The use of the occupational disruptiveness scale of the neuropsychiatric inventory-nursing home version to measure the impact of rivastigmine on the disruptive behavior of nursing home residents with Alzheimer's disease

OBJECTIVES: The Neuropsychiatric Inventory-Nursing Home Version (NPI-NH) was used to study the impact of rivastigmine (Exelon; Novartis Pharmaceuticals Corporation, East Hanover, NJ), on occupational disruptiveness (OD), a proxy measure for professional caregiver burden. METHODS: The study was a prospective, multicenter, open-label, single-arm trial with NH residents prescribed rivastigmine (up to 6 mg bid) for Alzheimer's disease (AD) treatment. The NPI-NH was completed by NH staff caregivers at time of initiation of treatment with rivastigmine (T1), at treatment weeks 10 to 14 (T2), at treatment weeks 24 to 28 (T3), and at treatment weeks 50 to 54 (T4). RESULTS: Observations ranged from 173 at baseline to 73 at week 52. All but one patient had either moderate or severe dementia. Total OD score means were 4.7 +/- 6.1, 3.9 +/- 5.0, 4.19 +/- 5.6, and 2.79 +/- 2.8 at baseline, and weeks 12, 26, and 52 (T1-T4), respectively, with significant difference found between T1 and T4. Except for euphoria and disinhibition at T3 and T4, all correlations between OD scores and the domain scores of the NPI, were significant. Rivastigmine dose was an independent variable that affected OD change. CONCLUSION: Treatment with rivastigmine was associated with a reduction in the self-reported professional caregiver burden, as assessed by the NPI-NH OD scale.     

Impact of Cognitive,Functional, Behavioral Disorders,and Caregiver Burden on the Risk of Nursing Home Placement

ObjectivesTo estimate the attributable fraction of nursing home placement associated with cognitive impairment, neuropsychiatric symptoms, behavioral disorders, functional limitations, and caregiver burden.DesignLongitudinal study conducted on the “MEMORA cohort” linked with both regional public health insurance and hospital discharge databases.SettingMemory center at the University Hospital of Lyon, France.ParticipantsA sample of 2456 outpatients attending the memory center between 2012 and 2017.MeasuresCognitive impairment, functional limitations, neuropsychiatric symptoms/behavioral disorders, and caregiver burden were measured with the Mini-Mental State Examination, the Instrumental Activities of Daily Living scale, the Neuropsychiatric Inventory (NPI), and a short version of the Zarit Burden Inventory, respectively. Sociodemographics characteristics were collected during the first visit. Comorbidities were gathered from the hospital discharge database. Dates of nursing home placement were obtained from the public health insurance database.ResultsMore than 38% of nursing home placements were attributable to caregiver burden, and the attributable fraction associated with functional limitations exceeded 35%. Between 20% and 25% of nursing home placements were due to cognitive impairment whereas less than 16% were attributable to neuropsychiatric symptoms or behavioral disorders. The associations between anxiety or agitation and nursing home placement were mediated by caregiver burden. Apathy or aberrant motor behaviors were associated with a higher risk of nursing home placement independently of caregiver burden.Conclusions/ImplicationsOur findings suggest that a high proportion of nursing home placements are attributable to caregiver burden and functional limitations in outpatients attending a memory center. Cognitive impairment and neuropsychiatric symptoms or behavioral disorders contribute less to nursing home placements. Interventions directed to delay nursing home placement should emphasize actions toward reducing caregiver burden and functional limitations of patients.     

Analysis of burden in caregivers of people with Alzheimer’s disease using self-report and supervision hours

Objectives

This study aimed to describe the baseline characteristics of informal carers of community-living Alzheimer’s disease (AD) patients by AD severity group and to identify factors associated with two measures of caregiver burden.

Design and setting

GERAS is a prospective observational study in France, Germany, and the UK, designed to assess costs and resource use associated with AD, for patients and their caregivers, stratified by disease severity.

Participants

1497 community-dwelling AD patients and their primary caregivers.

