A new measurement of activities of daily living for Thai elderly with dementia

A Multidimensional, Person-Centered Framework for Functional Assessment in Dementia: Insights from the 'What', 'How', 'To Whom', and 'How Much' Questions

Dementia is a syndrome characterized by cognitive and neuropsychiatric symptoms associated with progressive functional decline (FD). FD is a core diagnostic criterion for dementia, setting the threshold between its prodromal stages and the full-blown disease. The operationalization of FD continues to generate a great deal of controversy. For instance, the threshold of FD for the diagnosis of dementia varies across diagnostic criteria, supporting the need for standardization of this construct. Moreover, there is a need to reconsider how we are measuring FD to set boundaries between normal aging, mild cognitive impairment, and dementia. In this paper, we propose a multidimensional framework that addresses outstanding issues in the assessment of FD: i) What activities of daily living (ADLs) are necessary to sustain an independent living in aging? ii) How to assess FD in individuals with suspected neurocognitive disorders? iii) To whom is the assessment directed? and iv) How much does FD differentiate healthy aging from mild and major neurocognitive disorders? Importantly, the To Whom Question introduces a person-centered approach that regards patients and caregivers as active agents in the assessment process of FD. Thus, once impaired ADLs have been identified, patients can indicate how significant such impairments are for them in daily life. We envisage that this new framework will guide future strategies to enhance functional assessment and treatment of patients with dementia and their caregivers.

The benefits of Shuai Shou Gong (SSG) demonstrated in a Randomised Control Trial (RCT) study of older adults in two communities in Thailand

INTRODUCTION

Shuai Shou Gong (SSG) is a type of Arm Swing Exercise (ASE) developed and practiced especially by older people in China for over one thousand years to maintain physical health and well-being. Until now the potential benefits of SSG have not been investigated in a Randomised Control Trial (RCT).

MATERIALS AND METHODS

Fifty six older women were recruited from each of two urban communities in Khon Kaen, Thailand. One community was randomly assigned as the Exercise Group (mean age 68.3 years, standard deviation 5.6 years) and the other as the Control Group (69.4 years, 4.4 years). The Exercise Group performed SSG for 40 minutes, three days per week for two months, whereas the Control Group maintained their usual daily life. Measurements of Posture (C7 to Wall Distance (C7WD), Standing Height (SH), Flexibility (Back Scratch of Left and Right arms (BSL and BSR) and Chair Sit and Reach of Left and Right legs (CSRL and CSRR), Gait (Timed Up and Go (TUG)), and Cognition (Barthel Activities of Daily Living Index (BADL) and Rosenberg Self Esteem Scale (RSES) questionnaires) were recorded for each group prior to, on day 1, week 4, and week 8 of the SSG training.

RESULTS

The 8 week SSG training course produced a significant interaction between group and time for the combined set of all outcome measures (C7WD, SH, BSL, BSR, CSRL, CSRR, TUG, BADL, and BSES) (Modified ANOVA-Type Statistic (MATS) p-value < 0.001) and for the four categories of Posture, Flexibility, Gait, and Cognition (all Wald-Type Statistic (WTS) p-values < 0.05) and in all cases the changes in the Exercise Group were in the direction predicted to be beneficial. No significant interaction effect between time and group was found after either one session or four weeks of SSG training for any of the categories (all WTS p > 0.05) with significant effects only arising after eight weeks (all WTS p < 0.05). Thus although alterations were shown to be increasingly beneficial over time the minimum period required to produce a statistically significant benefit from performing SSG training was 8 weeks. For the Control Group no significant changes were identified for Posture, Flexibility and Cognition however a significant deterioration was observed in TUG (WTS p = 0.003).

CONCLUSIONS

SSG is a holistic, gentle, rhythmic, whole body sequence of movements that may be readily learned and enjoyed in a group setting and has been confirmed in an RCT study of older adult females to produce significant benefits in Posture, Flexibility, Gait and Cognition.

US Adults' Likelihood to Participate in Dementia Prevention Drug Trials: Results from the National Poll on Healthy Aging

BACKGROUND

Recruitment to dementia prevention clinical trials is challenging, and participants are not representative of US adults at risk. A better understanding of the general public's interest in dementia prevention research participation is needed to inform future recruitment strategies.

OBJECTIVE

To examine US adults' characteristics associated with self-reported likelihood to participate in dementia prevention clinical trials.

