Case-Finding for Sarcopenia in Community-Dwelling Older Adults: Comparison of Mini Sarcopenia Risk Assessment with SARC-F and SARC-CalF.

BACKGROUND: We compared the diagnostic performance of the short five-item and full seven-item Mini Sarcopenia Risk Assessment Questionnaire (MSRA-5 and MSRA-7) against the Strength, Assistance walking, Rise from a chair, Climb stairs, and Falls (SARC-F) and SARC-F with calf circumference (SARC-CalF) scales for sarcopenia in healthy community-dwelling older adults. METHODS: We conducted a post-hoc cross-sectional secondary data analysis of a prospective cohort study, using data from 230 older adults (mean age 67.2±7.4 years, 92% Chinese, and 73% female) from the "Longitudinal Assessment of Biomarkers for characterization of early Sarcopenia and Osteosarcopenic Obesity in predicting frailty and functional decline in community-dwelling Asian older adults Study" (GeriLABS-2) conducted between December 2017 and March 2019 in Singapore. We performed receiver operating characteristic curve analysis to ascertain the area under the curve (AUC) for sarcopenia diagnosis using the Asian Working Group for Sarcopenia 2019 consensus criteria. We applied the Delong method to compare the AUCs of the four instruments. RESULTS: The MSRA-5 and MSRA-7 demonstrated poor diagnostic performance (AUC of 0.511, 95% confidence interval [CI] 0.433-0.589 and AUC of 0.526, 95% CI 0.445-0.606, respectively), compared to that in SARC-CalF (AUC of 0.739, 95% CI 0.671-0.808) and SARC-F (AUC of 0.564, 95% CI 0.591-0.636). The SARC-CalF demonstrated significantly superior discriminatory ability compared to that in the SARC-F, MSRA-5, and MSRA-7 (all p<0.01). The MSRA-5 demonstrated lower sensitivity (0.464) and specificity (0.597) than in the SARC-CalF (0.661 and 0.738, respectively), whereas the MSRA-7 had higher specificity (0.887) and lower sensitivity (0.145). CONCLUSION: Conclusions: The poor diagnostic performances of the MSRA-5 and MSRA-7 in our study suggest limitations of self-reported questionnaires for assessing general and dietary risk factors for sarcopenia in healthy and culturally diverse community-dwelling older adults. Studies in different populations are needed to ascertain the utility of the MSRA for the community detection of sarcopenia.

Effectiveness and usability of the system for assessment and intervention of frailty for community-dwelling pre-frail older adults: A pilot study.

Background: Effective multicomponent interventions in the community targeted at preventing frailty in at-risk older adults can promote healthy ageing. However, there is a lack of studies exploring the effectiveness of technology-enabled autonomous multi-domain community-based interventions for frailty. We developed a novel end-to-end System for Assessment and Intervention of Frailty (SAIF) with exercise, nutrition, and polypharmacy components. This pilot study aimed to explore SAIF's effectiveness in improving frailty status, physical performance and strength, and its usability in pre-frail older adults. Materials and methods: This is a single arm 8-week pilot study in 20 community-dwelling older adults who were pre-frail, defined using the Clinical Frailty Scale (CFS) as CFS 3 + (CFS 3 and FRAIL positive) or CFS 4. For outcomes, we assessed frailty status using the modified Fried Frailty Phenotype (FFP) and CFS; physical performance using Short Physical Performance Battery (SPPB); and Hand Grip Strength (HGS) at baseline and 8-week. User experience was explored using the System Usability Scale (SUS), interest-enjoyment subscale of the Intrinsic Motivation Inventory and open-ended questions. We analyzed effectiveness using repeated-measures tests on pre-post scores, and usability using a convergent mixed-method approach via thematic analysis of open-ended responses and descriptive statistics of usability/interest-enjoyment scales. Results: Sixteen participants (71.8 ± 5.5 years) completed the 8-week study. There was a significant improvement in FFP score (-0.5, p < 0.05, effect size, r = 0.43), but not CFS (-1.0, p = 0.10, r = 0.29). Five (31.3%) improved in frailty status for both FFP and CFS. SPPB (+1.0, p < 0.05, r = 0.42) and HGS (+3.5, p < 0.05, r = 0.45) showed significant improvements. Three themes were identified: "Difficulty in module navigation" (barriers for SAIF interaction); "User engagement by gamification" (facilitators that encourage participation); and "Perceived benefits to physical health" (subjective improvements in physical well-being), which corroborated with SUS (68/100) and interest-enjoyment (3.9/5.0) scores. Taken together, user experience results cohere with the Senior Technology Acceptance and Adoption Model. Conclusion: Our pilot study provides preliminary evidence of the effectiveness of SAIF in improving frailty status, physical performance and strength of pre-frail older adults, and offers user experience insights to plan the follow-up large-scale randomized controlled trial.

