Informal Caregivers of People with Dementia in Germany: Psychosocial Characteristics and Unmet Needs.

Background: Caregivers of people with dementia living at home (CPwDh) are likely to be affected by a range of health problems. However, CPwDh are often regarded as accompanying persons and receive less attention in research and care. Little is known about this population and their needs in Germany. However, better knowledge of CPwDH is needed to design effective interventions. Objective: The objective of this report is to describe the situation of CPwDh and highlight differences based on sex and living situation. Methods: This was a cross-sectional analysis of the psychosocial characteristics of participants in the GAIN trial, a cluster-randomized, controlled intervention trial investigating the effectiveness of a care management program. A total of n = 192 CPwDh were recruited in GP offices, memory clinics or through public campaigns in the German federal state of Mecklenburg-Western Pomerania. The inclusion criteria were an age of 18 years or above, being a CPwDh, written informed consent. In a comprehensive digital assessment, psychosocial variables, burden, and care needs were assessed. Results: Partners, women, and people living in the same household represented the majority of caregivers, and their mean number of needs was 8.7. Overall, participants indicated a mild to moderate burden. There are differences in burden based on sex and living situation, with caregivers living with people with dementia showing less burden and different psychosocial demographics. Conclusions: There is a need for interventions to reduce caregivers' unmet needs in the CPwDh. Such interventions should consider differences in sex and living situation to better address individual caregiver needs.

Factors Associated with Lower Social Activity in German Older Adults at Increased Risk of Dementia: A Cross-Sectional Analysis.

Background: Studies demonstrate associations between low social activity in older adults and cognitive decline. Little has been investigated regarding which factors are associated with low social activity in older adults at increased risk of dementia. Objective: We investigate which sociodemographic, psychological, health-related, and environmental factors are associated with low social activity in older adults at increased risk of dementia. Additionally, we describe the stages of health behavior change, the types of social activities, and the duration of the current level of social activity. Methods: We used baseline data of 1,015 participants from the AgeWell.de trial. We conducted logistic and Poisson regression analyses to investigate factors associated with low social activity. We report descriptive statistics on the stages of change in the sample, the types of social activities most frequently pursued, and the duration of the current level of social activity. Results: Lower income, non-usage of public transport, depressive symptoms, cognitive, mobility, and hearing impairment were negatively associated with social activity. The majority of the sample was in the maintenance stage, followed by the precontemplation stage. The most common social activities were traveling and hobbies with others. Participants have maintained their current level of social activity for several years. Conclusions: We identified a lack of resources (income, transport), depressive symptoms and poorer health (cognitive, mobility and hearing impairment) as barriers to social activity. Interventions promoting social activity in older adults at risk of dementia may specifically target individuals with these risk factors. Low-threshold opportunities for social activity may be particularly beneficial.

What influences life expectancy in people with dementia? Social support as an emerging protective factor.

BACKGROUND: The aim of this study was to investigate the role of support from the social environment for the life expectancy in people with dementia beyond well-established individual demographic and clinical predictors over a period of up to 8 years. METHODS: The analyses are based on data from 500 community-dwelling individuals in Germany who tested positive for dementia and were followed up for up to 8 years. Life expectancy was examined in relation to perceived social support as well as well-established socio-demographic (age, sex) and clinical predictors (cognitive status, functional status, comorbidities), using Cox regressions. RESULTS: Greater support from the social environment reduced the risk of mortality (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.63-0.98), with the role of emotional support being particularly important. Furthermore, higher age was associated with an increased mortality risk (HR: 1.08; 95% CI: 1.05-1.11), while female sex (HR: 0.64; 95% CI: 0.48-0.85) and higher cognitive (HR: 0.96; 95% CI: 0.93-0.98) and functional status (HR: 0.91; 95% CI: 0.86-0.97) were associated with higher life expectancy. CONCLUSION: Our study provides novel evidence that less support from the social environment, especially emotional support, is a risk factor for shorter life expectancy in people with dementia-beyond known clinical factors. Not only the clinical and caregiving needs but also their psychosocial needs of individuals with dementia should be emphasised.

A multidomain intervention against cognitive decline in an at-risk-population in Germany: Results from the cluster-randomized AgeWell.de trial.

