Navigating dementia feeding decisions in Asia: a mixed methods study of caregivers.

BACKGROUND: Tube feeding is discouraged among older adults with advanced dementia; nevertheless, caregivers often find feeding decisions challenging to navigate. AIM: This study aims to gain a comprehensive understanding of tube feeding among community-dwelling older adults with advanced dementia in Singapore and its relationship to older adult quality of life (QoL) and caregiver psychological distress. METHODS: We use a convergent mixed-methods design, synthesising analysis of qualitative caregiver interviews (n = 25) and two-year prospective, longitudinal cohort survey data (n = 215, 1018 observations). RESULTS: Findings from the qualitative interviews revealed caregivers' expectations of reduced QoL for older adults with feeding tubes and their own distress related to making feeding decisions and fears prompting plans to tube-feed. Sixteen percent of community-dwelling older adults with advanced dementia relied on feeding tubes during the two-year study period. Adjusting for potential confounding and using instrumental variables estimation, tube feeding was associated with reduced older adult QoL (P < .05) and increased caregiver anxiety and depression (P < .10). CONCLUSION: Consistent with expert guidelines, we found that tube feeding was associated with significantly reduced QOL among older adults living with dementia and increased distress among caregivers relative to those of older adults without feeding tubes. Despite caregivers' recognition of reduced QOL associated with older adult use of feeding tubes, many expressed angst related to feeding choices. Our findings suggest the need for decision tools to support caregivers in making informed decisions concordant with their values.

Knowledge and Attitudes towards Dementia among the General Public in Singapore: A Comparative Analysis.

INTRODUCTION: This paper provides a summary of findings on the public's knowledge and attitudes towards dementia. We aim to investigate if the attitudes of Singaporeans towards dementia have changed over the years by adopting a questionnaire used in a similar study in 2012. METHODS: A cross-sectional, descriptive study was conducted through the dissemination of an existing, online questionnaire to participants above 16 years of age. Out of 1,500 subjects, results from 1,373 participants were analysed. Descriptive statistics were used to analyse and compare results from the 2012 study while a latent class analysis was performed to understand the categories of study participants based on varying levels of attitudes, knowledge and stigma. RESULTS: The mean age of study participants was 43.8 (SD = 15.7). Majority of the participants were females (76.5%), between 51 and 60 years of age (29.6%) and belonged to the Chinese ethnic group (77.8%). Results demonstrated that there were significant differences in attitudes towards dementia between 2012 and 2021. There was a 70.2% improvement in stigma-associated attitudes and an increase in correct responses to 4 out of 5 questions in the knowledge section. CONCLUSION: Findings of this study suggest that the general public has a better knowledge and more positive attitude towards dementia. This could have been attributed to higher literacy levels of the current study population and effectiveness of established outreach initiatives in Singapore. However, further research with a more balanced representation of ethnic and cultural groups would offer more comprehensive insights into dementia health literacy.

Associations of Inflammatory, Metabolic, Malnutrition, and Frailty Indexes with Multimorbidity Incidence and Progression, and Mortality Impact: Singapore Longitudinal Aging Study.

