Das Heidelberger Instrument zur Erfassung von Lebensqualität bei Demenz (H.I. L.DE.)

Study protocol: randomized controlled trial of an individualized music intervention for people with dementia in the home care setting

BACKGROUND

Studies suggest that individualized music listening is an effective, non-pharmacological intervention for improving the quality of life of people with dementia in the institutional care setting. Noting that most people with dementia live at home, we conduct a randomized controlled trial to assess the feasibility and effectiveness of an app-based individualized music listening intervention for people with dementia in the home care setting. The intervention is delivered by family caregivers.

METHODS

We will recruit N = 130 dyads consisting of one person with dementia living at home and their family caregiver. After a baseline assessment, dyads are randomly assigned by gender to either the intervention or control group. People with dementia in the intervention group listen to individualized music playlists for 20 min every other day for six weeks via the self-developed Individualized Music and Dementia app. The control group receives standard care. All dyads complete paper-and-pencil questionnaires six weeks before the start of the intervention (T0), directly before the intervention (T1), directly after the intervention (T2), and six weeks later (T3). During the intervention period, all caregivers also complete daily ecological momentary assessments via the app. During three home visits, a trained project member will observe the dyads and collect hair samples. After the intervention, semi-structured interviews will be conducted to collect information about participants' experiences with the app and intervention. The primary outcome is the attainment of individual goals established during the baseline assessment. Secondary outcomes are the well-being, physiological stress and quality of life of people with dementia and their caregivers; people with dementia's behavioural and psychological symptoms of dementia, resistance during care, and reactions to the music; caregivers' burden of care, positive aspects of care, and caregiving self-efficacy; and the quality of the caregiver-care recipient interaction.

DISCUSSION

Our study will assess the extent to which an app-based individualized music listening intervention is feasible and effective for enhancing the well-being and quality of life of people with dementia living at home and their family caregivers.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00025502 and ISRCTN registry ISRCTN68084105, https://doi.org/10.1186/ISRCTN68084105.

Erfassung der kommunikativen Lebensqualität und Partizipation bei Demenz: Scoping Review

Die steigende Zahl der Menschen, die an Demenz erkranken, stellt Fachkräfte und Angehörige vor große Herausforderungen. Die Erfassung der kommunikationsbezogenen Lebensqualität und Partizipation sollte fester Bestandteil der Versorgung von Menschen mit Demenz sein. Um einen Überblick über die verfügbaren Verfahren hierfür zu erhalten, wurde von März bis Mai 2020 eine Datenbankrecherche in PSYNDEX, ScienceDirect und Web of Science Core Collection nach PRISMA Kriterien durchgeführt. Insgesamt wurden 22 Verfahren in die Analyse begründet eingeschlossen. Von diesen erfassen nur sieben die Kommunikationsfähigkeit und die soziale Interaktion, neun liegen insgesamt in deutscher Sprache vor. Siebzehn der 22 Verfahren stellen reine Fremdbeurteilungsverfahren dar. Bei der Erfassung der Lebensqualität spielt die Kommunikationsfähigkeit eine untergeordnete Rolle, die Beurteilung erfolgt häufig einseitig. Von praktischem Nutzen sind: DCI, CODEM, ISEKAD und Z-CADA.

Palliative Care in Advanced Dementia

Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.

Questioning the Questionnaire: Methodological Challenges in Measuring Subjective Quality of Life in Nursing Homes Using Cognitive Interviewing Techniques

Although the concept of subjective quality of life in the nursing home setting is seen as a promising approach to discovering opportunities for improvement from the resident's perspective, it appears problematic in classical surveys that self-reported quality ratings on the basis of satisfaction questions tend to turn out overly positive. The aim of this article is to analyze how people in residential care facilities interpret and process response stimuli received from a questionnaire on subjective quality of life. In this analysis, we aim to gain methodological insights into the way a survey instrument on subjective quality of life can adequately represent individual ratings, as well as expectations regarding different aspects of quality of life. To test the feasibility of the proposed approach, we employed a range of probing techniques from the cognitive interviewing approach. The result is a promising design principle for constructing survey instruments to measure subjective quality of life.