INTRODUCTION: We investigated the effectiveness of a multidomain intervention to preserve cognitive function in older adults at risk for dementia in Germany in a cluster-randomized trial. METHODS: Individuals with a Cardiovascular Risk Factors, Aging, and Dementia (CAIDE) risk score ≥ 9 aged 60 to 77 years were recruited. After randomization of their general practitioner (GP), patients received a multidomain intervention (including optimization of nutrition and medication, and physical, social, and cognitive activity) or general health advice and GP treatment as usual over 24 months. Primary outcome was global cognitive performance (composite z score, based on domain-specific neuropsychological tests). RESULTS: Of 1030 participants at baseline, n = 819 completed the 24-month follow-up assessment. No differences regarding global cognitive performance (average marginal effect = 0.010, 95% confidence interval: -0.113, 0.133) were found between groups at follow-up. Perceived restrictions in intervention conduct by the COVID-19 pandemic did not impact intervention effectiveness. DISCUSSION: The intervention did not improve global cognitive performance. HIGHLIGHTS: Overall, no intervention effects on global cognitive performance were detected. The multidomain intervention improved health-related quality of life in the total sample. In women, the multidomain intervention reduced depressive symptoms. The intervention was completed during the COVID-19 pandemic.

Associations of Depressive Symptoms with Subjective Cognitive Decline in Elderly People-A Cross-Sectional Analysis from the AgeWell.de-Study.

To develop effective dementia prevention strategies, it is necessary to understand risk factors, associated factors and early signs of dementia. Subjective cognitive decline (SCD) is the earliest form of dementia. The aim of this study is to assess depression as a factor that is significantly associated with SCD. The data of 1030 general practitioner patients from the AgeWell.de-study (60-77 years; CAIDE dementia risk score ≥ 9) were analysed. A descriptive analysis was conducted using validated instruments like the Geriatric depression scale (GDS), Lubben social network scale (LSNS-6) and education classes according to CASMIN (Comparative Analysis of Social Mobility in Industrial Nations). A multivariate regression model with the dependent variable SCD was calculated. Of the 1030 participants, 5.9% had depressive symptoms and 31.3% SCD. The group with depressive symptoms showed significantly higher body-mass-index (p = 0.005), lower education class (p = 0.022), lower LSNS-6 score (p < 0.001), higher sports activity (p < 0.001), and more sleeping problems (p = 0.026). In the regression model a higher GDS-score [Odds ratio (OR): 1.219 (p < 0.001)], more sleeping problems [OR: 1.550 (p = 0.017)] and higher education class [middle/high: OR: 1.474/1.875 (p = 0.037/0.004)] were significantly associated with SCD. This study identified depressive symptoms, sleeping problems, and higher education classes as factors associated with SCD, which can represent an early form of dementia.

Dementia in Germany: Epidemiology and Prevention Potential.

BACKGROUND: The further development of public-health approaches for the prevention of dementia requires estimates of the number of people with dementia, trends in incidence and prevalence, and the potential impact of preventive measures. METHODS: The projections described here are based on incidence and prevalence data for Europe and on current and projected population figures from the German Federal Statistical Office. Four scenarios were calculated on the basis of two different population projections and the assumption of either stable or declining prevalence. Data from the German Aging Survey were used to estimate the prevention potential for eleven potentially modifiable risk factors for dementia. Weighting factors were determined to adjust for correlations between risk factors. RESULTS: Approximately 1.8 million people were living with dementia in Germany as of December 31, 2021; the number of new dementia cases in 2021 is estimated at 360 000 to 440 000. In 2033, depending on the scenario, 1.65 to 2 million people aged 65 and older may be affected; we consider likelihood of the lower end of this range to be very low. It is estimated that 38% of these cases are associated with 11 potentially modifiable risk factors. A 15% reduction in the prevalence of risk factors could potentially decrease the number of cases by up to 138 000 in 2033. CONCLUSION: We assume that the number of people with dementia in Germany will increase, but there is considerable prevention potential. Multimodal prevention approaches to promote healthy aging should be further developed and put into practice. Better data are needed on incidence and prevalence of dementia in Germany.

Social Network and Participation in Elderly Primary Care Patients in Germany and Associations with Depressive Symptoms-A Cross-Sectional Analysis from the AgeWell.de Study.