INTRODUCTION: The detection of systemic risk factors aids in the formulation of strategies to prevent multimorbidity and its associated mortality impact. We aimed to determine the associations of inflammatory, metabolic, malnutrition, and frailty indexes with multimorbidity onset and progression and their predictions of multimorbidity-associated mortality risk. METHODS: A prospective cohort study (Singapore Longitudinal Aging Study [SLAS]) of 5,089 community-dwelling older adults aged ≥55 years in two waves of recruitment (SLAS-1: March 2005-September 2007, SLAS-2: January 2013-August 2018). Baseline variables included inflammatory (neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR)) and metabolic profiles (atherogenic index of plasma (AIP), triglyceride-glucose index of insulin resistance (TyG)), physical frailty, and nutritional risk (Mini Nutritional Assessment-Short Form (MNA-SF), Nutritional Screening Initiative (NSI), Elderly Nutritional Indicators for Geriatric Malnutrition Assessment (ENIGMA)). At follow-up, 3-5 years after the baseline interview, incident multimorbidity (≥2 chronic diseases) was determined among multimorbidity-free participants (N = 1,657) and worsening multimorbidity (increase of ≥2 chronic diseases) among participants with baseline multimorbidity (N = 1,207). Mortality in all participants and those with multimorbidity (N = 2,291) was determined up to 31 December, 2016. Odds ratio (OR), hazard ratio (HR), and 95% confidence intervals (95% CI) were estimated in multivariate logistic and Cox regression models, in base model adjustments for age, sex, ethnicity, housing type, smoking, and a number of comorbidities, and further stepwise selection adjustment for other systemic risk indexes. RESULTS: At baseline, NLR, LMR, AIP, TyG, physical frailty, ENIGMA, NSI, and MNA-SF were significantly associated with prevalent multimorbidity (p < 0.001). Among multimorbidity-free participants, LMR, TyG, and ENIGMA were significantly associated with incident multimorbidity in both the base model and further stepwise selection models: LMR (OR = 0.87, 95% CI: 0.81-0.94), TyG (OR = 1.36, 95% CI: 1.06-1.75), and ENIGMA (OR = 1.15, 95% CI: 1.02-1.30). Among participants with baseline multimorbidity, NLR, LMR, and TyG significantly predicted worsened multimorbidity at follow-up in base model analysis, and LMR (OR = 0.72, 95% CI: 0.60-0.86) and TyG (OR = 1.96, 95% CI: 1.24-3.09) remained as independent predictors in further stepwise selection models. Among participants with prevalent multimorbidity, NLR, TyG, frailty, MNA, and ENIGMA were significantly associated with mortality risk with base model adjustments and further stepwise selection models: NLR (HR = 1.20, 95% CI: 1.10-1.32), TyG (HR = 1.27, 95% CI: 1.04-1.54), frailty (HR = 1.22, 95% CI: 1.10-1.36), ENIGMA (HR = 1.13, 95% CI: 1.05-1.22), MNA (HR = 0.91, 95% CI: 0.85-0.97). A combined systemic risk index shows increasing quartiles, adjusted for age, sex, housing, and smoking status, significantly predicting mortality risk. DISCUSSION/CONCLUSION: The onset and progression of multimorbidity and its mortality impact are driven by systemic factors, including inflammation, metabolic dysfunction (insulin resistance), malnutrition, and frailty. The measurement of these systemic factors using simple, inexpensive clinical and blood chemistry tools can help in strategies to prevent and reduce its mortality impact.

The Healthy Ageing Questionnaire Index: Validation in the Singapore Longitudinal Ageing Study.

INTRODUCTION: Healthy ageing (HA) indices typically use full questionnaire, performance- or blood-based assessment of functional ability which are time-consuming and resource-intensive. We developed and validated a simple and brief Healthy Ageing Questionnaire (HAQ) index with comparable measurement accuracy. METHODS: The 15-item HAQ (scored 0-100) was developed using data of 500 participants in the Singapore Study of Successful Ageing (SSOSA), a sub-cohort of the Singapore Longitudinal Ageing Study (SLAS-2). Its construct, concurrent, and predictive validity were evaluated in 2,161 participants in the SLAS-2 who were non-participants of the SSOSA. RESULTS: The HAQ index (mean = 64.0, SD = 11.8) showed a coherent 3-factor structure (Cronbach's alpha = 0.735). HAQ scores were higher among participants who were female, highly educated, not living alone, non-smoking, non-alcohol drinkers, not at risk of malnutrition, were robust or pre-frail, not disabled, had no or <5 medical conditions, and no recent fall or hospitalization. It was positively correlated with Mini-Mental State Examination and life satisfaction, and negatively correlated with age, logMAR vision, 5 times sit-and-stand, and timed-up-and-go. The HAQ index was significantly correlated but showed modest concordance with the Rowe-Kahn SA index. Increasing HAQ index quintiles were associated with decreased mortality risks from 40.6 to 9.7 deaths per 1,000 person-years; covariate-adjusted hazard ratio for the highest Q5 levels (HAQ score >70) was 0.44 (95% CI = 0.28-0.67). Using receiver operating characteristics analysis of predictive accuracy for survival, the area under the curve of HAQ was 0.675, and Rowe-Kahn SA index was 0.660 (p = 0.361). CONCLUSION: The HAQ is a brief and accurate HA index that is potentially useful across diverse settings and purposes in research, healthcare, and policy-making.

