Caregivers' Sense of Coherence: Implications on Direct and Indirect Costs of Dementia Care.

BACKGROUND: Dementia care is associated with physical, emotional, and monetary impact on the informal carers providing unpaid care. Differences in the personal characteristics of caregivers may help explain the variations in the costs of dementia care. OBJECTIVE: The aim of this study was to analyze the effect of caregivers' sense of coherence (SOC) on direct and indirect costs in dementia care. METHODS: A cross-sectional study was conducted in community dwelling caregivers of patients with Alzheimer's disease. Data of healthcare services were obtained from clinical registries, and information was collected from caregivers regarding their use of social care resources and time spent caregiving. The transformation of all costs into Euros was made assigning a fixed cost of 10.29 € /h and 16.24 € /h for assisting in instrumental and basic activities of daily living, respectively. Caregivers' SOC was assessed using the Orientation to Life Questionnaire (OLQ-13). Adjusted regression models were developed, with different types of costs as dependent variables. RESULTS: A sample of 147 caregivers was recruited. The mean OLQ-13 score was 73.3 points (SD = 11.6). The regression models showed a small association between caregivers' SOC and direct costs, mainly linked to the use of social care resources (r2 = 0.429; ß= -15.6 € /month), and a greater association between SOC and indirect costs (r2 = 0.562; ß= -222.3 € /month). CONCLUSION: Increasing caregivers' SOC could reduce dementia care costs by decreasing the use of social care resources and caregiving time.

Antonovsky's sense of coherence and resistance resources reduce perception of burden in family carers of people with Alzheimer's disease.

Objectives: Taking care of people with dementia (PWD) has been associated with some degree of burden. The variability of the carer's burden can be partially explained by their personal characteristics. Antonovsky's model of health defined the resistance resources (RRs) as essential mechanisms to cope with stressors, and to shape the personal sense of coherence (SOC). This study identifies the RRs related with carer's SOC, and their implications in the perception of burden in family dementia carers.Methods: A sample of 308 participants from the 'SOC & DEM study' (154 carers and 154 PWD) was recruited from two memory clinics. Carer's personal characteristics of burden, SOC, self-efficacy, coping strategies, perceived social support, and depression were evaluated using standardized instruments. PWD's degree of dependence and behaviour and psychological symptoms of dementia (BPSD) were assessed too. A path analysis was used to test the relationship between caregiver burden and SOC including the personal RRs of the carers and clinical data of PWD.Results: The path model identified SOC as a major factor related to carer's burden perception (r = -.327). Self-efficacy (r = .285), two coping strategies, 'use instrumental support' (r = -.235) and 'behavioural disengagement' (r = -.219), and social support perceived (r = .304) were the main carer's personal characteristics directly related with SOC. Caring experience (r = -.281) was the main carer factor related with burden while dependence (r = .156) and BPSD (r = .157) were the dementia factors.Conclusion: The SOC has previously related with carer's burden. The results contributed to identify relevant and modifiable personal characteristics as RRs that could reduce this burden.

Incidence and characteristics of uncommon dementia subtypes: Results from 10 years of clinical surveillance by the Registry of Dementia of Girona.

INTRODUCTION: Age- and sex-stratified incidence rates of uncommon dementia subtypes are imprecise and scarce. METHODS: We used data from 7357 newly diagnosed individuals aged between 30.6 and 101.0 years from the Registry of Dementia of Girona during 2007-2016 to determine the incidence rates of uncommon dementia subtypes stratified by sex and age groups and to describe their clinical characteristics. RESULTS: Uncommon dementia subtypes were classified according to their etiology. The incidence rate of uncommon dementia subtypes was 27.8 cases per 100,000 person-years for those aged 30 years and older, 3.7 cases per 100,000 person-years for people aged less than 65 years, and 110.9 per 100,000 person-years for those aged 65 years and older. Age, sex, dementia severity, and medical comorbidities were different depending on the dementia subtype. DISCUSSION: There are differences in the incidence rates and the demographic and clinical characteristics among uncommon dementia subtypes for age and sex groups.

Pain treatment and its cost in old people with dementia: a descriptive analysis from the Registry of Dementias of Girona (ReDeGi).

