.7%) and insomnia (11.0%). Depression and other comorbidities did not differ significantly by patient severity.

CONCLUSIONS

The current study provides unique insight into the specific degree of incremental burden associated with increasing AD dementia severity among patients and caregivers alike. Importantly, greater disease severity was associated with poorer quality of life among both patients and caregivers. These results suggest that earlier detection and treatment of AD dementia may provide an opportunity to reduce the burden of disease for patients, caregivers, and society at large.

Activities of Daily Living Assessment among Nursing Home Residents with Advanced Dementia: Psychometric Reevaluation of the Bristol Activities of Daily Living Scale

The purpose of this study was to conduct psychometric reevaluation of the Bristol Activities of Daily Living Scale (BADL) among a population logistically difficult to observe beyond cross-sectional analysis: nursing home residents with advanced dementia (AD). Data from observation-based measures were collected by nursing home staff at two intervals within a three-month time frame among 43 residents identified with AD via medical records and nursing home staff. Three broad properties of BADL were examined: factor structure, reliability, and validity. Principal components analysis determined underlying components. BADL internal consistency was assessed by Cronbach's and Guttman coefficients; test-retest reliability was also observed. Convergent validity was assessed by correlating BADL with theoretically linked measures of quality of life (QOL) and social engagement. Compared with the original evaluation, BADL showed inconsistent factor structure at interval 1 but comparable at interval 2. Reliability coefficients at both intervals were robust and comparable to the original evaluation. BADL demonstrated significant convergence with QOL and social engagement. Psychometric potency of BADL was confirmed, suggesting practice applicability with this AD population. Future research calls for further examination of tools to guide effective interventions with this vulnerable population.

Reliability and structural validity of the Chinese version of the Neuropsychiatric Inventory, Nursing Home version

BACKGROUND

With the increasing number of dementia patients in China, there is a pressing need for a reliable and valid Chinese instrument that can measure neuropsychiatric symptoms in institutionalized dementia patients. This study examined the reliability and structural validity of the Chinese version of the Neuropsychiatric Inventory, Nursing Home version (NPI-NH), in a sample of institutionalized dementia patients in China.

METHODS

A total of 112 residents with dementia (Clinical Dementia Rating = 1: 10.7%; Clinical Dementia Rating = 2: 39.3%; Clinical Dementia Rating = 3: 50.0%) and 30 informants participated in this cross-sectional study. Reliability was tested using Cronbach's α and intra-class correlation coefficient. Principal component analysis was used to evaluate the factor structure of the inventory.

RESULTS

Of the patients, 92.9% had at least one neuropsychiatric symptom. Apathy (57%) was the most common symptom. The Chinese version of the Neuropsychiatric Inventory, Nursing Home version, showed acceptable internal consistency (Cronbach's α for the total scale, frequency, severity, and disturbance subscales were 0.64, 0.70, 0.73, and 0.80, respectively) and test-retest reliability (intra-class correlation coefficient for the total scale, frequency, severity, and disturbance subscales were 0.93, 0.92, 0.89, and 0.91, respectively). Five factors-psychomotor behaviour, affective symptoms, psychosis, sleep disorders, and eating disorders-were identified for the total scale. The cluster symptoms aggression and irritability, depression and anxiety, and delusions and hallucinations were three of the optimally stable groups of symptoms.

CONCLUSIONS

This study demonstrated that the Chinese version of the Neuropsychiatric Inventory, Nursing Home version, is a valid and reliable instrument for evaluating neuropsychiatric symptoms in institutionalized dementia patients.

The relationship between cognition and depressive symptoms, and factors modifying this association, in Alzheimer's disease: A multivariate multilevel model

OBJECTIVES

To examine whether there was a bidirectional association between cognition and depressive symptoms in Alzheimer's disease (AD), and to explore the role of socio-demographic factors and daily performance in this association.

METHODS

We conducted a longitudinal study of 104 community-dwelling patients with confirmed AD from Taiyuan, China. We assessed cognition and depressive symptoms (dependent variables) with the Montreal Cognitive Assessment (MoCA) and the Geriatric Depression Scale-30 (GDS-30), respectively. Socio-demographic information and daily performance were treated as explanatory variables. A multivariate multilevel model was built to investigate the interrelationship between patients' cognition and depression, as well as the effect of related factors on both outcomes.

RESULTS

MoCA scores were negatively correlated with GDS-30 both at the subject level (correlation coefficient r₃=-0.68, χ²=19.26, P<0.001) and time point level (r₂=-0.35, χ²=35.68, P<0.001) in patients with AD. Multivariate analysis showed several significant factors for cognitive function, including educational level, personality, hobbies, exercise, reading, aluminum utensil use, dietary restriction and hypertension (regression coefficients: 0.60, 0.52, 0.51, 0.48, 0.45, -0.48, 0.67, and -0.74, respectively). Significant factors for depressive symptoms included family status, employment before retirement, homemaking, reading, aluminum utensil use, dietary restriction, and hypertension (regression coefficients: 3.09, -1.33, -1.62, -1.31, 0.96, -1.15, and 1.14, respectively).

CONCLUSION

These findings indicated that cognition was negatively associated with depression in patients with AD, and both were influenced by reading, aluminum utensil use, dietary restriction, and hypertension. Considering patient factors may help to slow the progression of dementia.