Measurements

Subjective caregiver burden assessed using the Zarit Burden Interview [ZBI] and time spent supervising patients (an objective measure of burden recorded using the Resource Utilization in Dementia instrument) during the month before the baseline visit were recorded. Separate multiple linear regression analyses using ZBI total score and caregiver supervision time as dependent variables were performed to identify patient and caregiver factors independently associated with caregiver burden.

Results

Increasing AD severity was associated with both subjective caregiver burden (ZBI total score) and overall caregiver time, which includes supervision time (both p<0.001, ANOVA). Better patient functioning (on instrumental activities of daily living) was independently associated with both a lower ZBI total score and less supervision time, whereas higher levels of caregiver distress due to patient behavior were associated with greater caregiver burden. Other factors independently associated with an increased ZBI total score included younger caregiver age, caregiver self-reported depression, caring for a male patient, and longer time since AD diagnosis. Caregivers living with the patient, being a male caregiver, patient living in a rural location, higher patient behavioral problem subdomain scores for apathy and psychosis, more patient emergency room visits, not receiving food delivery and receiving financial support for caregiving were all associated with greater caregiver supervision time.

Conclusion

Our results show that subjective caregiver burden and caregiver time are influenced by different factors, reinforcing the need to consider both aspects of caregiving when trying to minimize the burden of AD. However, interventions that minimize caregiver distress and improve patient functioning may impact on both subjective and objective burden.     

The cost benefit to health plans of pharmacotherapy for Alzheimer's disease

Treatment of Alzheimer's disease (AD) is a major public health issue, with the potential for significant impact on MCOs. As the number of people affected with AD continues to rise, the importance of this problem will grow as well. This article reviews patient and caregiver outcomes associated with reduced health care costs and their implications for MCOs. Cholinesterase inhibitors (ChEIs) are effective in treating cognitive, functional, and behavioral symptoms for patients with mild to moderate and moderate to severe AD. Treatment with memantine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been shown to benefit patients with moderate to severe AD. Pharmacoeconomic studies indicate that donepezil and memantine treatment may reduce total costs of care for AD patients and their caregivers, with potential economic benefits to MCOs.     

阿尔兹海默病患者生活质量及其影响因素分析

目的 了解阿尔兹海默病(AD)患者生活质量及其影响因素,为AD的临床治疗工作提供科学依据。方法 采用以医院为基础病例对照研究方法对华中科技大学同济医学院附属梨园医院精神科2013年1月-2014年12月收治的378例≥60岁AD患者及同期在该医院进行健康体检的400名≥60岁健康体检者进行问卷调查,评价其生活质量,并采用多元线性逐步回归模型分析AD患者生活质量相关影响因素。结果 病例组AD患者阿尔兹海默病生活质量量表(QOL-AD)总分为(31.43±4.21)分,低于对照组健康体检者的(44.56±4.18)分,差异有统计学意义(t=39.675,P<0.001);病例组AD患者简易精神状态检查量表(MMSE)和日常生活功能量表(ADL)得分分别为(15.82±7.65)和(51.71±13.28)分,均低于对照组健康体检者的(21.83±6.56)和(65.68±14.18)分(均P<0.05);病例组AD患者神经精神调查量表(NPI)和老年抑郁量表(GDS)得分分别为(31.14±7.27)和(19.24±6.56)分,均高于对照组健康体检者的(21.06±8.58)和(14.53±6.18)分(均P<0.05);相关分析结果显示,MMSE量表得分与QOL-AD量表总分呈正相关(r=0.342,P=0.016),GDS量表得分与QOL-AD量表总分呈负相关(r=-0.584,P<0.001);多元线性逐步回归分析结果显示,年龄越大、照顾者关系越不亲密、与照顾者同住、痴呆程度越重、GDS量表得分越高,AD患者生活质量越差。结论 AD患者生活质量较差,年龄、照顾者、居住情况、痴呆程度和GDS量表得分是AD患者生活质量的主要影响因素。     

A 6-month observational study of the relationship between weight loss and behavioral symptoms in institutionalized Alzheimer's disease subjects