Validating the Centre of Excellence on Longevity Self-AdMinistered (CESAM) Questionnaire: An Online Self-Reported Tool for Frailty Assessment of Older Adults.

OBJECTIVES: Subjective health measures are often used to assess frailty, but the validity of self-reported online tools to identify frailty remains to be established. We aimed to assess concurrent, known-groups, convergent and predictive validity of the Centre of Excellence on Longevity Self-AdMinistered (CESAM) questionnaire for frailty assessment of older adults in an outpatient setting. DESIGN: Cross-sectional analysis of 120 participants. SETTING AND PARTICIPANTS: Participants of age ≥65 were recruited from an outpatient geriatric clinic. Individuals who had severe neurological, cognitive, or motor deficits were excluded. METHODS: We assessed concurrent validity with area under receiver operating characteristic curve (AUC) against the Frailty Index (FI) and Clinical Frailty Scale (CFS). We analyzed known-groups validity between CESAM scores with frailty status (CFS and FI), Modified Barthel Index (MBI), and modified Chinese Mini-Mental State Examination (mCMMSE) using 1-way analysis of variance. We evaluated convergent validity using correlations with MBI, the Lawton index, mCMMSE, and Geriatric Depression Scale (GDS). Associations between CESAM-identified frailty for clinician-diagnosed geriatric syndromes, and health-related quality of life (HRQoL) was analyzed using regression analysis. RESULTS: The CESAM questionnaire demonstrated excellent diagnostic performance for frailty using FI ≥0.25 (AUC = 0.88; 95% CI: 0.82-0.94; P < .001) and CFS ≥4 (AUC = 0.78; 95% CI: 0.68-0.88; P < .001). CESAM scores increased significantly with increasing frailty (both CFS and FI), lower MBI, and lower mCMMSE scores (all P < .001), indicating concurrent validity. The moderate-good correlation of CESAM scores with MBI (r = -0.61; P < 0.001), Lawton Index (r = -0.54; P < .001), mCMMSE (r = -0.53; P < .001) and GDS (r = 0.58; P < .001) supports convergent validity. Using a cutoff of ≥8 for frailty identification, CESAM-identified frailty was associated with cognitive impairment (OR = 3.7; 95% CI: 1.7-8.2; P = .001) depression (OR = 4.0; 95% CI: 1.7-9.6; P = .002), falls (OR = 3.1; 95% CI: 1.2-8.2; P = .021) and poorer HRQoL (ß = -0.1; 95% CI: -0.2 to -0.02; P = .017). CONCLUSION AND IMPLICATIONS: Our results support the validity of an online self-reported tool to identify frailty and geriatric syndromes in an outpatient setting, an approach that is potentially applicable for remote screening of frailty.

Protocol for a mixed-methods and multi-site assessment of the implementation process and outcomes of a new community-based frailty programme.