People with dementia in nursing home research: a methodological review of the definition and identification of the study population

Background

There are various definitions and diagnostic criteria for dementia, leading to discrepancies in case ascertainment in both clinical practice and research. We reviewed the different definitions, approaches and measurements used to operationalize dementia in health care studies in German nursing homes with the aim of discussing the implications of different approaches.

Methods

We conducted a systematic search of the MEDLINE and CINAHL databases to identify pre-2016 studies conducted in German nursing homes that focused on residents with dementia or cognitive impairment. In- or exclusion of studies were consented by all authors; data extraction was independently carried out by 2 authors (RP, SJ). The studies’ sampling methods were compared with respect to their inclusion criteria, assessment tools and methods used to identify the study population.

Results

We summarized case ascertainment methods from 64 studies. Study participants were identified based on a diagnosis that was evaluated during the study, or a recorded medical dementia diagnosis, or a recorded medical diagnosis either with additional cognitive screenings or using screening tests exclusively. The descriptions of the diagnostics that were applied to assess a diagnosis of dementia were not fully transparent in most of the studies with respect to either a clear reference definition of dementia or applied diagnostic criteria. If reported, various neuropsychological tests were used, mostly without a clear rationale for their selection.

Conclusion

Pragmatic considerations often determine the sampling strategy; they also may explain the variances we detected in the different studies. Variations in sampling methods impede the comparability of study results. There is a need to consent case ascertainment strategies in dementia studies in health service research in nursing homes. These strategies should consider resource constraints and ethical issues that are related to the vulnerable population of nursing home residents. Additionally, reporting about dementia studies in nursing homes need to be improved. If a diagnosis cannot be evaluated based on either ICD or DSM criteria, the study population may not be reported as having dementia. If a diagnosis is evaluated based on ICD or DSM criteria within the study, there is a need for more transparency of the diagnostic process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0249-7) contains supplementary material, which is available to authorized users.

Linguistic validation and reliability properties are weak investigated of most dementia-specific quality of life measurements-a systematic review

OBJECTIVE

For people with dementia, the concept of quality of life (Qol) reflects the disease's impact on the whole person. Thus, Qol is an increasingly used outcome measure in dementia research. This systematic review was performed to identify available dementia-specific Qol measurements and to assess the quality of linguistic validations and reliability studies of these measurements (PROSPERO 2013: CRD42014008725).

STUDY DESIGN AND SETTING

The MEDLINE, CINAHL, EMBASE, PsycINFO, and Cochrane Methodology Register databases were systematically searched without any date restrictions. Forward and backward citation tracking were performed on the basis of selected articles.

RESULTS

A total of 70 articles addressing 19 dementia-specific Qol measurements were identified; nine measurements were adapted to nonorigin countries. The quality of the linguistic validations varied from insufficient to good. Internal consistency was the most frequently tested reliability property. Most of the reliability studies lacked internal validity.

CONCLUSION

Qol measurements for dementia are insufficiently linguistic validated and not well tested for reliability. None of the identified measurements can be recommended without further research. The application of international guidelines and quality criteria is strongly recommended for the performance of linguistic validations and reliability studies of dementia-specific Qol measurements.

[Research with participants suffering from dementia. Ethical and legal considerations in research involving human subjects]

Using case reports from the health services research project Action Alliance Pain-Free City Muenster, fundamental issues of research ethics, data protection and legal guardianship are shown and explained. A plan of important aspects to be considered while planning, conducting and recruiting for research with nursing home inhabitants suffering from dementia in a legally correct and safe manner is presented.

Scalability and internal consistency of the German version of the dementia-specific quality of life instrument QUALIDEM in nursing homes - a secondary data analysis

BACKGROUND

Quality of life (Qol) is a widely selected outcome in intervention studies. The QUALIDEM is a dementia-specific Qol-instrument from The Netherlands. The aim of this study is to evaluate the scalability and internal consistency of the German version of the QUALIDEM.