OBJECTIVE: Weight loss is a common occurrence in Alzheimer's disease (AD). This study was undertaken to investigate the relationship between weight loss and behavioral symptoms in institutionalized AD subjects. DESIGN: Observational study. SETTING: Two facilities that included assisted living and nursing care. PARTICIPANTS: Residents with probable or possible AD (n = 32). MEASUREMENTS: Weight was measured monthly. At baseline, month 3, and month 6, a knowledgeable staff member provided information that included the Neuropsychiatric Inventory: Nursing Home Version (NPI-NH, ie, a measure of behavioral symptoms) and a questionnaire regarding eating habits, food intake, and appetite. Two-day calorie counts were done and accelerometers were worn to monitor physical activity. RESULTS: At baseline, the mean body mass index (BMI) was 24.0 (standard deviation, 3.5) with 12 subjects exhibiting a BMI <22. BMI was negatively associated with the baseline NPI-NH total score (Spearman Correlation Coefficient -0.52, P <0.01), which indicates that subjects with low BMIs were more likely to have higher frequency and severity of behavioral problems. Individual behavior scores for agitation/aggression (-0.40, P <0.05), depression (-0.31, P = 0.08), irritability/lability (-0.47, P <0.01), aberrant motor behavior (ie, pacing, -0.42, P <0.05), nighttime behavior (-0.37, P = 0.05), and appetite/eating (-0.48, P <0.01) at baseline were negatively correlated with baseline BMI. Behaviors not correlated with BMI were delusions, hallucinations, elation, apathy, and disinhibition. Although this was a small sample followed for a relatively short time period, change in specific NPI-NH scores from baseline to month 6 were correlated with the change in weight over the 6-month period. Both agitation/aggression (-0.37, P = 0.05) and disinhibition (-0.45, P <0.05) showed negative correlation with weight change, which indicates an association between changes in these behaviors and weight loss. There were no significant differences between those who lost weight (n = 13) and those who did not (n = 19) on baseline variables, which included age, comorbidity, functional status, and NPI-NH. However, those who lost weight had a significantly higher BMI at baseline than those who gained weight. CONCLUSIONS: These preliminary results suggest that behavioral disturbances play a role in low body weight and weight loss in AD subjects.     

Behavioural and psychological symptoms of dementia,cognitive impairment and caregiver burden in patients with dementia

ObjectiveThis study aims to determine the relationships between behavioural and psychological symptoms of dementia (BPSD), cognitive impairment and burden of care of patients with dementia.MethodA cross-sectional, non-randomised study of 65 elderly patients with dementia and their caregivers was conducted over a 3-month period in January 2007 at the memory clinics of Universiti Kebangsaan Malaysia Medical Centre and Hospital Kuala Lumpur. Patients' cognitive functions were assessed with the Mini Mental State Examination (MMSE). Caregivers were interviewed to determine the severity of BPSD and caregiver burden (CB) using the Neuropsychiatric Inventory (NPI) Questionnaire and Zarit Burden Interview (BI) respectively.ResultsCognitive impairment did not contribute significantly to CB. Multiple linear regression analysis showed that high BPSD scores contributed 0.27 more in BI score, female patients contributed 0.37 less in BI score and caregivers with higher educational level contribute 0.5 more in BI score.ConclusionPatients' BPSD and male gender, but not cognitive impairment, were associated with CB. Even though CB was experienced more among caregivers with better education, all caregivers should be screened to ensure their general well-being.     

A comparison of HUI2 and HUI3 utility scores in Alzheimer's disease.

