Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper.

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Do changes in specific cognitive functions predict changes in health-related quality of life in people with Alzheimer's disease?

OBJECTIVE: Currently available pharmacological treatments in Alzheimer's disease (AD) have been associated with modest benefits to cognition, but the impact on health-related quality of life (HRQoL) is less well established. Our aim was to determine if decline of specific cognitive functions commonly associated with AD predict which patients maintain or experience a deterioration of their HRQoL over 18 months. METHODS: We completed an 18-month longitudinal study of 47 community-dwelling older adults diagnosed with probable AD of mild or moderate severity (NINCDS-ADRD criteria) and their family carers. The primary outcomes of interest were 18-month change in self-reported and carer-reported ratings on the quality of life-AD (QoL-AD). The main explanatory variables were 18-month change in specific cognitive functions using a broad range of established tests. Because of multiple comparisons, alpha was set at 1%. RESULTS: Twenty six of 47 and 20/47 participants with AD showed evidence of stable or increased QoL-AD over 18 months according to self report and carer report. Logistic regression analyses showed that for every increase in one standardized score of California Verbal Learning Test-II short delay free recall the odds of stable/increased self-rated QoL-AD over 18 months were 0.27 (95%CI: 0.11, 0.67; p = 0.005). After adjustment for anxiety and depression, this inverse association no longer met the study criteria for statistical significance (adjusted OR: 0.31, 95%CI: 0.11, 0.86; p = 0.025). None of the other standardized changes of cognitive scores were associated with self-rated or carer-rated QoL-AD grouping. CONCLUSION: Changes in specific cognitive functions are not associated with changes in HRQoL ratings in AD. Findings suggest that interventions that limit their focus to improving cognitive functions of people with mild to moderate AD living in the community might fail to have an impact on participants' HRQoL.

Determining the predictors of change in quality of life self-ratings and carer-ratings for community-dwelling people with Alzheimer disease.

The aim of this study was to determine the factors that mediate changes in Health Related Quality of Life (HRQoL) ratings by community-dwelling people with Alzheimer disease (AD) and carers over a period of 18 months. We completed an 18-month longitudinal study of 80 community-dwelling older adults diagnosed with probable AD of mild or moderate severity (NINCDS-ADRD criteria) and their family carers. The primary outcome of interest was the 18-month change in HRQoL ratings as measured with the Quality of Life-AD (QoL-AD) (by carer and by self). Explanatory variables included demographics, lifestyle, cognition, awareness, psychopathology, burden-of-care, use of medication, and functionality in daily life. We found a significant decline (8.7%, P=0.003) in QoL-AD carer-ratings, but not in self-ratings. The final parsimonious model of predictors of changes in QoL-AD self-ratings explained 22.6% of the variance; only changes on Hospital Anxiety and Depression Scale Anxiety retained significance. The final model of predictors of changes in carer-ratings explained 55.0% of the variance: that is, changes on Informant Questionnaire on Cognitive Decline in the Elderly, changes on Hospital Anxiety and Depression Scale Depression, practicing hobbies at 18 months, and number of visit(s) or admission(s) to hospital. HRQoL self-ratings and carer-ratings of community-dwelling people with AD do not decline at same rate over 18 months and changes are associated with different factors. Interventions designed to optimize quality of life of people with AD should consider carefully whose HRQoL ratings they wish to change.

Quality of life in Alzheimer's disease: different factors associated with complementary ratings by patients and family carers.

