Achieving consensus on assessing health-related quality of life (HRQoL) in people with cognitive impairments (CI)a Delphi study

BACKGROUND

The prevalence of impairments of cognitive functions is expected to increase. Enhancing the QoL of those affected is important. HRQoL in people with CI can be assessed by self-report, proxy-report or observation but there is uncertainty how to best assess HRQoL in people with CI, and which assessment method is most appropriate. Therefore the aim of our study was to use Delphi methodology in order to achieve consensus on how HRQoL should be assessed in people with CI and which content domains should be assessed.

METHODS

The Delphi process consisted of three online survey rounds and a concluding consensus conference. Participants were experts as well as individuals and relatives of people affected by CI. The Delphi survey was developed based on existing literature and included 55 statements at the first round. Consensus was considered to be achieved when a minimum of 75 % of responses fell into the categories 6 (agree) and 7 (strongly agree) (positive consensus) or in categories 1 (strongly disagree) and 2 (disagree) (negative consensus).

RESULTS

Consensus was reached for a total of 41 of 56 statements/substatements. In the 1st survey round 102 experts and 11 relatives participated. In the 2nd survey round 68 experts and 11 relatives continued to participate. In the 3rd survey round 41 experts and 9 relatives participated. In the consensus conference 17 experts and 4 relatives of individuals with CI and in the second one-hour online conference session 14 experts and 2 relatives of individuals with CI participated.

CONCLUSION

The combination of the three assessment methods self-report, proxy-report and observation across all stages of CI is the preferred method and should be used whenever possible. As domains Physical capacity, Psychological, Level of Independence, Social Relationships, Environment and Spirituality/Relogion/Personal Beliefs should be assessed.

Telephone-based aftercare groups for family carers of people with dementia - results of a mixed-methods process evaluation of a randomized controlled trial

BACKGROUND

Caring for a relative with dementia can be demanding and time-consuming. It is not uncommon for them to be overburdened and overworked, which can lead to symptoms of depression or anxiety disorders in 2/3 of cases. One possibility for treating family carers who have these issues is special medical rehabilitation (rehab). However, studies have shown that while such rehab is effective, it is not sustainable. To increase the sustainability of rehab for this target group, structured telephone-based aftercare groups were implemented in the present study. A process evaluation was conducted focusing on the acceptability of the aftercare programme and its perceived benefits by the participating family carers and group moderators.

METHODS

The process evaluation was embedded in a longitudinal randomized controlled trial and followed a mixed methods approach. Quantitative process data were collected using protocols and structured brief evaluations regarding the telephone-based aftercare groups. To assess the acceptability of the aftercare groups as well as their subjective evaluation by the participants, qualitative process data were collected through two longitudinal telephone-based interviews with a subsample of family carers as well as a focus group interview with the group moderators.

RESULTS

Telephone-based aftercare groups provide acceptable and supportive experiences, and they are shown to be practicable. The content structure and the procedure of the group sessions could be easily implemented in everyday life after inpatient rehab. The topics addressed with each patient were met with a consistently positive response. Learning from the other group members and sharing a bond based on the experience of caring for a relative with dementia were evaluated as positive outcomes in the group. The universality of suffering as a central effective factor of group psychotherapy also played a decisive role in this telephone-based support group format for a shared bonding and strengthening experience in the groups and thus for their effectiveness.

CONCLUSION

Telephone-based aftercare groups for family carers of people with dementia are a useful and acceptable tool in the context of rehab aftercare. This location-independent aftercare programme could be adapted for other indications, focuses or topics in everyday care.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00013736, 14/05/2018.

Telephone-based aftercare groups for family carers of people with dementia - results of the effect evaluation of a randomised controlled trial

BACKGROUND

The care of people with dementia is associated with enormous stress and, in a quarter of cases, leads to depression and anxiety disorders in the caring relatives. A specially designed inpatient psychosomatic rehabilitation (rehab) programme for family carers of people with dementia has proven to be effective but not sustainable. Therefore, the present study aims to increase the sustainability of the inpatient rehab programme by using thematically structured telephone aftercare group sessions.