PURPOSE: The Health Utilities Index (HUI) is a generic, multiattribute, preference-based health-status classification system. The HUI Mark 3 (HUI3) differs from the earlier HUI2 by modifying attributes and allowing more flexibility for capturing high levels of impairment. The authors compared HUI2 and HUI3 scores of patients with Alzheimer's disease (AD) and caregivers, and contrasted results of a cost-effectiveness analysis of new drugs for AD using the two systems. METHODS: In a cross-sectional study of 679 AD patient/caregiver pairs, stratified by patient's disease stage (questionable/mild/moderate/severe/profound/terminal) and setting (community/assisted living/nursing home), caregivers completed the combined HUI2/HUI3 questionnaire as proxy respondents for patients and for themselves. RESULTS: Mean (SD) global utility scores for patients were lower on the HUI3 (0.22[0.26]) than on the HUI2 (0.53 [0.21]). Patient HUI3 utility scores ranged from 0.47(0.24) for questionable AD to -0.23 (0.08) for terminal AD, compared with a range of 0.73 (0.15) to 0.14 (0.07) for the HUI2. Among the 203 patients in the severe, profound, and terminal stages, 96 (48%) had negative global HUI3 utility scores, while none had a negative HUI2 score. The utility scores for caregivers were similar on the HUI3 (0.87 [0.14]) and HUI2 (0.87 [0.11]). Cost-effectiveness analysis of a new medication to treat AD showed somewhat more favorable results using the HUI3. CONCLUSIONS: The HUI2 and HUI3 discriminate well across AD stages. Compared with the HUI2, the HUI3 yields lower global utility scores for patients with AD, and more scores for states judged worse than dead. The HUI3 may yield substantially different results from the HUI2, particularly for persons who have serious cognitive impairments such as AD.     

Spotlight on Galantamine in Alzheimer’s Disease

Galantamine is one of several orally administered cholinesterase inhibitors that improve cognition in patients with mild to moderate Alzheimer’s disease. Compared with placebo, galantamine 16 or 24 mg/day improved cognition and activities of daily living, delayed emergence of behavioral symptoms and reduced caregiver burden in three pivotal randomized studies of 5 or 6 months’ duration.Galantamine may reduce the considerable economic burden of Alzheimer’s disease by delaying the need for full-time care (FTC) in patients with mild to moderate Alzheimer’s disease. In pharmacoeconomic analyses with a time horizon of 10 years conducted in Canada, Sweden, The Netherlands and the US, data from the pivotal trials were incorporated into a model to examine economic implications associated with galantamine treatment. FTC was defined in the model as the consistent requirement for caregiving and supervision for the greater part of each day regardless of the location of care and the identity of caregiver. When the effect of galantamine 16 or 24 mg/day was analysed from the perspective of a comprehensive healthcare payor, treatment was associated with cost savings (inclusive of drug costs) relative to no treatment, regardless of country for which the model was customized. Cost savings resulted from the delay in the time until FTC was required in patients with mild to moderate disease. In sensitivity analyses, cost savings were most sensitive to the cost of institutional care.In the analyses that considered the effect of galantamine 24 mg/day solely on cognition, galantamine was predicted to reduce the time FTC was required by ≈ 10% in patients with mild to moderate Alzheimer’s disease compared with no pharmacological treatment. Greater reductions in the time that FTC was required were predicted when the effects of galantamine 16 or 24 mg/day on behavioral symptoms in addition to cognition were considered in the US analysis or in sensitivity analyses in studies in other countries.In conclusion, pharmacoeconomic analyses, which were based on modelling of data from pivotal clinical trials with galantamine and included drug costs, indicate that galantamine treatment may result in cost savings from a healthcare payor perspective. The effects of galantamine on cognition and behavioral symptoms in patients with mild to moderate Alzheimer’s disease are predicted to delay the need for FTC, which may result in cost savings. From a societal perspective, the caregiver burden of caring for a patient with Alzheimer’s disease in the community may be decreased and the time that patients have without severe disease may be prolonged.     

Resource Use and Cost of Alzheimer’s Disease in France: 18-Month Results from the GERAS Observational Study

Background

There is little longitudinal data on resource use and costs associated with Alzheimer’s disease (AD) in France.

Institutionalization of Alzheimer's disease patients: reducing precipitating factors through family counseling.

Although home-care of Alzheimer's disease (AD) patients is more cost-effective than institutionalization, there is limited knowledge concerning the causes and prevention of institutionalization. The goal of this project was to determine the circumstances related to institutionalization of AD patients and to determine if a family counseling program can reduce these precipitating factors. In Study 1, we surveyed 109 family members of institutionalized AD patients. Primary precipitating factors included difficulties with patient behavior, insufficient auxiliary help and respite, financial difficulties, and caregiver emotional and physical complaints. In Study 2 we evaluated the effectiveness of an enhanced counseling program which included specific intervention techniques to cope with precipitating factors. For 41 AD family members who were seriously contemplating institutionalization, the precipitating factors prior to counseling were similar to those found in Study 1. After six months of individual counseling, home visits, and participation in caregiver support groups, there was only one placement, and a consistent reduction in the precipitating factors. These preliminary results suggest that a specially designed counseling program may delay or forestall institutionalization.     