Physiological and Cognitive Determinants of Gait Variability of Asian Population: The Yishun Study.

INTRODUCTION: Gait variability is associated with frailty, dementia, and falls. Studies on the association of physiological and cognitive factors with gait variability have seldom included middle-aged adults, even though these adults already experienced loss of muscular strength and postural stability. This study aimed a) to examine and compare the trend of gait variability in men and women, across the adult age spectrum, and b) to identify and compare the contributions of physiological and cognitive factors to gait variability. METHODS: This was a population-based cross-sectional study at a single center. A random sample of 507 community-dwelling, well-functioning adults aged 21-90 years were studied. Cognition was measured using the Repeatable Battery for the Assessment of Neuropsychological Status. Physiological factors examined included visual contrast sensitivity (VCS), postural sway, hand reaction time, handgrip strength (HGS), knee extensor strength, and gait variability (coefficient of variation [CoV]). Multivariable regression models were used to examine the association between physiological and cognitive performance with gait CoV. RESULTS: Women walked with greater stride width CoV (p < 0.01) and double support time (DST) CoV (p < 0.01) than men. The stride width (p = 0.01) and DST variability (p = 0.03) were significantly higher in older men as compared to men in younger age-groups. Gait speed accounted for most of the gait CoV variances and attenuated the effects of physiological performance and/or attention cognition on most gait variability, except for CoV of DST and stride width. Adults with better VCS (ß = -0.19), faster hand reaction (ß = 0.12), and greater HGS (ß = -0.15) had lower variability in step length. CONCLUSION: The trends of stride width CoV and DST CoV across adult age spectrum were different between men and women. Greater stride width variability was partly attributed to greater HGS, possibly to better control lateral stability during walking. Physiological factors outweigh cognition in regulating most of the gait CoV in this study. They are modifiable and potential targets for healthy aging program.

Effects of Humanitude care on people with dementia and caregivers: A scoping review.

AIMS AND OBJECTIVES: This study aimed to comprehensively review the research literature to provide an overview of the effects of Humanitude on people with dementia and their caregivers. BACKGROUND: Humanitude is a relationship-centred and compassionate care approach that focuses on improving the communication between people with dementia and their caregivers. There is a lack of updated and comprehensive synthesis on the evidence of the effects of Humanitude in dementia care. DESIGN AND METHODS: This paper adopted the scoping review framework by Arksey and O'Malley. We searched through the following databases: Pubmed, CINAHL, EMBASE, PsycINFO, ProQuest, Scopus and Web of Science from its inception to 3 September 2021. Three investigators independently screened the titles and abstracts and assessed the full-text articles for eligibility. The PRISMA-ScR checklist was included in this scoping review. RESULTS: We retrieved 1317 articles from databases and grey sources. Eleven studies were included after the screening. The synthesised results suggest that Humanitude can reduce agitation and psychological symptoms and improve the general well-being of people with dementia. Humanitude also has positive effects in improving care communication, empathy, job satisfaction and reducing burnout among caregivers. CONCLUSION: Humanitude shows the potential for positive effects on people with dementia and their caregivers. However, most studies did not include a comparator group and could not provide rigorous findings as compared to randomised controlled trials. There is a need for randomised controlled studies to demonstrate the effectiveness of Humanitude on people with dementia and their caregivers. RELEVANCE FOR CLINICAL PRACTICE: This paper reviewed the literature on all types of publications that examine the use of Humanitude in people with dementia and their caregivers. Thus, it provided an up-to-date overview of the effects of Humanitude to inform clinical practice.

Adaptation and Validation of the Person-Centred Assessment Tool for the Acute Care Setting.