BACKGROUND: Frailty is increasing in prevalence internationally with population ageing. Frailty can be managed or even reversed through community-based interventions delivered by a multi-disciplinary team of professionals, but to varying degrees of success. However, many of these care models' implementation insights are contextual and may not be applicable in different cultural contexts. The Geriatric Service Hub (GSH) is a novel frailty care model in Singapore that focuses on identifying and managing frailty in the community. It includes key components of frailty care such as comprehensive geriatric assessments, care coordination and the assembly of a multi-disciplinary team. This study aims to gain insights into the factors influencing the development and implementation of the GSH. We also aim to determine the programme's effectiveness through patient-reported health-related outcomes. Finally, we will conduct a healthcare utilisation and cost analysis using a propensity score-matched comparator group. METHODS: We will adopt a mixed-methods approach that includes a qualitative evaluation among key stakeholders and participants in the programme, through in-depth interviews and focus group discussions. The main topics covered include factors that affected the development and implementation of each programme, operations and other contextual factors that influenced implementation outcomes. The quantitative evaluation monitors each programme's care process through quality indicators. It also includes a multiple-time point survey study to compare programme participants' pre- and post- outcomes on patient engagement, healthcare services experiences, health status and quality of life, caregiver burden and societal costs. A retrospective cohort study will compare healthcare and cost utilisation between participants of the programme and a propensity score-matched comparator group. DISCUSSION: The GSH sites share a common goal to increase the accessibility of essential services to frail older adults and provide comprehensive care. This evaluation study will provide invaluable insights into both the process and outcomes of the GSH and inform the design of similar programmes targeting frail older adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04866316 . Date of Registration April 26, 2021. Retrospectively registered.

Cognitive Assessment by Telemedicine: Reliability and Agreement between Face-to-Face and Remote Videoconference-Based Cognitive Tests in Older Adults Attending a Memory Clinic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has spurred the rapid adoption of telemedicine. However, the reproducibility of face-to-face (F2F) versus remote videoconference-based cognitive testing remains to be established. We assessed the reliability and agreement between F2F and remote administrations of the Abbreviated Mental Test (AMT), modified version of the Chinese Mini-Mental State Examination (mCMMSE), and Chinese Frontal Assessment Battery (CFAB) in older adults attending a memory clinic. METHODS: The participants underwent F2F followed by remote videoconference-based assessment by the same assessor within 3 weeks. Reliability was evaluated using intraclass correlation coefficients (ICC; two-way mixed, absolute agreement), the mean difference between remote and F2F-based assessments using paired-sample t-tests, and agreement using Bland-Altman plots. RESULTS: Fifty-six subjects (mean age, 76±5.4 years; 74% mild; 19% moderate dementia) completed the AMT and mCMMSE, of which 30 completed the CFAB. Good reliability was noted based on the ICC values-AMT: ICC=0.80, 95% confidence interval [CI] 0.68-0.88; mCMMSE: ICC=0.80, 95% CI 0.63-0.88; CFAB: ICC=0.82, 95% CI 0.66-0.91. However, remote AMT and mCMMSE scores were higher compared to F2F-mean difference (i.e., remote minus F2F): AMT 0.3±1.1, p=0.03; mCMMSE 1.3±2.9, p=0.001. Significant differences were observed in the orientation and recall items of the mCMMSE and the similarities and conflicting instructions of CFAB. Bland-Altman plots indicated wide 95% limits of agreement (AMT -1.9 to 2.6; mCMMSE -4.3 to 6.9; CFAB -3.0 to 3.8), exceeding the a priori-defined levels of error. CONCLUSION: While the remote and F2F cognitive assessments demonstrated good overall reliability, the test scores were higher when performed remotely compared to F2F. The discrepancies in agreement warrant attention to patient selection and environment optimization for the successful adaptation of telemedicine for cognitive assessment.

Corrigendum: Effectiveness and usability of the system for assessment and intervention of frailty for community-dwelling pre-frail older adults: A pilot study.

[This corrects the article DOI: 10.3389/fmed.2022.955785.].