Family Caregivers of Cancer Patients: Perceived Burden and Symptoms During the Early Phases of Cancer Treatment

This study investigated levels of symptoms, caregiver burden, and changes over time in 278 family caregivers (FC) of cancer patients. FCs experienced high levels of depressive symptoms and sleep disturbance, low levels of fatigue, and low to moderate levels of caregiver burden, yet these symptoms remained relatively stable over time. Being female and not being employed were factors associated with an increased risk of symptoms and caregiver burden. The understanding evolving from this study can enhance social- and health care professionals’ awareness of FCs’ challenging situation and the potential impact this has on the FCs’ ability to provide care to the patient.     

上海市闵行区社区慢性精神分裂症患者综合干预研究

目的通过了解精神科药物治疗结合技能训练对社区慢性精神分裂症患者精神症状和社会功能方面的作用,探索有效的社区精神卫生管理模式。方法将全区符合入组标准的登记在册143名精神分裂症患者随机分成干预组和对照组,对干预组在药物治疗基础上每周开展2次技能训练,持续12周,后期每月一次团体心理健康讲座,全程结合个别心理治疗。在入组前、入组3个月、入组一年后分别采用自知力与治疗态度问卷（ITAQ）、阳性与阴性症状量表（PANSS）、康复状态量表（MRSS）、家庭负担量表（FIS）进行评估。结果干预一年后ITAQ总评分为（27.4±5.14）分,优于对照组（21.67±5.53）分（t=6.09,P〈0.05）;干预3个月、1年后PANSS量表阴性症状分值分别为（11.67±3.92）和（11.46±5.16）分,均优于对照组的（9.75±3.68）和（8.98±3.07）分（t=2.95,P〈0.05;t=3.26,P〈0.05）;干预3个月后、1年后MRSS量表中社交量表分值分别为（14.64±8.90）和（15.63±9.72）分,均优于对照组（10.07±9.28）和（9.9±10.45）分（t=2.95,P〈0.05;t=3.24,P〈0.05）;干预3个月后、1年后FIS量表中对其他成员的躯体和心理健康的影响分值分别为（0.41±1.01）和（0.11±0.55）分,均优于对照组的分值（1.22±1.45）和（0.92±1.19）分（t=3.86,P〈0.05;t=5.06,P〈0.05）,差异均有统计学意义。结论在药物治疗的基础上,开展技能训练能改善精神分裂症患者的自知力与治疗态度、精神症状以及家庭负担。     

脑灵汤对阿尔茨海默病患者MMSE及血清促炎症细胞因子的影响

目的观察脑灵汤治疗轻-中度AD的临床疗效及作用机制。方法 120例轻-中度AD患者,随机分为中药治疗组、西药对照组各60例。中药治疗组用脑灵汤治疗,西药对照组用多奈哌齐治疗,疗程均为12周。观察两组治疗前后MMSE、血清中IL-1β、IL-6细胞因子的变化。结果经治疗12周后,治疗组与对照组的总疗效相当(P0.05),治疗组对MMSE量表积分改善与对照组比较差异无统计学意义(P0.05)。2治疗组能显著降低阿尔茨海默病患者血清中的IL-1β、IL-6促炎症细胞因子的含量,与对照组比较差异有统计学意义(P0.01)。结论脑灵汤治疗轻一中度AD的疗效显著,脑灵汤对MMSE量表积分改善明显,能显著改善AD患者的认知功能。其能明显降低血清中IL-1β、IL-6等促炎症细胞因子的水平,这可能是脑灵汤治疗AD的机制之一。     

Health state valuation in mild to moderate cognitive impairment: feasibility of computer-based, direct patient utility assessment.