DESIGN

We conducted a cross-sectional survey using the October 2018 wave of the University of Michigan National Poll on Healthy Aging.

SETTING

The National Poll on Healthy Aging is a nationally representative survey of adults using KnowledgePanel (Ipsos Public Affairs LLC), a probability-based panel of the civilian, noninstitutionalized US population.

PARTICIPANTS

We analyzed data from 1,028 respondents, ages 50 to 64 years, who completed a web survey module on brain health.

MEASUREMENTS

We used logistic regression models to examine associations between sociodemographic and dementia-related factors (e.g., family history) and self-reported likelihood to participate in a dementia prevention clinical trial of a new medicine ("very" or "somewhat likely" vs. "not likely" survey responses). Among respondents not likely to participate, we examined frequency of reasons endorsed for this decision, stratified by age, sex, and race and ethnicity.

RESULTS

Of the 1,028 respondents, half were female, 68% Non-Hispanic White, 13% Hispanic, and 12% Non-Hispanic Black. Twelve percent of respondents reported being very likely to participate in a dementia prevention trial, 32% somewhat likely, and 56% not likely. Factors associated with higher likelihood to participate were higher perceived risk of dementia [OR, 2.17 (95% CI, 1.61, 2.93)], a positive family history of dementia [OR, 1.75 (95% CI, 1.27, 2.43)], and having discussed dementia prevention with a doctor [OR, 2.20 (95% CI, 1.10, 4.42)]. There were no differences in likelihood to participate by sociodemographic characteristics. Among 570 respondents not likely to participate, 39% said they did not want to be a guinea pig, 23% thought dementia would not affect them, 22% thought there would be too high a chance for harm, 15% indicated study participation would take too much time, and 5% reported fear of learning information about oneself. There were no differences across age, sex, and racial and ethnic groups.

CONCLUSIONS

In this study, perceived risk of dementia, family history, and discussion of prevention with a doctor were associated with likelihood to participate in a dementia prevention clinical trial, whereas sociodemographic factors including race and ethnicity were not. Findings suggest that recruitment interventions focused on increasing knowledge of dementia risk and prevention trials and involving healthcare providers may be effective tools to improve enrollment rates, regardless of target community.

Instrumental Activities of Daily Living Scales to Detect Cognitive Impairment and Dementia in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The largest proportion of people with dementia worldwide live in low- and middle- income countries (LMICs), with dementia prevalence continuing to rise. Assessment and diagnosis of dementia involves identifying the impact of cognitive decline on function, usually measured by instrumental activities of daily living (IADLs).

OBJECTIVE

This review aimed to identify IADL measures which are specifically developed, validated, or adapted for use in LMICs to guide selection of such tools.

METHODS

A systematic search was conducted (fourteen databases) up to April 2020. Only studies reporting on development, validation, or adaptation of IADL measures for dementia or cognitive impairment among older adults (aged over 50) in LMICs were included. The QUADAS 2 was used to assess quality of diagnostic accuracy studies.

RESULTS

22 papers met inclusion criteria; identifying 19 discrete IADL tools across 11 LMICs. These were either translated from IADL measures used in high-income countries (n = 6), translated and adapted for cultural differences (n = 6), or newly developed for target LMIC populations (n = 7). Seven measures were investigated in multiple studies; overall quality of diagnostic accuracy was moderate to good.

CONCLUSION

Reliability, validity, and accuracy of IADL measures for supporting dementia diagnosis within LMICs was reported. Key components to consider when selecting an IADL tool for such settings were highlighted, including choosing culturally appropriate, time-efficient tools that account for gender- and literacy-bias, and can be conducted by any volunteer with appropriate training. There is a need for greater technical and external validation of IADL tools across different regions, countries, populations, and cultures.

Relationships between amyloid levels, glucose metabolism, morphologic changes in the brain and clinical status of patients with Alzheimer's disease

OBJECTIVE

The current study was conducted to improve the understanding of relationships between regional cortical amyloid load, glucose metabolism, cortical morphology (volume), and severity of clinical symptoms in patients with AD, MCI, and age-matched controls.