COVID-19 and older people in Asia: Asian Working Group for Sarcopenia calls to actions.

The coronavirus disease 2019 (COVID-19) pandemic has casted a huge impact on global public health and the economy. In this challenging situation, older people are vulnerable to the infection and the secondary effects of the pandemic and need special attention. To evaluate the impacts of COVID-19 on older people, it is important to balance the successful pandemic control and active management of secondary consequences. These considerations are particularly salient in the Asian context, with its diversity among countries in terms of sociocultural heritage, healthcare setup and availability of resources. Thus, the Asian Working Group for Sarcopenia summarized the considerations of Asian countries focusing on responses and difficulties in each country, impacts of health inequity related to the COVID-19 pandemic and proposed recommendations for older people, which are germane to the Asian context. More innovative services should be developed to address the increasing demands for new approaches to deliver healthcare in these difficult times and to establish resilient healthcare systems for older people. Geriatr Gerontol Int 2020; 9999: n/a-n/a.

Associations of lifestyle activities and a heathy diet with frailty in old age: a community-based study in Singapore.

Frailty is an age-related state characterized by a reduced physiological reserve, and is associated with adverse health outcomes in the elderly. We analyzed the data from 895 adults aged 60 years and above, and investigated the relationships between midlife and late-life social activities, intellectual activities, working hours, and dietary habits and frailty status. Participation in social or intellectual activities in late life was less prevalent among those who were frail than among those who were robust. A greater proportion of those who were frail had worked long hours in midlife. After adjustment for confounders, participating in social activities or intellectual activities in late life was associated with a reduced risk for prefrailty and frailty, while working long hours in midlife was associated with a higher risk for frailty. The risk of frailty decreased with increasing healthy diet scores in midlife and late life. When the results were stratified by gender, late-life participation in social activities and midlife or late-life participation in intellectual activities correlated negatively with prefrailty/frailty only in women. Our study suggests that social and intellectual activities are inversely associated with frailty status, but the association seems to differ based on gender.

Shared leadership in interprofessional teams: beyond team characteristics to team conditions.

Shared leadership has been shown to enhance processes, effectiveness, and performances in interprofessional teams. While earlier studies suggest the association of internal team environment (ITE) and transactive memory system (TMS) with shared leadership, the relative influence of these team conditions vis-a-vis team characteristics (such as team size, stability, and interprofessional roles) on shared leadership is not well understood. This study aims to examine the comparative influence of team characteristics versus team conditions of ITE and TMS on shared leadership during interprofessional team meetings (IPTMs). We compared interprofessional teams from two departments, namely larger and more diverse teams of Geriatric Medicine versus the smaller and more homogeneous Palliative Medicine. We administered a questionnaire survey to healthcare professionals who attended IPTMs in both departments (N = 133). Our results revealed significantly higher scores in shared leadership, ITE and TMS in Palliative Medicine (p < .05). Using hierarchical regression analysis adjusting for team conditions, department and number of IPTMs attended were not significant in the final model (both p > .05). Instead, TMS (ß= 0.250, p < .01) and ITE (ß= 0.584, p < .01) outperformed team characteristics as conditions that are highly associated with shared leadership, explaining an additional 29.8% and 19.0%, respectively, of model variance. Further analysis revealed a stronger correlation between shared leadership subdomains with TMS in Geriatric Medicine and with ITE in Palliative Medicine. Our results demonstrate how a positive working environment with a high level of shared memory engendered a perception of shared leadership, and how these team conditions can be tapped upon to circumvent differences in team characteristics to facilitate shared leadership. Identifying key conditions that are highly associated with shared leadership is critical for the teaching of dynamic leadership roles to junior clinicians which in turn, can enhance patient care.

The Aging of a Young Nation: Population Aging in Singapore.