INTRODUCTION: Person-centred care (PCC) is synonymous with best practice in the care of persons with dementia. Despite this, PCC is not routinely assessed, and there is no validated tool for in the acute care setting. We aimed to validate the Person-Centred Assessment Tool (P-CAT) in an acute setting. METHODS: P-CAT was administered independently to a total of 161 nurses (n = 16, from a specialized dementia unit with PCC training; n = 116, geriatric wards; n = 30, medical/surgical wards). The word "residents" was replaced with "patients" in P-CAT. We employed confirmatory factor analysis with principal component extraction to verify the previously reported three- and two-factor solutions. A one-way between-groups ANOVA was then used to investigate group differences in the P-CAT score (total scale and subscale). RESULTS: Factor analysis revealed a two-factor solution (explained variance 42.28%): (i) extent of personalizing care and (ii) amount of organizational and environmental support. Out of the 13 items, only 2 items did not load as expected. The internal consistency reliability of the scale was satisfactory (Cronbach's α = 0.77). Nurses' P-CAT scores were significantly different across ward settings [Welch's F(2,37.20) = 13.01, p < 0.001, ω2 = 0.09], with the highest among those PCC trained. Post hoc analyses revealed a significant difference in mean subscale scores between PCC-trained nurses and nurses from the other two ward settings. P-CAT scores were not significantly correlated with age, r(159) = 0.01, p = 0.861, or with nursing experience, r(159) = 0.04, p = 0.615. DISCUSSION/CONCLUSION: P-CAT possesses adequate validity and reliability as a quantitative assessment tool of PCC in the acute care setting.

The Elderly Nutritional Index for Geriatric Malnutrition Assessment (ENIGMA): concurrent, construct and predictive validity in an external evaluation cohort of community-dwelling older persons.

We previously developed a malnutrition risk index, the Elderly Nutritional Index for Geriatric Malnutrition Assessment (ENIGMA) with good predictive accuracy for mortality risk in an original population cohort (SLAS1). Herein, we further evaluate the concurrent and predictive validity of the ENIGMA construct in an external validation cohort (SLAS-2) of 2824 community-dwelling older adults aged 55+ years. They were assessed on the ENIGMA index, Mini Nutritional Assessment-Short Form (MNA-SF) and the Geriatric Nutritional Risk Index (GNRI), known correlates of malnutrition, and baseline and follow-up functional dependency and 10-year mortality risk. Higher ENIGMA risk categories were significantly associated (P < 0·001) with lower education, living alone, smoking, low physical activity, BMI < 18·5 kg/m2, poorer muscle strength and functional mobility, exhaustion, physical frailty, homocysteine, glomerular filtration rate, Hb, red and white blood cell counts, platelets, systemic inflammation indexes, metabolic syndrome, CVD, cognitive impairment and depressive symptoms (Geriatric Depression Scale ≥ 5). ENIGMA scores showed statistically significant (P < 0·001) correlations but low-to-moderate concordance with MNA-SF (r = 0·148, agreement = 45·9 %, kappa = 0·085) and GNRI scores (r = 0·156, agreement = 45·8 %, kappa = 0·096). Controlling for known correlates of malnutrition, only high-risk ENIGMA among the indexes significantly predicted baseline functional dependency (OR = 1·64, 95 % CI 1·01, 2·65) and mortality (hazard ratio = 1·65 (95 % CI 1·04, 2·62). ENIGMA marginally out-performed MNA-SF and GNRI in predicting baseline functional dependency (AUC: 0·625 v. 0·584 v. 0·526), follow-up functional dependency (AUC: 0·594 v. 0·525 v. 0·479) and 10-year mortality risk (AUC: 0·641 v. 0·596 v. 0·595). The concurrent and predictive validity of the ENIGMA construct is replicated in an external evaluation study of community-dwelling older persons.

Functional health index of intrinsic capacity: multi-domain operationalisation and validation in the Singapore Longitudinal Ageing Study (SLAS2).