BACKGROUND: Pain prevalence is high among elderly people, and equally prevalent in those with dementia. The aim of this study was to describe the use analgesics, as well as the cost of these treatments in old people with dementia. METHODS: We used a cross-sectional design using 1186 cases registered by the Registry of Dementias of Girona from 2007 to 2008. All drugs were categorized following the Anatomic Therapeutic Chemical classification and grouped according to the World Health Organization (WHO) analgesic ladder steps. Descriptive statistical methods were used. RESULTS: Analgesics were prescribed to 78.6% (95% CI, 76.2-81.0) of the registered cases. Of them, 80.6% (95% CI, 78.0-83.2) were treated following step 1 of the WHO analgesic ladder, 16.8% (95% CI, 14.4-19.3) following step 2 and 2.6% (95% CI, 1.5-3.6) following step 3. Pain treatment in old people with dementia had a cost of 42.1 € per patient and year, with no significant differences depending on the subtype of dementia. CONCLUSIONS: The use of analgesics in our sample was not associated to age or to dementia severity, which are themselves risk factors for increased pain. Moreover, no differences were detected depending on the subtype of dementia.

Accidente isquémico cerebral e infarto esplénico / Ischemic stroke and splenic infarction

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Environmental determinants of quality of life in nursing home residents with severe dementia.

OBJECTIVES: To determine the relationship between quality of life (QOL) and environmental factors of temperature, noise, and lighting in nursing home residents with severe dementia. DESIGN: Cross-sectional, observational, analytical. SETTING: Eight public, long-term care nursing homes in the province of Girona, Spain. PARTICIPANTS: Random sample of 160 nursing home residents with severe dementia. MEASUREMENTS: Functional and cognitive impairment, pain, neuropsychiatric disturbances, and QOL were determined using standardized instruments. Temperature, noise, and lighting in bedrooms, dining rooms, and living rooms were measured in the morning and afternoon using a multifunction environment meter in a standardized manner. RESULTS: Adjusted multivariate linear regression models demonstrated that environmental measures were independently associated with QOL and related factors. High temperature in the bedroom was associated with lower QOL (standardized ß = 0.184), high noise levels in the living room were associated with low behavioral signs of social interactions (ß = 0.196), and low lighting levels in the bedroom were associated with number of signs of negative affective mood (ß = -0.135). CONCLUSION: The QOL of nursing home residents with severe dementia was related to environmental factors such as temperature, noise, and lighting. The monitoring of these environmental factors may improve these individuals' QOL.

Valor económico anual de la asistencia informal en la enfermedad de Alzheimer / Annual economic cost of informal care in Alzheimer’s disease

Introducción. El coste indirecto asociado a la atención de los pacientes con enfermedad de Alzheimer (EA) lo asume principalmente la familia. Objetivo. Describir el coste asociado al tiempo de dedicación, su evolución anual, las características y la carga del cuidador asociada. Sujetos y métodos. Pacientes diagnosticados de EA no institucionalizados, seguidos ambulatoriamente en una unidad de diagnóstico y sus cuidadores principales. Estudio prospectivo y observacional de 12 meses de evolución. Se evaluaron las características clínicas del paciente a través del Cambrigde Cognitive Examination Revised, para la capacidad cognitiva; el Disability Assessment in Dementia, para la capacidad funcional, y el inventario neuropsiquiátrico, para los trastornos no cognitivos. Se recogieron los datos sociodemográficos a través del Cambridge Examination for Mental Disorders of the Elderly Revised. Se registró la dedicación del cuidador, sus características sociodemográficas y la carga (a través de la escala de Zarit). Resultados. La muestra estuvo formada por 169 pacientes y 169 cuidadores. El coste en el momento basal fue de 6.364,8 €/año, asociado principalmente al apoyo en actividades instrumentales. A los 12 meses se observó un incremento global del 29% (1.846,8 €/año). El incremento del coste se asoció a la discapacidad física (F = 25,2; gl = 1; p < 0,001), el deterioro cognitivo (F = 8,5; gl = 1; p = 0,004), la edad del paciente (F = 9,2; gl = 1; p = 0,003) y si el cuidador era o no el único (F = 20,4; gl = 1; p < 0,001). El coste de la asistencia explicó el 6,7% de la varianza total de la carga percibida por los cuidadores. Conclusiones. El coste indirecto medio de la atención fue de 6.364,8 €/año, con un incremento del 29% anual que se asoció a la discapacidad física y cognitiva, a la edad del paciente y a tener un solo cuidador (AU)

