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.

Nelis S, Clare L. Dualities of dementia illness narratives and their role in a narrative economy

The concept of 'narrative economies' has recently been proposed as a set of exchange relationships that, through biography and story-telling, facilitate access to resources and act as a source of value. We utilise this concept to inform our analysis of 18 qualitative interviews with five people with dementia and four informal carers. Our participants are members of a pre-existing group of dementia advocates, representing the voices of those living with the condition. There are a growing number of people in the early stages of dementia - like our participants - being called upon to account for their experience, as a means of developing a politicised 'collective illness identity'. These interviews present an opportunity to study a group of people who are actively involved in speaking as, and for, people with dementia. Four themes emerged from the data: becoming a voice of or for people with dementia; biographical reinforcement; responsibilisation; and resistance. These themes illustrate the ways in which people with dementia participate in their own identity construction and, as representatives of those living with dementia, they also illustrate the ways in which illness narratives produce material and symbolic value.

Alternative metrics for assessing clinical benefit with immunotherapy in oncology

Therapies for cancer have traditionally been assessed with metrics such as the response rate, hazard ratio, or median survival. Such metrics have value in measuring the outcomes of conventional therapies, but may not be the most appropriate for new therapies. Immuno-oncology therapies offer a new approach to treating cancer by stimulating patients' immune systems to fight cancer. The value of these novel therapies has so far been assessed with traditional metrics, but the different ways in which immuno-oncology therapies work can mean the full value is not captured. Immuno-oncology therapies can produce longer survival times but this effect can be delayed or even preceded by an apparent phase of progression, which median survival or response rates may not reflect. This paper discusses a range of traditional and alternative metrics and their benefits or disadvantages in measuring the effects of immuno-oncology therapies, using examples of several novel drugs as case studies.

Socio-economic differentials in cannabis use trends in Australia

AIM

To test if the degree of change in cannabis use between 2001 and 2013 differed according to socio-economic status.

DESIGN

Repeated cross-sectional household surveys that were nationally representative.

SETTING

Australia.

PARTICIPANTS

Adult samples from the 2001 and 2013 National Drug Strategy Household Surveys (n = 23 642 in 2001 and n = 21 353 in 2013), the largest nationally representative survey on drug use in Australia.

MEASUREMENTS

Frequency of cannabis use coded as daily use, weekly use, less than weekly use and non-current use; socio-economic status (SES) as measured by personal income and educational level.

FINDING

There were significant differences in changes to levels of cannabis use between SES groups. Among participants who completed high school, the probability of daily use decreased from 0.014 to 0.009 (P < 0.001), and the probability of weekly use decreased from 0.025 to 0.017 (P < 0.001). These probabilities remained stable for participants who did not complete high school. The probability of weekly cannabis use decreased from 0.032 to 0.023 among participants with middle level income (P = 0.004), and from 0.021 to 0.013 among those with high income (P = 0.005). There were no significant changes in these probabilities among those with low income (0.026 in 2001 and 0.032 in 2013; P = 0.203).

CONCLUSION

The decline in cannabis use in Australia from 2001 to 2013 occurred largely among higher socio-economic status groups. For people with lower income and/or lower education, rates of frequent cannabis use remained unchanged.

Abstract P5-20-05: Impact of type of (neo)adjuvant systemic therapy (AdjTx) and total exposure to trastuzumab (TET) on long-term outcome of HER2-positive (HER2+) early stage breast cancer (ESBrCa)

Background

Trastuzumab (T) administered for 12 months (mos) as part of a taxane (Tax)– or Tax+anthracycline (Anthra)–based AdjTx is the standard of care as (neo)AdjTx of HER2+ ESBrCa. Several prospective randomized trials have investigated a shorter duration of Adj T (i.e. 9 weeks or 6 mos) compared to standard 12 mos of T. However, the results have not been conclusive so far. The impact of administering non-Tax/non-Anthra-based AdjTx and single-agent T on long-term outcome of HER2+ ESBrCa is not fully known.