BACKGROUND: ad hoc approaches are used to create composite indexes of intrinsic capacity (IC) based on five domains recommended by the World Health Organization for healthy ageing. We examined how combinations of domain-specific measures determine measurement performances of composite IC indexes. METHODS: in this population-based prospective cohort study, community-dwelling older persons (N = 2,906) aged 55 years and above were recruited. We used 12 domain-specific measures: cognition (Mini-Mental State Examination, MMSE), psychological (Geriatric Depression Scale, GDS), locomotion (Timed Up-and Go [TUG], GV, Knee Extension Strength, Performance Orientated Mobility Assessment), sensory (logarithm of the Minimum Angle of Resolution [LogMAR] vision and Whisper Test hearing) and vitality (forced expiratory volume in 1 second pulmonary function, Elderly Nutritional Indicators for Geriatric Malnutrition Assessment [ENIGMA], Nutritional Screening Initiative) to derive 144 composite 2- to 5-domain functional health indexes (FHI), and evaluated their abilities to predict 9-year mortality and their associations with health determinants. RESULTS: with 5-domain FHI, TUG, logMAR and MMSE showed the largest factor loadings (0.65-0.75). All single-domain FHI were significantly associated with mortality risks. Area under the receiver operating characteristic curve (AUC) values of mortality prediction increased with the number of domains (from mean 0.615 for single-domain FHI to mean 0.705 for 5-domain FHI), but the difference between 3-domain versus 4-domain FHI (P = 0.082) or versus 5-domain FHI (P = 0.109) was not statistically significant. Highest AUCs (P < 0.001) of best performing FHI were single-domain TUG: 0.735; 2-domain TUG + ENIGMA: 0.743; 3-domain TUG + LogMAR + ENIGMA: 0.762; 4-domain TUG + MMSE + LogMAR + ENIGMA: 0.757; 5-domain TUG + MMSE + GDS + LogMAR + ENIGMA: 0.751. FHI showed excellent construct validity based on correlations with known health determinants. CONCLUSIONS: among Singaporean older adults, cognition, sensory and locomotion are predominant IC domains. A multi-domain IC index performs better with more domain measures, but a minimalist 3-domain index performs just as robustly as a 4- or 5-domain index.

Functional mobility decline and incident mild cognitive impairment and early dementia in community-dwelling older adults: the Singapore Longitudinal Ageing Study.

BACKGROUND: Motor and gait disturbances are evident in early Alzheimer and non-Alzheimer dementias and may predict the likelihood of mild cognitive impairment (MCI) or progression to dementia. OBJECTIVE: We investigated the Timed-Up-and-Go (TUG) measure of functional mobility in predicting cognitive decline and incident MCI or early dementia (MCI-dementia). DESIGN: Prospective cohort study with 4.5 years follow-up. SETTING: Population based. PARTICIPANTS: 2,544 community-dwelling older adults aged 55+ years. METHODS: Participants with baseline data on TUG, fast gait speed (GS), knee extension strength (KES) and performance-oriented mobility assessment (POMA) gait and balance were followed up for cognitive decline (Mini-Mental State Exam; MMSE drop of ≥2, among 1,336 dementia-free participants) and incident MCI-dementia (among 1,208 cognitively normal participants). Odds ratio (OR) and 95% confidence intervals (95% CI) were adjusted for age, sex, education, smoking, physical, social and productive activity, multi-morbidity, metabolic syndrome and MMSE. RESULTS: Per standard deviation increase in TUG, POMA, GS and KES were significantly associated with incident MCI-dementia: TUG (OR = 2.84, 95% CI = 2.02-3.99), GS (OR = 2.17, 95% CI = 1.62-2.91), POMA (OR = 1.88, 95% CI = 1.22-2.92) and KES (OR = 1.52, 95% CI = 1.15-2.02). Adjusted OR remained significant only for TUG (OR = 1.52, 95% CI = 1.01-2.31) and GS (OR = 1.53, 95% CI = 1.08-2.16). Areas under the curve (AUC) for TUG (AUC = 0.729, 95% CI = 0.671-0.787) were significantly greater than GS (AUC = 0.683, 95% CI = 0.619-0.746), KES (AUC = 0.624, 95% CI = 0.558-0.689) and POMA (AUC = 0.561, 95% CI = 0.485-0.637). Similar associations with cognitive decline were significant though less pronounced, and adjusted ORs remained significant for TUG, GS and POMA. CONCLUSION: Functional mobility decline precedes incident MCI and early dementia. The TUG appears to be especially accurate in predicting the future risks of adverse cognitive outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03405675. Registered 23 January 2018 (retrospectively registered).