Introduction. The indirect cost associated with the care of patients with Alzheimer’s disease is taken on primarily by the family. Aim. To describe the cost associated with time dedication, its annual evolution, associated characteristics and related caregiver burden. Subjects and methods. Non-institutionalized patients diagnosed with Alzheimer’s disease who are managed on an outpatient basis in a diagnosis unit and their primary caregivers. Prospective and observational study conducted over 12 months. The patient’s clinical features were assessed using the Cambrigde Cognitive Examination Revised for cognitive capacity, the Disability Assessment in Dementia for functional capacity and the Neuropsychiatric Inventory for non-cognitive disorders. Sociodemographic data were collected by means of the Cambridge Examination for Mental Disorders of the Elderly Revised. The caregiver’s dedication, sociodemographic characteristics and burden (by means of the Zarit interview) were recorded. Results. Sample comprised of 169 patients and 169 caregivers. The cost at baseline was 6364.8 €/year, and was mainly associated with support in instrumental activities. At 12 months, an overall increase of 29% was observed (1846.8 €/year). Cost increase was associated with physical (F = 25.2; df = 1; p < 0.001) and cognitive (F = 8.5; df = 1; p = 0.004) disability, patient age (F = 9.2; df = 1; p = 0.003) and with whether the caregiver was the only caregiver or not (F = 20.4; df = 1; p < 0.001). The cost of care explained 6.7% of the total variance of the burden perceived by caregivers. Conclusions. Care has a mean indirect cost of 6364.2 €/year, with an annual increase of 29% that was associated with physical and cognitive disability, patient age and having one single caregiver (AU)

[Annual economic cost of informal care in Alzheimer's disease]. / Valor económico anual de la asistencia informal en la enfermedad de Alzheimer.

INTRODUCTION: The indirect cost associated with the care of patients with Alzheimer's disease is taken on primarily by the family. AIM: To describe the cost associated with time dedication, its annual evolution, associated characteristics and related caregiver burden. SUBJECTS AND METHODS: Non-institutionalized patients diagnosed with Alzheimer's disease who are managed on an out-patient basis in a diagnosis unit and their primary caregivers. Prospective and observational study conducted over 12 months. The patient's clinical features were assessed using the Cambrigde Cognitive Examination Revised for cognitive capacity, the Disability Assessment in Dementia for functional capacity and the Neuropsychiatric Inventory for non-cognitive disorders. Sociodemographic data were collected by means of the Cambridge Examination for Mental Disorders of the Elderly Revised. The caregiver's dedication, sociodemographic characteristics and burden (by means of the Zarit interview) were recorded. RESULTS: Sample comprised of 169 patients and 169 caregivers. The cost at baseline was 6364.8 euro/year, and was mainly associated with support in instrumental activities. At 12 months, an overall increase of 29% was observed (1846.8 euro/year). Cost increase was associated with physical (F = 25.2; df = 1; p < 0.001) and cognitive (F = 8.5; df = 1; p = 0.004) disability, patient age (F = 9.2; df = 1; p = 0.003) and with whether the caregiver was the only caregiver or not (F = 20.4; df = 1; p < 0.001). The cost of care explained 6.7% of the total variance of the burden perceived by caregivers. CONCLUSIONS: Care has a mean indirect cost of 6364.2 euro/year, with an annual increase of 29% that was associated with physical and cognitive disability, patient age and having one single caregiver.

Syndromic association of behavioral and psychological symptoms of dementia in Alzheimer disease and patient classification.