This study aims to describe social network and social participation and to assess associations with depressive symptoms in older persons with increased risk for dementia in Germany. We conducted a cross-sectional observational study in primary care patients (aged 60−77) as part of a multicenter cluster-randomized controlled trial (AgeWell.de). We present descriptive and multivariate analyses for social networks (Lubben Social Network Scale and subscales) and social participation (item list of social activities) and analyze associations of these variables with depressive symptoms (Geriatric Depression Scale). Of 1030 included patients, 17.2% were at risk for social isolation (Lubben Social Network Scale < 12). Looking at the subscales, a reduced non-family network was found almost twice as often as a reduced family network. Patients with depressive symptoms had significantly smaller social networks than patients without depression (p < 0.001). They rather engaged in social activities of low involvement level or no weekly social activity at all (p < 0.001). The study shows associations of depressive symptoms with a decreased social network and less social participation in elderly participants. Sufficient non-family contacts and weekly social activities seem to play an important role in mental health and should be encouraged in elderly primary care patients.

What makes a good quality indicator set? A systematic review of criteria.

BACKGROUND: While single indicators measure a specific aspect of quality (e.g. timely support during labour), users of these indicators, such as patients, providers and policy-makers, are typically interested in some broader construct (e.g. quality of maternity care) whose measurement requires a set of indicators. However, guidance on desirable properties of indicator sets is lacking. OBJECTIVE: Based on the premise that a set of valid indicators does not guarantee a valid set of indicators, the aim of this review is 2-fold: First, we introduce content validity as a desirable property of indicator sets and review the extent to which studies in the peer-reviewed health care quality literature address this criterion. Second, to obtain a complete inventory of criteria, we examine what additional criteria of quality indicator sets were used so far. METHODS: We searched the databases Web of Science, Medline, Cinahl and PsycInfo from inception to May 2021 and the reference lists of included studies. English- or German-language, peer-reviewed studies concerned with desirable characteristics of quality indicator sets were included. Applying qualitative content analysis, two authors independently coded the articles using a structured coding scheme and discussed conflicting codes until consensus was reached. RESULTS: Of 366 studies screened, 62 were included in the review. Eighty-five per cent (53/62) of studies addressed at least one of the component criteria of content validity (content coverage, proportional representation and contamination) and 15% (9/62) addressed all component criteria. Studies used various content domains to structure the targeted construct (e.g. quality dimensions, elements of the care pathway and policy priorities), providing a framework to assess content validity. The review revealed four additional substantive criteria for indicator sets: cost of measurement (21% [13/62] of the included studies), prioritization of 'essential' indicators (21% [13/62]), avoidance of redundancy (13% [8/62]) and size of the set (15% [9/62]). Additionally, four procedural criteria were identified: stakeholder involvement (69% [43/62]), using a conceptual framework (44% [27/62]), defining the purpose of measurement (26% [16/62]) and transparency of the development process (8% [5/62]). CONCLUSION: The concept of content validity and its component criteria help assessing whether conclusions based on a set of indicators are valid conclusions about the targeted construct. To develop a valid indicator set, careful definition of the targeted construct including its (sub-)domains is paramount. Developers of quality indicators should specify the purpose of measurement and consider trade-offs with other criteria for indicator sets whose application may reduce content validity (e.g. costs of measurement) in light thereof.

Implicit perceptual learning of visual-auditory modality sequences.

We examined perceptual modality sequence learning by presenting number words either visually (V) or auditorily (A). Manual responses were assigned to number identity, which was random, but the stimulus modalities followed a predictable 6-element sequence (e.g., VVAAVA). In two experiments, we assessed sequence-specific learning as the performance difference between the predictable sequence and a random transfer sequence. We expected learning benefits, but for visual trials we did not find any clear predictability benefits, and, surprisingly, for auditory trials we even found a general processing disadvantage (i.e., a predictability cost) for auditory trials (Experiment 1) or a cost-benefit pattern (Experiment 2, with equated shift rates in predictable and random sequences), with costs for auditory repetition trials and benefits for shifting to auditory processing. Hence, overall there was a general learning "cost" (Experiment 1) or a null net benefit of predictability for performance (Experiment 2). Together, the findings reveal a modality-specific sensitivity towards variations in shift frequency and modality predictability only for auditory trials, but there was no overall benefit of modality-specific sequence learning.