Methods

We conducted a retrospective analysis on a prospectively maintained departmental database of all patients (pts) with Stage I-III HER2+ ESBrCa treated with at least one dose of (neo)Adj T. Pre-planned duration of T was 12 mos for all pts. TTE was defined as the interval in weeks between the first and the last dose of T. In order to ensure that most pts had a minimum FU of 3 yrs we included all pts who received 1st T before March 31st 2014. The database was locked for outcome analyses on March 31st 2017.

Results

506 pts treated between October 2001 and March 2014 were included in the study. Main pts characteristics: median age: 55 years (range: 26-85), oestrogen (ER) and/or progesterone (PR) receptors positive: 321 (63%), axillary lymph nodes positive: 266 (52%), Adj T: 386 (76%), neoAdj T: 120 (24%), Tax- and Tax/Anthra–based AdjTx: 457 (90%), non-Tax/non-Anthra AdjTx and single-agent T (without chemotherapy): 49 (10%). Median FU is 73.3 months (range: 1.4-176.3). In the overall population, DFS and OS rates are 83% and 91%, respectively. Pts treated with non-Tax/non-Anthra AdjTx had a significantly higher risk of BrCa relapse [DFS: HR 3.54 (95%CI:1.24 to 10.06, p=0.018)], and death [OS: HR 2.73 (95%CI:0.63 to 11.77 p=0.176)] compared to those treated with Tax–based AdjTx (e.g. TCH [docetaxel/carboplatin/T]). Pts who received single-agent T also had highly significantly worse DFS [HR 4.21 (95%CI:2.18 to 8.38, p&lt;0.0001)] and OS [HR 6.75 (95%CI:3.13 to 14.6 p=&lt;0.0001)] compared to those treated with Tax-based AdjTx. When adjusted for age (&lt;55 vs &gt;55 yrs), the detrimental impact of type of AdjTx remained highly statistically significant (p&lt;0.0001). Patients with TTE&lt;24 weeks had a highly significantly worse DFS [HR 4.7 (95%CI:2.34-9.47, p&lt;0.0001)] and OS [HR 5.36 (95%CI:2.39-12.01, p&lt;0.0001)] compared to pts with TTE&gt;24weeks. In most cases, shorter duration of T was due to reduction in LVEF or patients refusal. In the multivariate model, positive lymph nodes, type of (neo)AdjTx and TET (&lt;24 weeks vs &gt;24 weeks) remained all significant and independent variables associated with worse DFS and OS.

Conclusions

Our mature results indicate that the administration of non-Tax/non-Anthra-based AdjTx and single-agent T is associated with a significant increase in the risk of disease relapse and death and should not be considered as therapeutic options for pts with HER2+ ESBrCa. The administration of T for &lt;24weeks irrespective of the type of AdjTx is also associated with significantly worse outcome.

Citation Format: Gullo G, Walsh N, Fennelly D, Walshe J, O'Mahony K, Silva N, Ballot J, Calzaferri G, Quinn C, McDonnell D, Crown J. Impact of type of (neo)adjuvant systemic therapy (AdjTx) and total exposure to trastuzumab (TET) on long-term outcome of HER2-positive (HER2+) early stage breast cancer (ESBrCa) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-20-05.