METHODS

This secondary data analysis is based on a total sample of 634 residents with dementia from 43 nursing homes. The QUALIDEM consists of nine subscales that were applied to a subsample of 378 people with mild to severe dementia and six consecutive subscales that were applied to a subsample of 256 people with very severe dementia. Scalability, internal consistency and distribution scores were calculated for each predefined subscale using the Mokken scale analysis.

RESULTS

In people with mild to severe dementia, seven subscales, care relationship, positive affect, negative affect, restless tense behavior, positive self-image, social relations and feeling at home, were scalable (0.31 ≤ H ≤ 0.65) and internally consistent (Rho ≥ 0.62). The subscales social isolation (H = 0.28) and having something to do (H = 0.18) were not scalable and exhibited insufficient reliability scores (Rho ≤ 0.53). For people with very severe dementia, five subscales, care relationship, positive affect, restless tense behavior, negative affect and social relations, were scalable (0.33 ≤ H ≤ 0.65), but only the first three of these subscales showed acceptable internal consistency (Rho 0.59 - 0.86). The subscale social isolation was not scalable (H = 0.20) and exhibited poor internal consistency (Rho = 0.42).

CONCLUSIONS

The results show an acceptable scalability and internal consistency for seven QUALIDEM subscales for people with mild to severe dementia and three subscales for people with very severe dementia. The subscales having something to do (mild to severe dementia), negative affect (very severe dementia), social relations (very severe dementia) and social isolation (both versions) produced unsatisfactory results and require revision.

Facial expression in Alzheimer's disease: impact of cognitive deficits and neuropsychiatric symptoms

In Alzheimer's disease (AD), nonverbal aspects of communication become increasingly important in caregiver-patient interactions when the ability to communicate verbally is fading with progression of the disease. We therefore investigated the impact of cognitive deficits and neuropsychiatric symptoms, particularly apathy, on facial expression in AD. While overall neuropsychiatric symptoms were not associated with facial expression, apathy exhibited substantial correlations, even after controlling for cognitive deficits. Moreover, apathy appeared to moderate the influence of cognitive deficits: without considering apathy, cognitive deficits were associated with less specific facial expressions. After controlling for apathy, cognitive decline was related to increased facial expressiveness. In conclusion, apathetic symptoms appear to be specifically associated with facial expression in AD and thus could contribute to a disregard for patients' needs in everyday life.

The Functional Quality of Life (fQOL)-Model

Quality of life (QOL) is increasingly being suggested as a crucial outcome variable for interventions that aim to maintain or improve health and psychological resources in old age. Currently, two main approaches to measuring QOL can be distinguished: (1) the sQOL approach which measures an individual’s subjective evaluation of his or her overall life situation and QOL; (2) the oQOL approach that infers QOL of an individual from the outside, e.g., via measurement of health impairments. Both approaches, however, are problematic: In the first case, a large majority of individuals report relatively high levels of sQOL that are sometimes in stark contrast to observable impairments (known as the well-being paradox; Staudinger, 2000 ). This suggests that improving impaired resources does not necessarily lead to improved sQOL (although there may be positive effects on the autonomy of these individuals). The second approach is problematic because improved oQOL leads only to an increase in self-reported overall sQOL under very rare conditions – and one cannot assume that an increase in resources necessarily has led or will lead to higher levels of sQOL. Therefore, we propose a new, functional quality of life (fQOL) approach to determine quality of life. It combines the existing approaches by linking the subjective representations of objectively measurable resources to their functional value for pursuing individually meaningful activities and goals. From this model, fQOL-improving interventions as well as methods to evaluate the effectiveness of QOL-interventions can be derived.

Psychometric properties of the German "Pain Assessment in Advanced Dementia Scale" (PAINAD-G) in nursing home residents

OBJECTIVES

The study aims to evaluate the psychometric properties of the German version of a scale for the assessment of pain in advanced dementia (PAINAD-G).

DESIGN

Cross-sectional study.

SETTING

Eight nursing homes.