Towards a Process Model of Sustained Attention Tests.

Taking up new approaches and calls for experimental test validation, in the present study we propose and validate a process model of sustained attention tests. Four sub-components were postulated: the perception of an item, a simple mental operation to solve the item, a motor reaction, and the shift to the next item. In two studies, several cognitive tasks and modified versions of the d2-R test of sustained attention were applied in order to determine performance in the proposed sub-components. Their contribution for the prediction of performance in sustained attention tests and tests of higher cognitive abilities was assessed. The sub-components of the process model explained a large amount of variance in sustained attention tests, namely 55-74%. More specifically, perceptual and mental operation speed were the strongest predictors, while there was a trend towards a small influence of motor speed on test performance. The measures of item shifting showed low reliabilities and did not predict test scores. In terms of discriminant validity, results of Study 1 indicated that the postulated sub-components were insufficient to explain a large amount of variance in working memory span tasks, in Study 2 the same was demonstrated for reasoning tasks. Altogether, the present study is the first to disentangle sub-components in sustained attention tests and to determine their role for test performance.

On the Locus of the Practice Effect in Sustained Attention Tests.

The present study set out to explore the locus of the poorly understood but frequently reported and comparatively large practice effect in sustained attention tests. Drawing on a recently proposed process model of sustained attention tests, several cognitive tasks were administered twice in order to examine which specific component of test performance benefitted from practice and to which extent. It was shown that the tasks representing the three sub-components of sustained attention tests, namely the perception of an item, the simple mental operation to solve an item, and the motor reaction to indicate a response to an item, benefitted from practice. Importantly, the largest practice gain was observed for the task that required item-solving processes in addition to perceptual and motor processes. Two additional postulated mechanisms in sustained attention tests-the deliberate shifting between items and the preprocessing of upcoming items-did not become more efficient through practice. Altogether, the present study shows that the practice effect in sustained attention tests seems to be primarily due to faster item-solving processes and, to a limited extent, due to a faster perception of the item, as well as a faster motor response. Moreover, besides the sub-components, it is likely that also the coordination of perceptual, item-solving, and motor processes benefitted from practice. Altogether, the present paper may have taken a first step towards a better understanding of the specific processes that cause the large practice gains in sustained attention tests.

Consistent Shifts of Stimulus Modality Induce Chunking in Sequence Learning.

The ability to learn event sequences is crucial to human behavior because it enables us to interact adaptively with our environment. The sensory environment is essential in guiding the acquisition of these sequences, so the role of the stimulus modality in sequence learning is of high relevance. The present study examined structured stimulus modality shifts in sequence learning using the serial reaction time task (SRT). Participants had to respond to numbers that were presented either in the visual or in the auditory modality. Importantly, the numbers, as well as the stimulus modality, followed a fixed pattern. We found better performance in sequenced than in random blocks, indicating sequence learning. Moreover, the performance was better when the stimulus modality remained the same than when the modality changed between successive trials (the modality shift effect, MSE). However, sequence learning facilitated performance primarily in modality repetitions, so that the MSE became progressively larger in the sequenced blocks, while it was small in the random blocks, and this pattern was particularly pronounced for the participants who showed a high recall level for the response sequence. To account for this effect, we assume that consistent modality shifts induce parsing of the sequence into chunks. Because chunk retrieval at chunk boundaries incurs RT costs, the acquired sequence knowledge is more efficiently expressed in modality repetitions (i.e., within chunks). Together, the data suggest that the formation of explicit knowledge enhances chunking in sequence learning.

Power to the will: how exerting physical effort boosts the sense of agency.

The sense of agency refers to the experience of being in control of one's actions and their consequences. The 19th century French philosopher Maine de Biran proposed that the sensation of effort might provide an internal cue for distinguishing self-caused from other changes in the environment. The present study is the first to empirically test the philosophical idea that effort promotes self-agency. We used intentional binding, which refers to the subjective temporal attraction between an action and its sensory consequences, as an implicit measure of the sense of agency. Effort was manipulated independent of the primary task by requiring participants to pull stretch bands of varying resistance levels. We found that intentional binding was enhanced under conditions of increased effort. This suggests not only that the experience of effort directly contributes to the sense of agency, but also that the integration of effort as an agency cue is non-specific to the effort requirement of the action itself.