Efficacy and outcomes of a mobile app targeting alcohol use in young people

Mobile apps provide a highly accessible way of reducing alcohol use in young people. This paper determines the 1-month efficacy and 2, 3 and 6month outcomes of the Ray's Night Out app, which aims to increase alcohol knowledge and reduce alcohol use in young people. User-experience design and agile development processes, informed by the Information-Motivation-Behavioral skills model and evidence-based motivational interviewing treatment approaches guided app development. A randomized controlled trial comparing immediate versus 1-month delayed access to the app was conducted in 197 young people (16 to 25years) who drank alcohol in the previous month. Participants were assessed at baseline, 1, 2, 3 and 6months. Alcohol knowledge, alcohol use and related harms and the severity of problematic drinking were assessed. App quality was evaluated after 1-month of app use. Participants in the immediate access group achieved a significantly greater increase in alcohol knowledge than the delayed access group at 1-month, but no differences in alcohol use or related problems were found. Both groups achieved significant reductions in the typical number of drinks on a drinking occasion over time. A reduction in maximum drinks consumed was also found at 1month. These reductions were most likely to occur in males and problem drinkers. Reductions in alcohol-related harm were also found. The app received a high mean quality (M=3.82/5, SD=0.51). The Ray app provides a youth-friendly and easily-accessible way of increasing young people's alcohol knowledge but further testing is required to determine its impact on alcohol use and related problems.

Free smoking cessation mobile apps available in Australia: a quality review and content analysis

OBJECTIVES

This review aimed to identify free, high-quality, smoking cessation mobile applications (apps) that adhere to Australian smoking cessation treatment guidelines.

METHODS

A systematic search of smoking cessation apps was conducted using Google. The technical quality of relevant apps was rated using the Mobile Application Rating Scale. The content of apps identified as high quality was assessed for adherence to smoking cessation treatment guidelines.

RESULTS

112 relevant apps were identified. The majority were of poor technical quality and only six 'high-quality' apps were identified. These apps adhered to Australian treatment guidelines in part. The efficacy of two apps had been previously evaluated.

CONCLUSIONS

In lieu of more substantial research in this area, it is suggested that the high-quality apps identified in this review may be more likely than other available apps to encourage smoking cessation. Implications for public health: Smoking cessation apps have the potential to address many barriers that prevent smoking cessation support being provided; however few high-quality smoking cessation apps are currently available in Australia, very few have been evaluated and the app market is extremely volatile. More research to evaluate smoking cessation apps, and sustained funding for evidence-based apps, is needed.

Illness representations in caregivers of people with dementia

OBJECTIVES

Illness representations shape responses to illness experienced by the self or by others. The illness representations held by family members of those with long-term conditions such as dementia influence their understanding of what is happening to the person and how they respond and provide support. The aim of this study is to explore components of illness representations (label, cause, control and timeline) in caregivers of people with dementia.

METHOD

This was an exploratory study; the data reported came from the Memory Impairment and Dementia Awareness Study (MIDAS). Data from semi-structured interviews with 50 caregivers of people with dementia were analysed using content analysis.

RESULTS

The majority of caregivers gave accounts that appeared to endorse a medical/diagnostic label, although many used different terms interchangeably. Caregivers differentiated between direct causes and contributory factors, but the predominant explanation was that dementia had a biological cause. Other perceived causes were hereditary factors, ageing, lifestyle, life events and environmental factors. A limited number of caregivers were able to identify things that people with dementia could do to help manage the condition, while others thought nothing could be done. There were varying views about the efficacy of medication. In terms of timeline, there was considerable uncertainty about how dementia would progress over time.

CONCLUSION

The extent of uncertainty about the cause, timeline and controllability of dementia indicated that caregivers need information on these areas. Tailored information and support taking account of caregivers' existing representations may be most beneficial.

Development and evaluation of an ultrasonic personal aerosol sampler

Assessing personal exposure to air pollution has long proven challenging due to technological limitations posed by the samplers themselves. Historically, wearable aerosol monitors have proven to be expensive, noisy, and burdensome. The objective of this work was to develop a new type of wearable monitor, an ultrasonic personal aerosol sampler (UPAS), to overcome many of the technological limitations in personal exposure assessment. The UPAS is a time-integrated monitor that features a novel micropump that is virtually silent during operation. A suite of onboard environmental sensors integrated with this pump measure and record mass airflow (0.5-3.0 L/min, accurate within 5%), temperature, pressure, relative humidity, light intensity, and acceleration. Rapid development of the UPAS was made possible through recent advances in low-cost electronics, open-source programming platforms, and additive manufacturing for rapid prototyping. Interchangeable cyclone inlets provided a close match to the EPA PM_2.5 mass criterion (within 5%) for device flows at either 1.0 or 2.0 L/min. Battery life varied from 23 to 45 hours depending on sample flow rate and selected filter media. Laboratory tests of the UPAS prototype demonstrate excellent agreement with equivalent federal reference method samplers for gravimetric analysis of PM_2.5 across a broad range of concentrations.