BACKGROUND: Quality of life (QoL) in dementia is a complex construct and factors that predict QoL ratings are unclear. We designed this study to determine: (1) the agreement in QoL ratings between community-dwelling patients with mild to moderate dementia and family carers; and (2) the factors associated with self-reported and two types of carer-reported QoL ratings: carer-carer perspective and carer-patient perspective. METHODS: A cross-sectional study was carried out of 80 community-dwelling patients with the diagnosis of probable Alzheimer's disease (AD) of mild or moderate severity according to NINCDS-ADRD criteria, and their 80 family carers. The QoL-AD was the primary outcome measure. We collected patients' self-reported QoL ratings and two types of carer-reported QoL ratings: carer-patient and carer-carer perspectives. Explanatory variables included demographics, lifestyle, and clinical information from patients and carers, along with cognition, awareness, psychopathology, burden-of-care, and functionality in daily life. Bland-Altman plots guided the interpretation of agreement by visualizing the distribution of all the ratings. Univariate and multivariate regression analyses were conducted to examine the contribution of candidate explanatory factors. RESULTS: Patients and their carers showed good agreement in their QoL ratings, although the total scores of carers (regardless of perspective) were lower than the scores of patients. Depression, insight and use of anti-dementia agents were associated with QoL self-ratings, whereas cognitive function was directly associated and depression inversely associated with carers' QoL ratings. CONCLUSION: Mild to moderate community-dwelling AD patients and their carers (with different perspectives) agree within an acceptable range in QoL ratings but the ratings are driven by different factors, and consequently are not interchangeable but complementary. They provide valuable information when used separately, not in a composite score.

Cognitive Domains and Health-Related Quality of Life in Alzheimer's Disease.

OBJECTIVES: The nature of the association between the cognitive decline and quality of life (QoL) during the course of Alzheimer's disease (AD) has not been studied in detail. We designed this study to determine if the association between cognitive domains in AD and health-related quality of life (HRQoL) changed over 18 months. METHODS: We recruited 80 community-dwelling older adults with mild to moderate AD and 61 healthy elderly controls as well as their next-of-kin. The primary outcome measure was the QoL-AD. Specific cognitive functions were assessed with a broad range of neuropsychological measures, which were later grouped into cognitive domains following factor analyses at the baseline and 18-month assessments. Other explanatory variables included demographics, psychopathology, burden of care, and use of medication. RESULTS: Self-reported QoL-AD scores were not associated with any of the identified cognitive domains at either assessment. The cognitive domains of people with AD changed between baseline and the 18-month assessment, as did the association of these factors with carer-rated HRQoL. The HRQoL scores assigned by the next-of-kin declined alongside a general measure of cognitive function. DISCUSSION: These results indicate that HRQoL is not consistently associated with specific cognitive domains in AD and that cognitive-enhancing focused therapies may fail to affect the HRQoL of people with AD.

Use of Potentially Harmful Medications and Health-Related Quality of Life among People with Dementia Living in Residential Aged Care Facilities.

BACKGROUND: Use of potentially harmful medications (PHMs) is common in people with dementia living in Residential Aged Care Facilities (RACFs) and increases the risk of adverse health outcomes. Debate persists as to how PHM use and its association with quality of life should be measured. We designed this study to determine the association of exposure to PHM, operationalized by three different measures, with self-reported Health-Related Quality of Life among people with dementia residing in RACFs. METHODS: Cross-sectional study of 351 people aged >65 years diagnosed with dementia residing in RACFs and with MMSE ≤24. The primary outcome measure was the self-rated Quality of Life - Alzheimer's disease questionnaire (QoL-AD). We collected data on patients' medications, age, gender, MMSE total score, Neuropsychiatric Inventory total score, and comorbidities. Using regression analyses, we calculated crude and adjusted mean differences between groups exposed and not exposed to PHM according to potentially inappropriate medications (PIMs; identified by Modified Beers criteria), Drug Burden Index (DBI) >0 and polypharmacy (i.e. ≥5 medications). RESULTS: Of 226 participants able to rate their QoL-AD, 56.41% were exposed to at least one PIM, 82.05% to medication contributing to DBI >0, and 91.74% to polypharmacy. Exposure to PIMs was not associated with self-reported QoL-AD ratings, while exposure to DBI >0 and polypharmacy were (also after adjustment); exposure to DBI >0 tripled the odds of lower QoL-AD ratings. CONCLUSION: Exposure to PHM, as identified by DBI >0 and by polypharmacy (i.e. ≥5 medications), but not by PIMs (Modified Beers criteria), is inversely associated with self-reported health-related quality of life for people with dementia living in RACFs.