BACKGROUND: Most patients with dementia will, at some point, need a proxy health care decision maker. It is unknown whether persons with various degrees of cognitive impairment can reliably report their health-related preferences. METHODS: The authors performed health state valuations (HSVs) of current and hypothetical future health states on 47 pairs of patients with mild to moderate cognitive impairment and their caregivers using computer-based standard gamble, time tradeoff, and rating scale techniques. RESULTS: Patients' mean (SD) age was 74.6 (9.3) years. About half of the patients were women (48%), as were most caregivers (73%), who were on average younger (mean age= 66.2 years, SD= 12.2). Most participants were white (83%); 17% were African American. The mean (SD) Mini-Mental State Examination (MMSE) score of patients was 24.2 (4.6) of 30. All caregivers and 77% of patients (36/47) completed all 18 components of the HSV exercise. Patients who completed the HSV exercise were slightly younger (mean age [SD]= 74.1 [8.5] v. 75.9 [11.8]; P = 0.569) and had significantly higher MMSE scores (mean score [SD] = 25.0 [4.3] v. 21.4 [4.4]; P = 0.018). Although MMSE scores below 20 did not preclude the completion of all 18 HSV ratings, being classified as having moderate cognitive impairment was associated with a lower likelihood of completing all scenario ratings (44% v. 82%). Patient and caregiver responses showed good consistency across time and across techniques and were logically consistent. CONCLUSION: Obtaining HSVs for current and hypothetical health states was feasible for most patients with mild cognitive impairment and many with moderate cognitive impairment. HSV assessments were consistent and reasonable.     

照顾者的照顾负担、应对方式与焦虑抑郁情绪 相关性分析

摘要:目的　探讨肠癌化疗病人主要照顾者焦虑抑郁情绪、照顾负担、应对方式现况及其相关性。方法　采用自编的一般资料问卷、医院焦虑抑郁量表（HAD）、照顾负担量表（ZBI）、简易应对方式量表（SCSQ）对319例肠癌化疗主要照顾者进行问卷调查。结果　有焦虑情绪者138例（43.3%）,有抑郁情绪者86例（27.3%）,66例（20.7%）处于焦虑抑郁共存状态;照顾负担总分为（28.7±11.3）分,83例（26.0%）处于轻度负担,182例（57.1%）处于中度负担,54例（17.54％）处于重度负担;消极应对维度均分为（1.22±0.58）分,低于国内常模,差异有统计学意义（P＜0.01）;照顾负担得分、消极应对方式得分与照顾者焦虑得分呈正相关（r＝0.50,0.19）;照顾负担得分、消极应对方式得分与照顾者抑郁得分呈正相关（r＝0.41,0.16）;积极应对方式得分与照顾者抑郁得分呈负相关（r＝-0.24）。结论　肠癌化疗病人主要照顾者存在不同程度的焦虑抑郁情绪,照顾负担以中度为主,应对方式良好,三者之间存在一定的相关性。     

Family caregiving in advanced chronic organ failure

ObjectivesTo assess caregiver burden as well as positive aspects of family caregiving in advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and chronic renal failure (CRF).DesignCross-sectional observational study.SettingPatients recruited at the outpatient clinics of academic and general hospitals in the Netherlands.ParticipantsPatients with advanced COPD (n = 73), CHF (n = 45), and CRF (n = 41) and their family caregivers.MeasurementsCaregiver burden and positive aspects of caregiving were assessed using the Family Appraisal of Caregiving Questionnaire for Palliative Care and were compared among family caregivers of patients with COPD, CHF, or CRF using linear regression analysis while controlling for characteristics of patients and family caregivers.ResultsMost family caregivers were female partners of participating patients. Caregiver distress and caregiver strain scores were relatively low, whereas scores for positive caregiving appraisals and family well-being were relatively positive. Caregiver strain, positive caregiving appraisals, and family well-being were comparable for family caregivers of patients with COPD, CHF, or CRF. Caregiver distress was higher for family caregivers of patients with COPD than CHF. The experience of caregiving was influenced by being the patient's spouse, patient's psychological symptoms, and the presence of comorbidities.ConclusionsFamily caregiving for patients with COPD, CHF, or CRF should not only be seen as a burden, but also as a positive experience. To support family caregivers, attention should be paid to caregiver burden and the positive aspects of family caregiving.     