METHODS

To objectivize the radiological evaluation of patients with suspected AD, head-to-head multi-modality imaging studies were conducted using MRI and PET/CT with [¹⁸F]FDG and [¹⁸F]AV45 for visualization and quantitation of brain morphology, glucose metabolism, and amyloid levels, respectively. A total of 84 subjects was studied, including 33 patients with AD, 31 patients with MCI, and 20 age-matched healthy controls (HC). A new quantitative index was calculated as a ratio of regional SUV of [¹⁸F]AV45 (normalized to cerebellar cortex) over the corresponding regional SUV of [¹⁸F]FDG, divided by the corresponding regional volume, measured from the co-registered MRI and normalized to the normal age-matched control group (AV45/FDG/NVol index). Relationships between clinical scores (TMSE, ADAS) and AV45/FDG/NVol indices for different structures of the brain in study groups were determined using linear regression analyses.

RESULTS

A significant direct linear correlation was observed between the AV45/FDG/NVol index and ADAS-Cog test score and an inverse correlation with TMSE score at baseline and with the degree of changes in ADAS and TMSE scores assessed one year later (disease progression). The observed correlations between AV45/FDG/NVol index and clinical scores were higher than those with MRI-based cortical volumes, FDG SUV, or cerebellum-normalized AV45 SUV alone.

CONCLUSIONS

Current study demonstrated that AV45/FDG/NVol index mapping of the brain is a novel quantitative molecular imaging biomarker that correlates with clinical neurocognitive status and may facilitate more accurate diagnosis, staging, and prognosis of AD. Additional larger scale clinical studies are required to further evaluate the efficacy of this new quantitative index as a diagnostic and prognostic biomarker of AD as well as for the evaluation of safety and efficacy of novel agents undergoing clinical trials for therapy of AD.

What matters to patients with stroke in India and why: a qualitative study

PURPOSE

To gain insight into the preferred outcomes of patients with stroke living in India and develop a conceptual framework of participation in daily activities based on patient perspectives informed by the International Classification of Functioning, Disability, and Health.

METHODS

This study took a phenomenological approach. A purposive sample of 30 patients with stroke and diverse socio-demographic and disease related characteristics participated in semi-structured interviews. Interviews consisted of open-ended questions about their post stroke rehabilitation goals. Data were analyzed using content analysis.

RESULTS

Patients expressed preference for outcomes such as the use of eastern toilets, squatting and sitting on the floor, eating with the right hand, taking a "bucket bath," walking for long distances (1-2 km) and the use of public transportation. Patients attributed their outcome preferences to contextual factors such as the physical environment (natural and built environment), family structure and living conditions, cultural values, norms and practices. Based on the outcomes identified by the patients, we developed the conceptual framework of participation in daily activities relevant to Indian context consisting of Mobility, Self-care, Domestic Life, and Social participation domains informed by the International Classification of Functioning, Disability, and Health.

CONCLUSIONS

Outcome preferences of patients with stroke are not universal. The conceptual framework including its domains and contents developed in this study can be a useful guide to clinicians and researchers in choosing what to measure within Indian as well as other similar sociocultural contexts.Implications for rehabilitationPost-stroke functional outcome measurement is meaningful only when it is conceptualized within the context in which the personal, social, and cultural values of patients are well-recognized.There are notable differences in the type of activities constituting daily activities and how they were performed in India compared to a western cultural context.Patients' daily functioning is characterized by the differences in personal preferences, cultural norms and practices, family and living arrangements, lifestyle, and characteristics of natural and built environment and the available public infrastructure.Differentiating activities patients cannot do from the "no need to do" or "don't want to do" should be viewed as a critical aspect of patient reported outcome measurement.

Current approaches to dementia screening and case finding in low- and middle-income countries: Research update and recommendations

Approximately 47 million people have dementia worldwide, with this figure, it is expected to almost triple by 2050. Most people with dementia (approximately two-thirds) live in low- and middle-income countries (LMICs). This presents a significant challenge for such countries that often have limited financial resources and less well-developed health and social care systems. In the absence of a cure, reducing the future costs of dementia care and burden of disease may be best achieved by a greater emphasis on (1) more timely diagnosis with earlier intervention to maintain functional independence and (2) undertaking "screening" in groups at high risk of developing dementia, case finding, and using brief cognitive assessment instruments. In clinical settings, a wide range of instruments for dementia screening and diagnosis are currently available; however, few cognitive assessment tools have been developed specifically for clinical use within LMIC settings. Screening for dementia and cognitive impairment in LMICs largely relies on tools adapted from high-income countries (HICs); these often lack validation in these settings leading to education, literacy, and cultural biases. Research is urgently needed to develop cognitive assessment tools and dementia diagnostic approaches that are appropriate and feasible for clinical use in LMIC settings.