Abstract P1-05-18: Genomic copy number alterations (CNA) associated with pCR in HER2-positive (HER2+) early-stage breast cancer (BrCa) patients receiving neoadjuvant trastuzumab (T)

Introduction: Genetic alterations such as amplifications and deletions frequently contribute to tumorigenesis. These alterations can change gene expression which alters the normal cell growth and survival regulatory mechanisms. Characterisation of DNA copy number alterations (CNA) is important to understand cancer progression and response to therapy. The aim of this study is to determine patterns of CNAs in HER2+ early-stage BrCa patients achieving pathological complete response (pCR) to neoadjuvant T therapy.

Methods: Retrospective analysis of our database of 95 HER2+ BrCa (stages I-III) who received T neoadjuvantly revealed 46 % (44/95) achieved pCR compared with 53 % (51/95) who did not respond (NR). DNA from pre-treatment tumour biopsy specimens from neoadjuvant T therapy patients was extracted, and array-based comparative genomic hybridization (aCGH, n = 8; 6 pCR:2 NR) was used to identify CNAs, which correlated with pCR. Pathway analysis was then used to identify functionally relevant genes in aberrant regions.

Results: aCGH analysis of DNA from pCR and NR identified distinct patterns of CNAs. HER2 amplicon was confirmed by IHC and aCGH in all samples. Although there was no significant difference in the average CNAs between groups (20±17 vs 17±2), there was greater variation in the range of CNAs in pCR (8-56 CNA) compared to NR (15-19 CNA). More gains and amplifications were observed in pCR patients with more deletions in the NR group. The most common chromosomal amplification region included chr8q12.1-q24 with 87.5% of all cases displaying gains. Of the 6 patients who achieved pCR, 50% displayed a deletion in chr9 spanning p24.3-p21.3, consistent with a deletion of tumour suppressor CDKN2A. No aberrations in chr9 were observed in NR cohort. The deleted genomic region contained 65 common protein-coding genes, with the interferon biological pathway as the most significant (p=1.03E-36).

Conclusions: Distinct genomic CNAs were observed between patients achieving pCR compared to NR. However, of the 8 pts characterised here, none have relapsed. Follow-up data revealed a relapse rate of 6.8 % (3/44) vs 11.8 % (6/51) in the pCR and NR groups, respectively. To further elucidate the immunological response, we will present CNA data patterns on relapse and response and compare the impact of CNAs, immune-related proteins and pCR as surrogate predictors for outcome.

Citation Format: Walsh N, Gullo G, Maguire A, O'Donovan N, Quinn C, Crown J. Genomic copy number alterations (CNA) associated with pCR in HER2-positive (HER2+) early-stage breast cancer (BrCa) patients receiving neoadjuvant trastuzumab (T) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-18.

The reliability of the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) among dermatologists, rheumatologists and neurologists

BACKGROUND

Previous studies have shown that skin disease in dermatomyositis (DM) is best assessed using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). Although the CDASI has been validated for use by dermatologists, it has not been validated for use by other physicians such as rheumatologists and neurologists, who also manage patients with DM and assess skin activity in clinical trials.

OBJECTIVES

To assess the reliability of the CDASI among dermatologists, rheumatologists and neurologists.

METHODS

Fifteen patients with cutaneous DM were assessed using the CDASI and the Physician Global Assessment (PGA) by five dermatologists, five rheumatologists and five neurologists.