PARTICIPANTS

Ninety-nine residents in 8 nursing homes diagnosed with Alzheimer's disease (68.3%) or other types of dementia (31.7%) participated after informed consent was obtained from their proxies. Nurses in charge of the residents observed their pain behavior over a 2-minute period while performing routine nursing activities--once in the morning and once in the evening.

MEASUREMENTS

PAINAD-G relies on the observation of 5 behavioral categories indicative of pain: breathing, vocalization, facial expression, body language, and consolability.

RESULTS

Psychometric analyses revealed good internal consistency of the scale (Cronbach's alpha = 0.85). Inter-rater stability amounted to r = 0.80 and retest reliability to r = 0.90. Principal component analysis allowed the extraction of one factor that accounted for 63.5% of the cumulative factor variance. Validity data shows that PAINAD-G scores were higher in residents assumed to suffer from pain in comparison to those without pain. On the other hand, the level of pain rating did not correspond with the PAINAD-G scores. Residents rated to suffer from pain showed more pain behavior with increased cognitive deterioration. Measures that indicate nonpain disorders did not correlate with the PAINAD-G scores.

DISCUSSION

PAINAD-G is a 1-dimensional scale that demonstrates good reliability. The outcome supports the assumption that the scale actually measures pain.

Development of a short version of the Apathy Evaluation Scale specifically adapted for demented nursing home residents

OBJECTIVE

Apathy is among the most frequent neuropsychiatric symptoms in dementia, particularly Alzheimer disease. The Apathy Evaluation Scale (AES) has been widely employed for assessing apathy in different patient groups. To further facilitate the usage of the AES, an abbreviated version was constructed.

METHOD

On basis of a sample of 356 nursing home residents, a cross-validation procedure was carried out to develop a brief version of the AES. According to a thorough clinical examination, 85% of the residents were demented, 8% presented with mild cognitive impairment, whereas 7% did not present any cognitive deficits. After subdividing the patient group into two matched samples, the first subsample was used to identify problematic items due to defined psychometric and content-related criteria. The original 18-item scale was thus reduced to 10 items. Psychometric properties of the shortened version were subsequently reassessed in the second subsample.

RESULTS

The short version demonstrated favorable psychometric properties that could be confirmed by cross-validation with the second sample. Correlations with the original full-length version were high (r = 0.97 for both subsamples); the shortened scale yielded no substantial losses regarding internal consistency or construct validity (correlations with the respective subscales of the Neuropsychiatric Inventory).

CONCLUSION

The frequency of apathetic symptoms in the nursing home residents included confirms the clinical importance of apathy for understanding dementia. Given this specific patient population, setting, and mode of data collection, the short-version AES seems to be a valuable and time-efficient instrument for assessing apathy.

Beurteilung von Schmerz bei Demenz (BESD)

BACKGROUND

The observation scale PAINAD (pain assessment in advanced dementia) is composed of five behavioral categories: breathing, vocalization, facial expression, body language, and consolability. The present study investigates the construct validity of the German version.

PATIENTS AND METHODS

We conducted a prospective one-dimensional observation study with repeated measurements (t(1)=pretreatment, t(2)=2 h posttreatment, t(3)=24 h posttreatment). The sample consisted of 12 verbally noncommunicative demented inpatients with severe comorbidity treated in three geriatric clinics. Their age was M=84.3 years (SD=4.4) on the average. Ten of them were female. Inclusion criteria were pain-related physical illness and observed pain behavior. Every patient was treated with analgesics after t(1). After t(2) the medication was discontinued in five patients until t(3). Nurses documented the PAINAD scores after an observation period of 2 min during routine care.

RESULTS

Pain behavior at t(2) diminished considerably displaying a large effect size. Scores continued to be low at t(3) only in the sample with continued medication. Scores in the other part of the sample returned to initial values.

CONCLUSION

The data demonstrate that pain medication strongly impacts the pain behavior of demented patients. The outcome supports the assumption that PAINAD really measures pain.