The juxtaposition of a young city-state showing relative maturity as a rapidly aging society suffuses the population aging narrative in Singapore and places the "little red dot" on the spotlight of international aging. We first describe population aging in Singapore, including the characteristic events that shaped this demographic transition. We then detail the health care and socioeconomic ramifications of the rapid and significant shift to an aging society, followed by an overview of the main aging research areas in Singapore, including selected population-based data sets and the main thrust of leading aging research centers/institutes. After presenting established aging policies and programs, we also discuss current and emerging policy issues surrounding population aging in Singapore. We aim to contribute to the international aging literature by describing Singapore's position and extensive experience in managing the challenges and maximizing the potential of an aging population. We hope that similar graying populations in the region will find the material as a rich source of information and learning opportunities. Ultimately, we aspire to encourage transformative collaborations-locally, regionally, and internationally-and provide valuable insights for policy and practice.

Impact of diabetes on caregiver stress in patients with Alzheimer's disease: data from the ICTUS study.

ABSTRACTBackground:To estimate the impact of comorbid diabetes on caregiver stress in Alzheimer's disease (AD) patients from the Impact of Cholinergic Treatment Use (ICTUS) study. METHODS: Using the Data from the ICTUS study, diabetes mellitus (DM) was recorded at baseline and caregiver burden was assessed twice per year using the Zarit Burden Interview (ZBI) scale. The three-factorial model of ZBI (the effect on the social and personal life of caregivers, the psychological burden and the feelings of guilt) was adopted. Linear mixed models were used to examine the relation between DM and the scores of ZBI. RESULTS: The present analyses were conducted on 1,264 AD subjects. A total of 156 patients (12.3%) had DM with taking antidiabetic medication and/or self-report of a history. At baseline, the caregivers of patients with or without DM had similar ZBI global scores and similar scores of three different factors of ZBI. Unadjusted and adjusted models both indicated that ZBI global score increased over a 24-month follow-up without significant effect of DM. Similarly, unadjusted model showed that DM was not determining any significant difference in the score of any factor. However, adjusted model indicated that in diabetic patients, the scores of the social and personal life of caregivers and the psychological burden increased more slowly than those in non-diabetic patients (p = 0.04 and 0.01, respectively). CONCLUSIONS: DM may affect the caregivers' daily social and personal life and psychological burden in AD patients. It is necessary for further research.

Cost-effectiveness modelling of novel oral anticoagulants incorporating real-world elderly patients with atrial fibrillation.

BACKGROUND: Novel oral anticoagulants (NOACs) expand the treatment options for patients with atrial fibrillation (AF). Their benefits need to be weighed against the risk-benefit ratio in real-world elderly patients, prompting this cost-effectiveness study of NOACs (apixaban, dabigatran, edoxaban and rivaroxaban), warfarin and aspirin for stroke prevention in AF. METHODS: Applying effectiveness estimates from a network meta-analysis involving over 800,000 patients from randomised controlled trials and observation studies, our Markov model projected cost and health outcomes for a cohort of 65-year-old AF patients over a life-time. We performed subgroup analysis stratified by age (65-74 and ≥75years), with further analysis limited to observational studies involving dabigatran and rivaroxaban. RESULTS: Compared to warfarin, NOACs (except dabigatran 110) were associated with incremental cost-effectiveness ratios ranging from USD 24,476 to USD 41,448 that were within cost-effectiveness threshold of USD 49,700 (one gross domestic product per capita in Singapore in 2015). Aspirin regimens were dominated. In elderly aged ≥75years, cost effectiveness of NOACs (except apixaban) decreased, owing to worsened performance in safety profile. Analysis limited to observational studies revealed that dabigatran 150 and rivaroxaban were not cost-effective, reflecting increased bleeding risks in non-controlled settings. Threshold analyses revealed that apixaban was no longer cost-effective at two to three times higher bleeding risk. CONCLUSIONS: Whilst NOACs are cost-effective in the younger elderly compared to warfarin, their benefits appear to be offset by worsened risk profile in older elderly, especially in non-controlled settings. Decisions on appropriate AF treatment should balance treatment-related benefits, risks, and patient preference.