Emotional and physical demands on caregivers in home care to the elderly in Switzerland and their relationship to nursing home admission

BACKGROUND: Planning the home care of growing numbers of old, dependent people must include the caregivers' burden. METHODS: A convenience sample of 129 caregivers of elderly patients with multiple diagnoses was interviewed about the caregiving context, burden, caregivers' tolerance of patients' troublesome behaviours and physical symptoms, mutuality and feelings of closeness between caregiver and patient. Continued maintenance of home care was assessed by a follow-up telephone call. RESULTS: Caregivers were mainly spouses (67%) and female (73%), and the mean duration of care was 5.5 years. In five activities of daily living (ADL) 50-69% of the patients needed full help. Caregivers reported predominantly negative effects of caregiving on their physical and mental health, rest and sleep, leisure time and social life, problems with patients' symptoms and behaviours and little or no conversing (51%) or exchanging feelings with patients (71%). PREDICTIVE MODELS: Contributors to variance were for burden (35%), impact of care on caregivers' mental health, social relations and leisure time, patients' gender, accumulation of patients' symptoms and behaviours; for caregivers' tolerance toward patients' symptoms and behaviours (17%) caregivers' physical health, patients' level of confusion, feelings of mutuality; for mutuality (22%) and for closeness (19%) caregivers' mental health, patients' accumulation of symptoms and behaviours. Within 23 months 19% of the patients had been institutionalized. Factors giving a higher likelihood of institutionalization were: being male, caregiver was not a partner, and less closeness between caregiver and patient. CONCLUSION: Caregiving of older persons has bio-psychosocial ramifications for caregivers. Closeness between caregiver and patient seems to be a key factor in determination of the long-term outcome.     

Association between illness progression measures and total cost in Alzheimer’s disease

Objective

To compare the associations between dependence and clinical measures of cognition, function and behaviour and total care cost using data from a longitudinal study in Alzheimer’s disease (AD).

Design

Longitudinal, observational study.

Setting

Community-dwelling subjects.

Participants

Male and female subjects between 50 and 85 years of age with mild to moderate AD.

Intervention

None.

Measurements

Subject dependence was assessed using the Dependence Scale (DS), cognition (ADAS-Cog, MMSE), function (DAD), behaviour (NPI) and resource utilization with the Resource Utilization in Dementia Questionnaire.

Results

The repeated measures models confirmed a significant association between the DS and total care cost indicating an increase in cost with increasing dependence. A 1-unit increase in DS score was associated with a 28.60% increase in total care cost. Model 2 indicated that a one point change in MMSE, DAD and NPI is associated with 5.29%, 2.32% and 1.71% increase in total cost, respectively. Model 3 indicated that a one point change in ADAS-Cog, DAD and NPI is associated with a 1.74%, 2.42%and 1.62% increase in total cost, respectively.

Conclusion

Strategies which prevent deterioration in clinical measures or delay dependence should result in total cost savings. The quantitative relationships observed should assist in the economic assessment of interventions which effect cognition, function, behaviour and dependence.     

Institutionalization of Alzheimer's Disease Patients

Although home-care of Alzheimer's disease (AD) patients is more cost-effective than institutionalization, there is limited knowledge concerning the causes and prevention of institutionalization. The goal of this project was to determine the circumstances related to institutionalization of AD patients and to determine if a family counseling program can reduce these precipitating factors. In Study 1, we surveyed 109 family members of institutionalized AD patients. Primary precipitating factors included difficulties with patient behavior, insufficient auxiliary help and respite, financial difficulties, and caregiver emotional and physical complaints. In Study 2 we evaluated the effectiveness of an enhanced counseling program which included specific intervention techniques to cope with precipitating factors. For 41 AD family members who were seriously contemplating institutionalization, the precipitating factors prior to counseling were similar to those found in Study 1. After six months of individual counseling, home visits, and participation in caregiver support groups, there was only one placement, and a consistent reduction in the precipitating factors. These preliminary results suggest that a specially designed counseling program may delay or forestall institutionalization.