Die Bedeutung unterschiedlicher Referenzgruppen für die Beurteilung der Lebensqualität demenzkranker Menschen

The HILDE project proceeds from a theoretical conception of quality of life which considers both the significance of objective living conditions claimed in the Swedish level of living approach and the significance of processes of subjective perceptions and judgements accentuated in the American quality of life approach. Since component definitions of quality of life regularly fail to reflect empirical relationships between the differentiated aspects, quality of life is defined as a constellation of personal and environmental material and immaterial resources and subjective wellbeing. Under the assumption that an adequate assessment of quality of life of people with dementia can not exclusively be based on their cognitive impairment, i.e. their stage of the disease, but must also reflect the realisation of individual preferences in a given life situation, the empirical portion of this contribution identifies and independently cross-validates in random subsamples four patterns of competence in a sample of 362 nursing home residents suffering from dementia. Each of these four different dementia syndrome groups is characterised by specific needs and values. They can be used as a point of reference within as well as between these competence groups, in order to plan individual interventions with competence-oriented expectations.

Alterspolitik und Gesundheit

Proceeding from a comprehensive definition of health which differentiates between personal and environmental aspects and which is explicitly not restricted to the absence of disease, age-related changes in functional capacity and characteristic diseases are discussed. To maintain or re-establish independency is said to be much more important than in the case of younger age groups because of the high prevalence of chronic diseases in old age. Discussing the development of costs in the health care system it is demonstrated that a considerable amount of the increasing costs for treatment in higher age groups is due to the higher portion of those who will die in the following years. As a consequence, an explosion of health care costs might be a too pessimistic scenario. The hypothesis of a compression of morbidity is discussed as a more optimistic perspective on cost development. Three additional parts deal with problems of German nursing care insurance, propositions for an integrative concept of preventive and rehabilitative care, and tasks and challenges of palliative care. The final part of this contribution inquires into priorities of future political action on the societal level, the level of public supplies, the personal level, and the family level.

Demenzkranke Menschen in individuell bedeutsamen Alltagssituationen

First outcomes of a current intervention study focussing on emotions of nursing home residents with mild, moderate and severe dementia are discussed in the present contribution. The aim of the study was to prove the effect from an individual approach in the care of people with dementia. By promoting individual everyday situations for each resident, positive emotions should be stimulated and individual well-being should be improved. Findings show the possibility to gain such individual everyday-situations for people with mild, moderate and severe dementia, which stimulate positive reactions and may be integrated into the care process. Of particular importance are those positive situations which focus on the communication between nurses and residents or in which the residents receive personal attention from nurses.

Selbstständigkeit, bewusst angenommene Abhängigkeit, Selbstverantwortung und Mitverantwortung als zentrale Kategorien einer ethischen Betrachtung des Alters

This contribution begins with a brief introduction into some seminal problems of ethics: the search for the essential being of things, the attitude of value consciousness in the context of ethical reflections, and the reflection on models of a 'good life' and on decisions as well as actions in significant moral situations. These introductory statements are illustrated by the example of stoic philosophy. In a second step, independence, consciously accepted dependency, self-responsibility and shared responsibility are discussed as highly significant categories for an ethical analysis of all ages. However these categories must be specified with reference to specific ages. In this contribution, such a specification is carried out for old age focussing on the particular relevance of the four categories for ethical analysis. In a third step, each of the four categories is discussed in detail in the context of basic ethical approaches. In this context, ethical analysis proceeds from the perspectives of the individual, the environment, and the society. Concerning the perspective of the society special interest is offered to societal models of good life in old age which might have an impact on the potential development of a pro-aging culture and shared responsibility in older people. Moreover, these models contribute to older people's ability to use the necessary means of support in cases of dependency and to consciously accept dependency.

[Conceptual and legal variations between the treatment of people with dementia receiving inpatient and ambulatory care]

In Germany, there clearly appears to be a gap between care carried out at home and in in-patient settings (residential nursing care). Numerous innovative projects of alternatively structured care, like for instance shared flats or group care units for people with dementia are placed in between the traditional, either home-based or institutionalised care patterns. It seems imperatively necessary to overcome the rigid separation between the inpatient sector and care carried out at home. In this article, backgrounds, necessities and perspectives of projects placed in between the traditional structures are discussed.