Severe Impairment Rating Scale: A Useful and Brief Cognitive Assessment Tool for Advanced Dementia for Nursing Home Residents.

To investigate the utility of the Severe Impairment Rating Scale (SIRS) as a cognitive assessment tool among nursing home residents with advanced dementia, we conducted a cross-sectional study of 96 residents in 3 nursing homes with Functional Assessment Staging Test (FAST) stage 6a and above. We compared the discriminatory ability of SIRS with the Chinese version of Mini-Mental State Examination, Abbreviated Mental Test, and Clock Drawing Test. Among the cognitive tests, SIRS showed the least "floor" effect and had the best capacity to distinguish very severe (FAST stages 7d-f) dementia (area under the curve 0.80 vs 0.46-0.76 for the other tools). The SIRS had the best correlation with FAST staging (r = -.59, P < .01) and, unlike the other 3 tools, exhibited only minimal change in correlation when adjusted for education and ethnicity. Our results support the utility of SIRS as a brief cognitive assessment tool for advanced dementia in the nursing home setting.

Caregiver Burden: Looking Beyond the Unidimensional Total Score.

The Zarit Burden Interview allows caregiver burden to be interpreted from a total score. However, recent studies propose a multidimensional Zarit Burden Interview model. This study aims to determine the agreement between unidimensional (UD) and multidimensional (MD) classification of burden, and differences in predictors among identified groups. We studied 165 dyads of dementia patients and primary caregivers. Caregivers were dichotomized into low-burden and high-burden groups based upon: (1) UD score using quartile cutoffs; and (2) MD model via exploratory cluster analysis. We compared UD versus MD 2×2 classification of burden using κ statistics. Caregivers not showing agreement by either definition were classified as "intermediate" burden. We performed binary logistic regression to ascertain differences in predictive factors. The 2 models showed moderate agreement (κ=0.72, P<0.01), yielding 104 low, 20 intermediate (UD "low burden"/MD "high burden"), and 41 high-burden caregivers. Neuropsychiatric symptoms [odds ratio (OR)=1.27, P=0.003], coresidence (OR=6.32, P=0.040), and decreased caregiving hours (OR=0.99, P=0.018) were associated with intermediate burden, whereas neuropsychiatric symptoms (OR=1.21, P=0.001) and adult children caregivers (OR=2.80, P=0.055) were associated with high burden. Our results highlight the differences between UD and MD classification of caregiver burden. Future studies should explore the significance of the noncongruent intermediate group and its predictors.

Montreal Cognitive Assessment for screening mild cognitive impairment: variations in test performance and scores by education in Singapore.

BACKGROUND: The Montreal Cognitive Assessment (MoCA) was developed as a screening instrument for mild cognitive impairment (MCI). We evaluated the MoCA's test performance by educational groups among older Singaporean Chinese adults. METHOD: The MoCA and Mini-Mental State Examination (MMSE) were evaluated in two independent studies (clinic-based sample and community-based sample) of MCI and normal cognition (NC) controls, using receiver operating characteristic curve analyses: area under the curve (AUC), sensitivity (Sn), and specificity (Sp). RESULTS: The MoCA modestly discriminated MCI from NC in both study samples (AUC = 0.63 and 0.65): Sn = 0.64 and Sp = 0.36 at a cut-off of 28/29 in the clinic-based sample, and Sn = 0.65 and Sp = 0.55 at a cut-off of 22/23 in the community-based sample. The MoCA's test performance was least satisfactory in the highest (>6 years) education group: AUC = 0.50 (p = 0.98), Sn = 0.54, and Sp = 0.51 at a cut-off of 27/28. Overall, the MoCA's test performance was not better than that of the MMSE. In multivariate analyses controlling for age and gender, MCI diagnosis was associated with a <1-point decrement in MoCA score (η(2) = 0.010), but lower (1-6 years) and no education was associated with a 3- to 5-point decrement (η(2) = 0.115 and η(2) = 0.162, respectively). CONCLUSION: The MoCA's ability to discriminate MCI from NC was modest in this Chinese population, because it was far more sensitive to the effect of education than MCI diagnosis.