RESULTS

The mean CDASI activity scores for dermatologists, rheumatologists and neurologists were 21·0, 21·8 and 20·8, respectively. These mean scores were not different among the specialists. The CDASI damage score means for dermatologists, rheumatologists and neurologists were 5·3, 7·0 and 4·8, respectively. The mean scores between dermatologists and rheumatologists were significantly different, but the means between dermatologists and neurologists were not. The intraclass correlation coefficients (ICCs) for interrater reliability for CDASI activity and damage were good to excellent for dermatologists and rheumatologists, and moderate to excellent for neurologists. The ICCs for intrarater reliability for CDASI activity and damage were excellent for dermatologists and rheumatologists and moderate to excellent for neurologists. The PGA displayed lower interrater and intrarater reliability relative to the CDASI.

CONCLUSIONS

Our results confirm the reliability of the CDASI when used by dermatologists and rheumatologists. The data for its use by neurologists were not as robust.

"I Don't Think Of It As An Illness": Illness Representations in Mild to Moderate Dementia

The self-regulatory model proposes that illness representations influence adjustment and coping in chronic conditions. Better understanding of the illness representations held by people with dementia could help with targeting information and support so as to optimize adjustment and coping. In this mixed-methods study of illness representations among people with mild to moderate Alzheimer's, vascular, or mixed dementia we aimed to clarify the nature of the representations held, to determine whether specific profiles can be identified based on perceptions of the identity and cause of the condition, and to examine associations between these profiles and other participant characteristics. Data were collected in the second wave of the Memory Impairment and Dementia Awareness Study (MIDAS). Sixty-four people with dementia, who had been told their diagnosis at a memory clinic, completed interviews and responded to questionnaires. In each case a carer was also interviewed. Cluster analysis based on responses about identity and cause identified three profiles. 'Illness' cluster participants saw themselves as living with an illness and used diagnostic labels, 'ageing' cluster participants did not use diagnostic labels and viewed their difficulties as related to ageing, and 'no problem' cluster participants considered that they did not have any difficulties. 'Illness' cluster participants had better cognition and better awareness, but lower mood, and perceived more practical consequences, than 'ageing' cluster participants. Holding an 'illness' model may not be advantageous. Rather than encouraging adoption of such a model, it may be preferable to target information and select interventions in line with the person's representation profile.

Osteoporosis Assessment and Treatment in Older Patients who Have Sustained a Hip Fracture

Background and aims

Currently fracture sufferers are not being assessed or treated for osteoporosis. Osteoporosis guidelines differ in their secondary prevention recommendations, with the Scottish Intercollegiate Guideline Network (SIGN) advocating bone densitometry in all fracture patients and anti-resorptive treatment only if evidence-based criteria are confirmed, but the National Institute of Clinical Excellence (NICE) technology appraisal recommends treatment for all older females without this bone densitometry confirmation. We aimed to determine the rate of referral for bone densitometry, the numbers achieving SIGN criteria for anti-resorptive therapy, and the rate of osteoporosis treatment in patients with hip fracture

Methods

A retrospective review of all patients older than 65 years who had sustained a hip fracture in Tayside between April 2003 and July 2005 was performed

Results

Only 8.6% of hip fracture patients underwent bone densitometry, of which 90.6% of females older than 75 years met SIGN criteria for anti-resorptive treatment. 74.3% of all patients referred for bone densitometry were treated with an anti-resorptive agent, compared to only to 12.7% of the large majority group who were not assessed for osteoporosis

Conclusion

Osteoporosis investigation and therefore treatment remains sub-optimal in hip fracture patients. Almost all females, older than 75 years, with a hip fracture met evidence-based criteria for anti-resorptive treatment. NICE guidance, recommending anti-resorptive treatment without bone densitometry confirmation of reduced bone mineral density, should maybe be implemented for this specific group of patients in an attempt to increase osteoporosis treatment rates.