Insights into globalization: comparison of patient characteristics and disease progression among geographic regions in a multinational Alzheimer's disease clinical program

BACKGROUND

Globalization of clinical trials has important consequences for trial planning and interpretation. This study investigated heterogeneity in patient characteristics and outcomes among world regions in the global idalopirdine Phase 3 clinical program.

METHODS

Data were pooled from three 24-week randomized controlled trials in patients aged ≥ 50 years with mild-to-moderate Alzheimer's disease (AD) (n = 2506). Patients received idalopirdine (10, 30, or 60 mg/day) or placebo, added to cholinesterase inhibitor treatment. Patients were categorized into the following regions: Eastern Europe/Turkey (n = 759), Western Europe/Israel (n = 709), USA/Canada (n = 444), South America/Mexico (n = 361), Asia (n = 134), and Australia/South Africa (n = 99). For each region, operational characteristics, baseline demographic and clinical characteristics, adverse events, and mean change from baseline to week 24 in clinical rating scale scores (placebo group only) were summarized using descriptive statistics.

RESULTS

Completion rates were 0.86-0.90 in all regions. Heterogeneity among global regions was evident. Protocol deviations were twice as common in South America/Mexico as in USA/Canada (2.64 vs 1.35 per patient screened). Educational level ranged from 9.2 years in South America/Mexico to 13.4 years in USA/Canada. APOE ε4 carriage was 80.6% in Australia/South Africa, 63.1% in Western Europe/Israel, and < 60% in other regions. Screening Mini-Mental State Examination scores were higher in Eastern Europe/Turkey (18.0) and USA/Canada (17.5) than in other regions (16.9-17.1). Baseline AD Assessment Scale-Cognitive subscale (ADAS-Cog) scores ranged from 24.3 in USA/Canada to 27.2 in South America/Mexico. Baseline AD Cooperative Study-Activities of Daily Living, 23-item version (ADCS-ADL23) scores ranged from 58.5 in USA/Canada to 53.5 in Eastern Europe/Turkey. In the placebo group, adverse events were 1.6-1.7 times more common in Western Europe/Israel, USA/Canada, and Australia/South Africa than in Eastern Europe/Turkey. On the ADAS-Cog, Australia/South Africa and Western Europe/Israel showed the most worsening among patients receiving placebo (1.56 and 1.40 points, respectively), whereas South America/Mexico showed an improvement (-0.71 points). All regions worsened on the ADCS-ADL23, from -3.21 points in Western Europe/Israel to -0.59 points in Eastern Europe/Turkey.

CONCLUSIONS

Regional heterogeneity-in terms of study conduct, patient characteristics, and outcomes-exists, and should be accounted for, when planning and conducting multinational AD clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01955161 . Registered on 27 September 2013. ClinicalTrials.gov, NCT02006641 . Registered on 5 December 2013. ClinicalTrials.gov, NCT02006654 . Registered on 5 December 2013.

Development and community-based validation of the IDEA study Instrumental Activities of Daily Living (IDEA-IADL) questionnaire

Background

The dementia diagnosis gap in sub-Saharan Africa (SSA) is large, partly due to difficulties in assessing function, an essential step in diagnosis.

Objectives

As part of the Identification and Intervention for Dementia in Elderly Africans (IDEA) study, to develop, pilot, and validate an Instrumental Activities of Daily Living (IADL) questionnaire for use in a rural Tanzanian population to assist in the identification of people with dementia alongside cognitive screening.

Design

The questionnaire was developed at a workshop for rural primary healthcare workers, based on culturally appropriate roles and usual activities of elderly people in this community. It was piloted in 52 individuals under follow-up from a dementia prevalence study. Validation subsequently took place during a community dementia-screening programme. Construct validation against gold standard clinical dementia diagnosis using DSM-IV criteria was carried out on a stratified sample of the cohort and validity assessed using area under the receiver operating characteristic (AUROC) curve analysis.

Results

An 11-item questionnaire (IDEA-IADL) was developed after pilot testing. During formal validation on 130 community-dwelling elderly people who presented for screening, the AUROC curve was 0.896 for DSM-IV dementia when used in isolation and 0.937 when used in conjunction with the IDEA cognitive screen, previously validated in Tanzania. The internal consistency was 0.959. Performance on the IDEA-IADL was not biased with regard to age, gender or education level.