OBJECTIVES: To identify patient groups with Alzheimer disease (AD) according to the presence of psychological and behavioral syndromes and to determine the clinical differences among these groups. METHODS: Cross-sectional and observational study of 491 patients with probable AD whom were administered the Neuropsychiatric Inventory (NPI) at the baseline visit and reevaluated after 12 months. RESULTS: Principal component analysis (PCA) of baseline NPI data revealed three factors, including a psychosis factor (delusions, hallucinations, and aberrant motor behavior), a depressive factor (depression, anxiety, irritability, agitation, and apathy) and a hypomanic factor (euphoria and disinhibition). Cluster analysis of factor scores indicated the presence of three patient groups: one group was characterized by low scores in factors, a second group including patients with high scores in the depressive factor, and a third group that included patients with high scores in the three factors. The PCA of the NPI scores carried out after 1 year showed the persistence of the three factors. The cluster analysis of their factor scores also showed the presence of the same three patient groups but with a few differences in certain symptoms. A higher frequency of personal psychiatric history but no family history was observed in the cluster with depressive symptoms. CONCLUSIONS: Three neuropsychiatric syndromes have been identified, which have made it possible to classify patients with AD in three distinct large groups. A temporal stability is evidenced among the group with low symptoms. Patients with high scores in depressive factor or in three factors showed greater temporal instability. Certain differences among the groups suggest that different physiopathogenic mechanisms may be involved in neuropsychiatric syndromes.

Cross-cultural adaptation and psychometric validation of a Spanish version of the Quality of Life in Late-Stage Dementia Scale.

PURPOSE: The aim of the study was to develop a cross-cultural adaptation and to evaluate the validity and reliability of a Spanish version of the Quality of Life in Late-Stage Dementia (QUALID) scale. METHODS: Observational and cross-sectional validation study. The QUALID was translated according to standardised procedures. Internal consistency was assessed using Cronbach's alpha. The QUALID structure was assessed using a Principal Component Analysis (PCA). Inter-respondent (one rater asking two respondents) and inter-rater (two raters asking one respondent) reliability was assessed using the Intraclass Correlation Coefficient (ICC). The criterion validity (concurrent) was assessed by Spearman's correlation between the QUALID score and the QoL-Visual Analogue Scale (QoL-VAS) score. The construct validity (convergent) was assessed by Spearman's correlations between QUALID score and scores on the Pain-Visual Analogue Scale (Pain-VAS), on the Mini-Mental State Examination (MMSE) and on the Neuropsychiatric Inventory-Nursing Home (NPI-NH). RESULTS: A total of 160 elderly residents and 152 respondents at 8 long-term care centres in the province of Girona (Spain) participated in the study. Results showed satisfactory levels of internal consistency (Cronbach's alpha coefficients 0.74) and evidenced the multidimensionality of the scale. Three factors were identified (behavioural signs of discomfort, behavioural signs of social interaction and signs of negative affective mood). Acceptable inter-respondent reliability (ICC = 0.74) and high inter-rater reliability (ICC = 0.95) were found. The QUALID score was associated with the QoL-VAS score, suggesting a good concurrent criterion validity, and also with the Pain-VAS, the MMSE and the NPI-NH scores, suggesting good construct validity. CONCLUSIONS: Our evaluation of the psychometric properties of the Spanish version of the QUALID indicates that it is a reliable and valid instrument with an adequate capacity to distinguish between different clinical status.

Trazodone for Alzheimer's disease: a naturalistic follow-up study.

This study intended to provide a patient profile for trazodone (a triazolopyridine-derivative of phenylpiperazine) prescription in everyday clinical practice in patients with Alzheimer's disease (AD), and to describe clinical evaluation and the impact on caregiver burden at a 6-month follow-up. A naturalistic, prospective and observational study was performed, with a 6-month follow-up in 396 patients with probable AD, according to the NINCDS-ARDRA criteria. At the baseline and at the 6-month visit, patients were administered the Neuropsychiatric Inventory (NPI) to determine their Behavioral and Psychological Symptoms of Dementia (BPSD), and the Zarit Burden Interview (ZBI) to assess the impact on caregiver burden. Trazodone was prescribed for 6.1% of patients. With respect to the baseline visit, the untreated group showed an increased global NPI score (3.1 points; 95% CI=1.9-4.2; p=0.001) and ZBI score (2.2 points; 95% CI=0.9-3.4; p=0.001). At 6 months, the global NPI and ZBI scores remained unchanged for the treated group. The treated group showed a significant reduction in the NPI irritability subscale score (2.1 points; 95% CI=0.4-3.7; p=0.015). In the clinical practice, trazodone treatment was prescribed for patients with irritability, agitation and disinhibition. After 6 months, patients treated with trazodone exhibited no increase in BPSD frequency or severity, nor was an increase noted in the caregiver burden.

