Ist die Lebensqualität von Demenzpatienten messbar?

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.

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

The purpose of this study is to evaluate the health-related quality of life (HrQoL) of patients with Alzheimer's disease (AD) in different care settings (institutionalized versus community-dwelling) across all severity stages of dementia. Patients were consecutively recruited with their primary caregivers (123 inpatients and 272 outpatients), and the impact of patient-related parameters such as behavioral and psychological symptoms of dementia (BPSD) (Geriatric Depression Scale [GDS] and Neuropsychiatric Inventory [NPI]) and functional capacity (Alzheimer's Disease Cooperative Study-Activities of Daily Living [ADCS-ADL]) on HrQoL was analyzed. Patients' HrQoL was assessed using self-reported and caregiver-rated generic (EuroQoL Instrument) and dementia-specific (Quality of Life-Alzheimer's Disease [Qol-AD]) scales. Patients reported a considerably higher HrQoL than their caregivers on the QoL-AD, EQ-5D, and EQ VAS (p <  0.001). Different dementia severity groups showed significantly worse results in HrQoL for patients with lower MMSE scores. The mean self-reported QoL-AD decreased from 32.3±5.7 in the group with the highest MMSE scores to 27.1±5.5 in patients with the lowest MMSE scores (p <  0.001). A considerably lower HrQoL was shown for institutionalized patients versus participants in outpatient settings (proxy-rated QoL-AD 19.7±4.6 versus 26.0±7.1, p <  0.001). Depressive symptoms (GDS), BPSD (NPI), and reduced functional capacity (ADCS-ADL) were evaluated for their impact on patients' HrQoL. Multivariate models explained between 22% and 54% of the variance in patients' HrQoL. To analyze the causative direction of the reported associations, further longitudinal studies should be conducted.

Development and evaluation of a short version of the quality of life questionnaire for dementia

BACKGROUND

There are many quality of life (QOL) instruments for evaluating dementia patients. The QOL questionnaire for Dementia (QOL-D) is one of such instruments and a validated objective measure of QOL for patients with dementia. It comprises 31 items encompassing six domains. However, with 31 items, its length is a disadvantage. The purpose of this study was to develop a short version of QOL-D (short QOL-D).

METHODS

We used data from two studies. The participants were 264 inpatients with dementia in the first sample and 395 outpatients at a memory clinic in the second sample. We used maximum likelihood factor analysis with promax rotation to reduce the number of items.

RESULTS

We produced a nine-item version of QOL-D (short QOL-D) with positive (six items) and negative (three items) dimensions. The correlation coefficients of short and total versions of QOL-D were 0.892-0.918 for total scores, 0.903-0.936 for positive dimension scores, and 0.788-0.837 for negative dimension scores. Total short QOL-D scores showed a significant correlation to the Geriatric Depression Scale score and the apathy score of the Neuropsychiatric Inventory.

CONCLUSIONS

The short QOL-D produced results comparable with that of the full version. Reducing the number of items may make administration of the instrument easier.

Transitions between care settings in dementia: are they relevant in economic terms?

OBJECTIVES

This study was performed to assess the economic effect of interventions affecting transitions between dementia care settings in Germany.

METHODS

A Markov-model that models the course of dementia with respect to typical care setting transitions was derived. Model data and parameters were retrieved by literature reviews. A deterministic and probabilistic sensitivity analysis was conducted to account for parameter uncertainty.

RESULTS

In the base case, the expected present value of remaining lifetime costs is €25,326 for each cohort member. As a function of effectiveness, pharmaceutical interventions may reduce the costs by 2% to 13% and psychosocial interventions come with savings of 1% to 10%. A structural intervention-promoting group living as a substitute for nursing home care increases costs by 2% to 8%. Sensitivity analyses indicate high variance and variability of results, as well as valuation of informal care being a crucial parameter.

CONCLUSIONS

There are economic benefits of delayed transitions to institutional settings, especially from the viewpoint of statutory care insurances, but these do unlikely exceed intervention costs. Thus, further intervention effects should be considered. Ultimately, concentrating research on preventive and protective factors of dementia could lead to an efficient intervention from every perspective.

Subjective well-being in Swedish active seniors or seniors with cognitive complaints and its relation to commonly available biomarkers

Well-being (WB) is a complex variable in its relation to physical health and other personal and social characteristics. The aim was to study subjective well-being (SWB) and its possible associations with traditional biomarkers of cardiovascular risk or dementia, in Swedish seniors. SWB was estimated by the Psychological General Well-Being (PGWB) index in two study groups. The active seniors (AS) group consisted of community-dwelling elderly Swedes leading an active life (n=389). The DGM cohort (n=300) consisted of subjects referred to the Memory Unit at the Department of Geriatrics, the cognitive problems had to be subjective, mild or moderate (MMSE≥10). There were differences in all six subdimensions of SWB or distress, and in the sum of PGWB scores, between the two study groups (p<0.001 for all), and adjustment for differences in biomarkers of somatic health (age, sex, blood pressure, BMI, HDL cholesterol, ApoB/ApoA1 ratio, creatinine, and homocysteine) did not attenuate these differences. In addition, cognition as assessed by the Clock-Drawing Test (CDT) showed independent associations with four of the PGWB subdimensions and with the PGWB sum. Among the subjects in the DGM cohort, SWB was equally low among subjects with an MCI (minor cognitive impairment) diagnosis or without a dementia diagnosis as among subjects diagnosed with dementia disorder. We conclude that the nosological grouping variable (AS vs. DGM cohort) and a cognitive factor were the main independent predictors of SWB in this sample of elderly Swedes, whereas biomarkers of somatic health played a subordinated role.

Dementia quality of life instrument--construct and concurrent validity in patients with mild to moderate dementia

BACKGROUND AND PURPOSE

To translate the Dementia quality of life instrument (DQoL) into German and assess its construct and concurrent validity in community-dwelling people with mild to moderate dementia.

METHODS

Dementia quality of life instrument data of two pooled samples (n=287) were analysed regarding ceiling and floor effects, internal consistency, factor reliability and correlations with corresponding scales on quality of life (Quality of Life in Alzheimer's Disease and SF-12), cognition (Mini-Mental State Examination, Alzheimer's Disease Assessment Scale - cognitive), depression (Cornell Scale for Depression in Dementia) and activities of daily living (Interview of Deterioration in Daily Living Activities in Dementia).

RESULTS

We found no floor effects (<2%), minor ceiling effects (1-11%), moderate to good internal consistency (Cronbach's α: 0.6-0.8) and factor reliability (0.6-0.8), moderate correlations with self-rated scales of quality of life (Spearman coefficient: 0.3-0.6) and no or minor correlations with scores for cognition, depression or activities of daily living (r<0.3). The original five-factor model could not be confirmed.

CONCLUSION

The DQoL can be used in dementia research for assessing positive and negative affect, feelings of belonging and self-esteem. The findings suggest further research to improve the structure of the scales aesthetics, feelings of belonging and self-esteem.

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.