Conclusions

The IDEA-IADL questionnaire appears to be a useful aid to dementia screening in this setting. Further validation in other healthcare settings in SSA is required.

The Dementia and Disability Project in Thai Elderly: rational, design, methodology and early results

Background

A strong inverse relationship of functional limitation and socioeconomic status has been established in western ageing society. Functional limitation can be related to chronic diseases, disuse, cognitive decline, and ageing. Among chronic diseases in the Thai population, cerebrovascular diseases, diabetes, and arthritis are common. These factors are known to contribute to disability and poor quality of life in the elder population. Neuropsychiatric problems, cognitive decline, dementia, and cultural issues in elderly people also can alter the quality of life of the elderly.

Methods

The Dementia and Disability Project in Thai Elderly (DDP) aims at comprehensively assessing community dwelling Thai elderly to understand the relationship between disability and motor function, neuropsychiatric symptoms, cognitive function, and chronic diseases. The DDP is the first study to look at the prevalence and etiology of dementia and of mild cognitive impairment (MCI) in Thai elders and to explore the relationship of cognition, disability, small vessel diseases and cortical degeneration with neuroimaging in Thai elderly people. 1998 Thai elders were screened in 2004–2006 and diagnosed as having MCI or dementia. 223 elders with MCI or dementia and cognitively normal elderly had brain magnetic resonance imaging (MRI) or at baseline. 319 elders from the 3 groups had blood tests to investigate the risks and possible etiologies of dementia including genotyping at baseline.

Results

The mean age of elders in this study is 69.51(SD=6.71, min=60, max=95) years. 689(34.9%) are men and 1284(65.1%) are women. Mean body weight was 58.36(SD=11.20) kgs. The regression model reveals that performance on gait and balance and serum triglyceride predicts activity of daily living performance (adjusted r² = 0.280, f=2.644, p=0.003). The majority of abnormal gait in Thai elders was lower level gait disturbance. Only 1.5% (29/1952) had highest level gait disorders. 39.5% of 1964 subjects were free of chronic diseases. Treatment gap (indicating those who have untreated or inadequate treatment) of diabetes mellitus and hypertension in Thai elders in this study was 37% and 55.5% respectively. 62.6% of Thai elders have ApoE3E3 allele. Prevalence of positive ApoE4 gene in this study is 22.85%. 38.6% of Thai elders who had MRI brain study have moderate to severe white matter lesions.

Conclusion

The large and comprehensive set of measurements in DDP allows a wide-ranging explanation of the functional and clinical features to be investigated in relation to white matter lesions or cortical atrophy of the brain in Thai elderly population. An almost 2 year follow up was made available to those with MCI and dementia and some of the cognitively normal elderly. The longitudinal design will provide great understanding of the possible contributors to disability in the elderly and to the progression of cognitive decline in Thai elders.

Psychometric evaluation of the Chinese version of the Activities of Daily Living Questionnaire (ADLQ-CV)

BACKGROUND

This study examines the psychometric properties of the Chinese version of the Activities of Daily Living Questionnaire (ADLQ-CV) in a sample of older Hong Kong Chinese adults with dementia.

METHOD

The ADLQ-CV was administered to primary family caregivers of 125 community-dwelling individuals with dementia. Assessments were then made of the scale's reliability, validity and factor structure.

RESULTS

Factor analysis yielded six factors that closely resembled the six subscales proposed in the original scale. The ADLQ-CV demonstrated excellent convergent validity with the Chinese version of the Disability Assessment for Dementia (rp = -0.92, p < 0.001). The internal consistency of the ADLQ-CV was good (Cronbach's alpha = 0.81). Excellent test-retest reliability (ICC = 0.998) and inter-rater reliability (ICC = 0.997) of the ADLQ-CV were obtained. The ADLQ-CV showed a significant negative association with global mental states (rp = -0.80, p < 0.001), but it did not correlate with the age or educational level of individuals with dementia.

CONCLUSION

The findings suggest that the ADLQ-CV is a valid and reliable instrument for evaluating the functional abilities of Hong Kong Chinese people with dementia. The brevity and simplicity of administration make it a potentially useful tool for routine assessment of functional status of people with dementia in community or hospital outpatient settings.