[Mortality-associated factors in patients with Alzheimer's disease treated with galantamine]. / Factores asociados a la mortalidad en pacientes con enfermedad de Alzheimer tratados con galantamina.

BACKGROUND AND OBJECTIVE: To study the effect of clinical and demographic variables on mortality in patients with probable Alzheimer's disease treated with the cholinesterase inhibitor galantamine. PATIENTS AND METHOD: This retrospective cohort study reviewed 172 medical records, gathering information such as demographic and clinical variables, adverse events, number of withdrawals and duration of treatment with galantamine. RESULTS: Of 172 patients, 18.6% had adverse events. Galantamine was well tolerated in 15.4% of patients but they abandoned the treatment because of several reasons after a median duration of treatment of 13.3 months and an average dose of 15.0 mg/day. The overall rate of mortality was 12.5%, being, 19.0% for those who abandoned the treatment and 11.3% for those who dit not. The univariate analysis showed that patients who died were older, had had more antipsychotic medications, had a higher total Blessed score and had suffered from more episodes of heart failure. The associated variables in the multivariate analysis using a binary logistic regression were mortality, sex, age, hypertension, heart failure, arrhythmia, antipsychotic treatment and greater cognitive impairment. CONCLUSIONS: The duration and the dose of treatment with galantamine were not associated with increased mortality. Related variables were an advanced age, male sex, cardiovascular diseases and antipsychotic treatment.

Comparison of different clinical diagnostic criteria for depression in Alzheimer disease.

OBJECTIVE: Data in the literature show different estimates of the prevalence of depression in patients with Alzheimer disease (AD) when different classification systems are used. This study describes the prevalence and clinical features of depression in AD based on five different depression classification systems. METHODS: This was a cross-sectional, observational study of 491 patients with probable AD. Depression was diagnosed using five classification systems (International Classification of Diseases, 10th Revision [ICD-10], Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV], Cambridge Examination for Mental Disorder of the Elderly [CAMDEX], Provisional Diagnostic Criteria for depression in AD [PDC-dAD], Neuropsychiatric Inventory [NPI]). RESULTS: The prevalence of depression was 4.9% (95% confidence interval [CI]: 3.2-7.1) according to ICD-10 criteria; 9.8% (95% CI: 7.3-12.6) according to CAMDEX; 13.4% (95% CI: 10.6-16.6) according to DSM-IV; 27.4% (95% CI: 23.6-31.5) according to PDC-dAD criteria; and 43.7% (95% CI: 39.4-48.2) when using the screening questions from the NPI depression subscale. The level of agreement between the classification systems was low to moderate (kappa <0.52). The characteristics associated with the most diagnostic disagreement were loss of confidence or self-esteem and irritability. CONCLUSIONS: This study shows that there is a high variability in the prevalence rates of depression in AD depending on the diagnostic criteria used and that there is a low rate of agreement among the diagnostic criteria analyzed. The results suggest that the use of generic diagnostic criteria such as the ICD-10, the CAMDEX, or DSM-IV provides low prevalence rates of depression in patients with AD compared with specific diagnostic criteria such as the PDC-dAD.

Factores asociados a la mortalidad en pacientes con enfermedad de Alzheimer tratados con galantamina / Mortality-associated factors in patients with Alzheimer's disease treated with galantamine