Differential perceptions of quality of life (QoL) in community-dwelling persons with mild-to-moderate dementia.

BACKGROUND: Discordance between patient- and caregiver-reported quality of life (QoL) is well recognized. This study sought to (i) identify predictors of discrepancy between patient- and caregiver-rated QoL amongst community-dwelling persons with mild-to-moderate dementia, and (ii) differentiate between patients who systematically rate their QoL lower versus those who rate their QoL higher relative to their caregiver ratings. METHODS: We recruited 165 patient-caregiver dyads with mild-to-moderate dementia. Quality of life in Alzheimer's disease (QoL-AD) scale was administered separately to patients and caregivers. Data on socio-demographics, interpersonal relationship, and disease-related characteristics (cognitive performance, mood, neuropsychiatric symptoms, functional ability, and caregiver burden) were collected. Patient-caregiver dyads were categorized based on whether patient-rated QoL was lower or higher than their respective caregiver ratings. Univariate analyses and multiple regression models were performed to identify predictors of dyadic rating discrepancy. RESULTS: Mean patient-rated QoL was significantly higher than caregiver rating (mean difference: 3.8 ± 7.1, p < 0.001). Majority (111 (67.2%)) of patients had more positive self-perceived QoL (QoL-ADp (QoL-AD self rated by the patient) > QoL-ADc (QoL-AD proxy-rated by a caregiver)), compared with those (44 (26.7%)) with poorer self-perceived QoL (QoL-ADp < QoL-ADc). Patient's education level, depressive symptoms, and severity of neuropsychiatric symptoms predicted magnitude of discrepancy. Depression (OR = 1.17, 95% CI = 1.02-1.35) and being cared for by other relative (non-spouse/adult child; OR = 7.54, 95% CI = 1.07-53.03) predicted poorer self-perceived QoL. CONCLUSIONS: Dyadic rating discrepancy in QoL should draw the clinician's attention to patient depression and neuropsychiatric symptoms. Consideration should also be given to nature of patient-caregiver relationship when discordance between patient and caregiver assessments of QoL is observed.

Worry about performance: a unique dimension of caregiver burden.

BACKGROUND: Recent studies that describe the multidimensionality of the Zarit Burden Interview (ZBI) challenge the traditional dual-factor paradigm of personal and role strains (Whitlatch et al., 1991). These studies consistently reported a distinct dimension of worry about caregiver performance (WaP) comprising items 20 and 21.The present study aims to compare WaP against conventional ZBI domains in a predominantly Chinese multi-ethnic Asian population. METHODS: We studied 130 consecutive dyads of family caregivers and patients. Factor analysis of the 22-item ZBI revealed four factors of burden. We compared WaP (factor 4) with the other three factors, personal strain, and role strain via: internal consistency; inter-factor correlation; item-to-total ratio across Clinical Dementia Rating (CDR) stages; predictors of burden; and interaction effect on total ZBI score using two-way analysis of variance. RESULTS: WaP correlated poorly with the other factors (r = 0.05-0.21). It had the highest internal consistency (Cronbach's α = 0.92) among the factors. Unlike other factors, WaP was highly endorsed in mild cognitive impairment and did not increase linearly with disease severity, peaking at CDR 1. Multiple regression revealed younger caregiver age as the major predictor of WaP, compared with behavioral and functional problems for other factors. There was a significant interaction between WaP and psychological strain (p = 0.025). CONCLUSION: Our results corroborate earlier studies that WaP is a distinct burden dimension not correspondent with traditional ZBI domains. WaP is germane to many Asian societies where obligation values to care for family members are strongly influential. Further studies are needed to better delineate the construct of WaP.