METHODS

The effectiveness of telephone aftercare groups was investigated in a randomized, controlled, prospective, mixed methods, longitudinal study. The aftercare intervention included social participation in monthly telephone group sessions for 6 months. The primary outcome was increased social participation of family carers, which, like the secondary outcomes (such as quality of life and subjective health), was assessed in written surveys at three or four measurement points.

RESULTS

Complete data from 69 participants from the intervention group and from 72 participants from the control group could be evaluated. A small-sized reduction in restrictions on social participation was observed in the intervention group, whereas the reduction in the control group was negligible. The repeated-measures analysis of variance (ANOVA) showed sustained effects on the secondary outcomes, such as depression, perceived social support, and the mental health domain of quality of life of family carers, in favour of the intervention group. The results also showed that telephone-based aftercare groups had a rather minor influence on the use of support services. Except for those from family, friends and neighbours, existing support offers were hardly used.

CONCLUSION

Telephone aftercare group sessions for carers of people with dementia were not able to increase social participation at the expected magnitude. Nevertheless, the clear effects on selected secondary health-related outcomes and the assessment of the telephone-based group sessions by the participants show that the caring relatives were able to benefit greatly from this aftercare measure. Family carers should be informed more extensively about the corresponding resources and encouraged to use them. Overall, this new aftercare concept can be recommended for implementation, and its use also seems to be target-oriented for other indications.

CLINICAL TRIAL REGISTRATION

German Clinical Trials Register: DRKS00013736 , 14/05/2018.

TALKING TIME: A pilot randomized controlled trial investigating social support for informal caregivers via the telephone

BACKGROUND

Caring for people with dementia at home requires considerable time, organization and commitment. Therefore, informal caregivers of people with dementia are often overburdened. This study examined the effects of the telephone-based Talking Time intervention, which is an approach used to strengthen the psychological health-related quality of life (HRQoL) and social support of informal caregivers of people with dementia living at home.

METHODS

This study was a Medical Research Council framework phase two randomized controlled trial. The intervention consisted of a preliminary talk, information booklet, six structured telephone-based support group meetings and a structured written self-evaluation of each support group meeting. The control participants performed their usual individual self-organized care. After completing the data collection, the control group received the Talking Time intervention for fidelity reasons. The primary outcome was the self-rated psychological HRQoL of the informal caregivers, which was measured with the mental component summary of the General Health Survey Questionnaire Short Form 12 (SF-12).

RESULTS

Thirty-eight informal caregivers and their relatives were included and allocated to the intervention or control groups (n = 19 each). After 3 months, the Talking Time intervention group demonstrated an increase in the self-rated psychological HRQoL scores, whereas the scores decreased in the control group. However, the standardized effect size of 1.65 (95% Confidence Interval, - 0.44 - 3.75) was not significant. Additionally, the secondary outcomes demonstrated no significant results. The differences between the groups in most outcomes were in the expected direction. No adverse effects were identified due to the intervention.

CONCLUSIONS

The Talking Time intervention is feasible and shows nonsignificant promising results with regard to the self-rated psychological HRQoL. After further adjustment, the intervention needs to be evaluated in a full trial.

TRIAL REGISTRATION

Clinical Trials: NCT02806583 , June 9, 2016 (retrospectively registered).

Telephone-based aftercare groups for family carers of people with dementia: study protocol of the Talking Time - REHAB project

Background

More than one million people in Germany live with dementia. Most of these people are cared for at home in the family setting. Supporting and caring for people with dementia is time-consuming, and family carers often have high stress levels and are at an increased risk of becoming physically and mentally ill. Medical rehabilitation (rehab) helps to relieve family carers and provide them with strategies to cope with stress. The aim of this study is to improve the sustainability of a multimodal rehab program for family carers of people with dementia. Research question: can the effects of this rehab be maintained through telephone-based aftercare groups following the rehab program?