Fundamento y objetivo: El propósito del presente trabajo ha sido estudiar el efecto de variables clínicas y demográficas en la mortalidad en pacientes con enfermedad de Alzheimer tratados con galantamina. Pacientes y método: Se ha realizado un estudio de cohorte retrospectivo a partir de la revisión de las historias clínicas de una muestra de pacientes diagnosticados de enfermedad de Alzheimer a quienes se había prescrito tratamiento con galantamina. Se recogió información sobre diversas variables demográficas y clínicas y sobre los acontecimientos adversos, abandonos y duración del tratamiento con fármacos anticolinesterásicos. Resultados: La muestra estuvo formada por 172 pacientes, de los que el 18,6% presentó intolerancia a la galantamina. El 15,4% de los pacientes que la toleraron abandonó el tratamiento por diversos motivos tras una duración media de 13,3 meses y una dosis media de 15,0 mg/día. La tasa de mortalidad total fue del 12,5%; la tasa en los pacientes que abandonó el tratamiento fue del 19,0% y en los que no lo abandonaron del 11,3%. El análisis univariante mostró que los fallecidos tenían una mayor edad y puntuación más elevada en la escala de Blessed, y que entre ellos era mayor el número de casos con insuficiencia cardíaca y el de casos tratados con antipsicóticos. El análisis multivariante mediante regresión logística binaria identificó como variables asociadas a la mortalidad el sexo, la edad, la hipertensión arterial, la insuficiencia cardíaca, la arritmia, el tratamiento con antipsicóticos y un mayor deterioro cognitivo. Conclusiones: El tiempo y la dosis de tratamiento con galantamina no se asociaron a un incremento de la mortalidad. Las variables relacionadas con ésta fueron la edad avanzada, el sexo masculino, los trastornos cardiovasculares y el tratamiento con fármacos antipsicóticos

Background and objective: To study the effect of clinical and demographic variables on mortality in patients with probable Alzheimer's disease treated with the cholinesterase inhibitor galantamine. Patients and method: This retrospective cohort study reviewed 172 medical records, gathering information such as demographic and clinical variables, adverse events, number of withdrawals and duration of treatment with galantamine. Results: Of 172 patients, 18.6% had adverse events. Galantamine was well tolerated in 15.4% of patients but they abandoned the treatment because of several reasons after a median duration of treatment of 13.3 months and an average dose of 15.0 mg/day. The overall rate of mortality was 12.5%, being, 19.0% for those who abandoned the treatment and 11.3% for those who dit not. The univariate analysis showed that patients who died were older, had had more antipsychotic medications, had a higher total Blessed score and had suffered from more epidodes of heart failure. The associated variables in the multivariate analysis using a binary logistic regression were mortality, sex, age, hypertension, heart failure, arrhythmia, antipsychotic treatment and greater cognitive impairment. Conclusions: The duration and the dose of treatment with galantamine were not associated with increased mortality. Related variables were an advanced age, male sex, cardiovascular diseases and antipsychotic treatment

Hemorragia cerebral masiva en un caso de enfermedad de Creutzfeldt-Jakob / Massive brain hemorrhage in a case of Creutzfeldt-Jakob disease

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[Cost relation between severity of Alzheimer's disease and cognitive and functional impairment]. / Análisis de los costes de la enfermedad de Alzheimer en función del deterioro cognitivo y funcional.

BACKGROUND AND OBJECTIVE: This study aims to identify the relationship between costs of medical and social attention in patients with dementia of Alzheimer disease (AD) type and clinical and sociodemographic data of patients and their caregivers. PATIENTS AND METHOD: It was an analytic observational study in a cohort of patients diagnosed with Alzheimer's disease who received ambulatory attention. Information about the use of health-related resources was collected and costs were estimated from a societal perspective. Indirect costs were calculated using a replacement cost approach. Patients and caregivers were examined with the Mini-Mental State Examination (MMSE), the Rapid Disability Rating Scale (RDRS-2), the Neuropsychiatric Inventory (NPI), the Burden Interview (BI) and the Resource Utilization in Dementia (RUD). Patients were grouped taking into account the score obtained in the MMSE. RESULTS: A cohort of 417 patients, mean age (SD) 75.2 (6.6) years, 71% females, was studied. Disease severity levels were distributed as follows: MMSE, 26% for MMSE > 19, 66% for MMSE = 19-11, and 8% for MMSE < 11. 69% of caregivers were women, with a mean age of 57.1 (15.8) years. The cost per patient and per month was estimated to be 419.3 Euro for MMSE > 19, 641.9 Euro for MMSE = 19-11, and 1150.6 Euro for MMSE < 11. CONCLUSIONS: The societal cost of AD increases dramatically with increasing disease severity. Caregiver burden and sex as well as the marital status of patients are associated with the cost of the disease.