Methods

A prospective randomized controlled longitudinal trial is performed. The intervention group (IG) participates in telephone-based aftercare groups; the control group (CG) receives treatment as usual. For evaluation, a mixed-methods approach is used. The effects of the intervention are quantitatively evaluated by written questionnaires at four measuring points (pre- and post-rehab, as well as 6 and 12 months after the end of rehab). Primary outcome: participation (IMET). Secondary outcomes: Depressive Mood State CES-D, General Complaints SCL-90-R, Subjective Quality of Life WHOQUOL-BREF, Social Support F-SozU, performance in different areas of life, single scales, and support offers (single items). The intervention process is evaluated through qualitative interviews and focus groups with regard to the acceptance of and satisfaction with the aftercare offered; in addition, a health economic evaluation is performed using the EQ-5D questionnaire. Rehabilitants are included in the study (N = 103 each in the IG and CG) who, accompanied by their family members with dementia, participate in the rehab measure in Ratzeburg. The IG participates monthly in 6 telephone aftercare groups over a period of 6 months. Typical stress situations are discussed and worked on.

Discussion

Upon successful evaluation, the offer to participate in telephone-based aftercare groups can be firmly established in the participating rehab clinic. Through minor adjustments, the offer would also be suitable for carers of physically ill people and for non-nursing-specific rehabilitation indications.

Trial registration

German Clinical Trials Register: DRKS00013736, May 14, 2018.

Individualized support for informal caregivers of people with dementia - effectiveness of the German adaptation of REACH II

Background

Individualized, outreach and structured multicomponent interventions are a promising intervention approach to relieve the burden of informal caregivers of people with dementia. In this study, we adapted and evaluated a multicomponent intervention (Resources for Enhancing Alzheimer’s Caregiver Health II, REACH II), which was developed in the USA, to the German health-care system. Therefore the project is called the German adaptation of REACH II (in German: Deutsche Adaptation der REACH II, DE-REACH).

Methods

The effectiveness of DE-REACH was examined in a randomized, controlled trial on 92 informal caregivers of people with dementia. The intervention comprised 12 individual two-weekly sessions (9 at home with the informal caregiver and 3 via telephone) and combined five modules. The reduction of the burden of the informal caregivers was chosen as the primary outcome.

Results

The results showed a great stabilizing effect of the intervention on caregiver burden (effect size d = 0.91), that is, comparing pre- and post-measurements the burden decreased very slightly in the intervention group whereas it increased very strongly in the control group. After a three-month follow-up period this effect decreased from a great to a moderate effect. There were also improvements as a result of the intervention in somatization, health-related psychological quality of life and the reaction of the informal caregivers in response to challenging behaviors of the relative with dementia. Moreover, the frequency of challenging behaviors of the affected person itself was reduced in favor of the intervention.

Conclusion

The findings of this study provide further evidence for the impact of multicomponent support interventions for informal caregivers of people with dementia.

Clinical trial registration

NCT01690117. Registered September 17, 2012.

Feasibility and effectiveness of a telephone-based social support intervention for informal caregivers of people with dementia: Study protocol of the TALKING TIME project

Background

Caring for people with dementia at home requires a significant amount of time, organization, and commitment. Therefore, informal caregivers, mainly relatives, of people with dementia often feel a high burden. Although on-site support groups are known to have positive effects on the subjective well-being (SWB) and perceived social support of informal caregivers, there are cases in which relatives have either no time or no opportunity to leave the person alone or in which there are no support groups nearby. The TALKING TIME project aims to close this supply gap by providing structured telephone-based support groups in Germany for the first time. International studies have shown benefits for informal caregivers.

Methods

The TALKING TIME study is a randomized controlled trial. The effects of the 3-month TALKING TIME intervention will be compared with those of a control group without intervention at two time points (baseline = T₀, after 3 months = T₁). The control group will receive the TALKING TIME intervention after T₁. With a planned sample size of 88 participants, the study is powered to detect an estimated effect size of 0.70 for psychological quality of life, considering an α of 0.05 (two-sided), a power of 80%. Caregivers are informal caregivers who are eligible if they are 18 years of age or older and have cared for a person with diagnosed dementia for at least four hours, four days per week, in the past six months. The exclusion criteria are psychiatric disorders of the informal caregiver. The primary outcome is the mental component summary of the SF-12 rated by informal caregivers. The secondary outcomes for informal caregivers are the physical component summary of the SF-12, the Perceived Social Support Caregiver Scale (SSCS) score, and the Caregiver Reaction Scale (CRS) score. The secondary outcome for care recipients is the Neuropsychiatric Inventory (NPI-Q). For the process evaluation, different quantitative and qualitative data sources will be collected to address reach, fidelity, dosage and context.

Discussion

The results will provide further information on the effectiveness and optimization of telephone-based support groups for informal caregivers of people with dementia, which can help guide the further development of effective telephone-based social support group interventions.

Trial registration

Clinical Trials: NCT02806583, June 9, 2016

German adaptation of the Resources for Enhancing Alzheimer's Caregiver Health II: study protocol of a single-centred, randomised controlled trial

Background

Caring for a family member with dementia is extremely stressful, and contributes to psychiatric and physical illness among caregivers. Therefore, a comprehensive programme called Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II) was developed in the United States to enhance the health of Alzheimer’s caregivers. REACH II causes a clear reduction of the stress and burdens faced by informal caregivers at home. The aim of this protocol is to adapt, apply, and evaluate this proven intervention programme in a German-speaking area for the first time. This newly adapted intervention is called Deutsche Adaption der Resources for Enhancing Alzheimer’s Caregiver Health (DeREACH).

Methods

A total of 138 informal caregivers at home are recruited in a single-centred, randomised controlled trial. The intervention (DeREACH) consists of nine home visits and three telephone contacts over six months, all of which focus on safety, psychological well-being and self-care, social support, problem behaviour and preventive health-related behaviours. A complex intervention assessment on effectiveness will be adopted when the primary outcome – namely, the reduction of caregiver burden – and other secondary outcomes, including changes with regard to anxiety and depression, somatisation, health-related quality of life, and perceived social support, are measured at baseline, as well as immediately and three months after the intervention. The change from baseline to post-intervention assessment with regard to the primary outcome will be compared between treatment and control group using t-tests for independent samples.

Discussion

It is anticipated that this study will show that DeREACH effectively reduces caregiver burden and therefore works under the conditions of a local German health-care system. If successful, this programme will provide an effective intervention programme in the German-speaking area to identify and develop the personal capabilities of informal caregivers to cope with the burdens of caring for people with dementia.

Trial registration

NCT01690117

Is the MWT-A Suitable for the Estimation of Premorbid Intelligence Level?

Vocabulary tests have long been used for estimating premorbid intelligence level in the neuropsychological assessment of dementia. However, doubts exist about the validity of such intelligence tests. The present study examines whether the Multiple-Choice Vocabulary Test – Version A (Mehrfachwahl-Wortschatz-Test – Version A, MWT-A) is valid for assessing premorbid intelligence level. Data from a total of 821 patients in a specialized outpatient clinic for dementia (memory clinic), covering the whole spectrum of cognitive impairment, were evaluated using analysis of variance with the dependent variable premorbid intelligence level (MWT-A) and the independent variable extent of global cognitive impairment (Mini-Mental-State Examination, MMSE: mean = 25.2, SD = 3.9). The latter was divided into six MMSE ranges or groups, respectively (29–30, 28–28, 27–27, 25–26, 22–24, 05–21). In the case of a pathologically relevant global cognitive impairment (24–26 MMSE points), the MWT-A underestimates the premorbid intelligence level. This effect is moderated neither by age nor education. Results indicate that the MWT-A is unsuitable for estimating premorbid intelligence level in neuropsychological assessments of cognitively impaired patients or demented patients.

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.

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.