Cardiometabolic and Vascular Disease Factors and Mild Cognitive Impairment and Dementia.

INTRODUCTION: There is empirical evidence that cardiovascular risk factors and vascular pathology contribute to cognitive impairment and dementia. METHODS: We profiled cardiometabolic and vascular disease (CMVD) and CMVD burden in community-living older adults in the Singapore Longitudinal Ageing Study cohort and examined the association of CMVD risk markers with the prevalence and incidence of mild cognitive impairment (MCI) and dementia from a median 3.8 years of follow-up. RESULTS: Prevalent MCI and dementia, compared with normal cognition, was associated with higher proportions of persons with any CMVD, hypertension, diabetes, coronary heart disease, atrial fibrillation, or stroke. Diabetes, stroke, and the number of CMVD risk markers remained significantly associated with dementia or MCI after adjusting for age, sex, formal education level, APOE-ε4 genotype, and level of physical, social, or productive activities, with odds ratios ranging from 1.3 to 5.7. Among cognitively normal participants who were followed up, any CMVD risk factor, dyslipidemia, diabetes, or heart failure at baseline predicted incident MCI or its progression to dementia after adjusting for potential confounders. CONCLUSION: Older adults with higher burden of CMVD, driven especially by diabetes, are likely to increase the risk of prevalent and incident MCI and dementia.

Associations of low handgrip strength and hand laterality with cognitive function and functional mobility - the Yishun Study.

BACKGROUND: Emerging evidence suggest that in addition to low hand grip strength (HGS), HGS asymmetry is associated with declining cognitive and physical functions. We examined the associations of low HGS and asymmetry with cognitive function and functional mobility in older adults. METHODS: Cross-sectional data of 330 community-dwelling adults (55.2% women) aged ≥ 55 years included HGS, Repeated Battery for the Assessment of Neuropsychological Status (RBANS), and Timed-Up-and-Go (TUG). Low HGS was defined as < 28 kg for men and < 18 kg for women. Participants with HGS above 10% stronger on either hand were considered as having HGS asymmetry. Multiple linear regression models were adjusted for sociodemographic, smoking, education, comorbidity count, physical activity participation, obesity, self-rated health and hand dominance. RESULTS: Low HGS, but not asymmetry, was independently associated with lower functional mobility performance (ß = 1.3, 95%CI = 0.6,1.9), global cognitive function (ß = -10.4, 95%CI = -17.0,-3.8), immediate (ß = -2.6, 95%CI = -4.5,-0.7) and delayed (ß = -2.8, 95%CI = -5.0,-0.7) memory. Compared to normal and symmetric HGS participants, low HGS in combination with HGS asymmetry was associated with poorer language scores. In participants with normal HGS, asymmetric HGS was associated with slower TUG than corresponding groups with symmetric HGS. CONCLUSION: Low HGS, but not asymmetry, was associated with lower cognition and functional mobility. Associations of combined low HGS and asymmetry with cognitive and physical functions were driven by grip strength rather than asymmetry.

Person-Centred Dementia Care in an Acute Hospital: Experiences from Nurses Working in a Specialized Dementia Unit.

BACKGROUND: Person-centred care (PCC) is synonymous with best practice in the care of persons with dementia. However, the research focus has been in long-term care settings with less attention in acute hospitals. We aimed to study the perspectives and experiences of nurses implementing PCC in an acute hospital dementia unit (Care for Acute Mentally Infirm Elders [CAMIE]). METHOD: This was an exploratory qualitative study involving individual, face-to-face, semi-structured in-depth interviews. A purposive sample of 10 nurses participated in the interview. We employed an inductive thematic analysis approach to analyse the qualitative data. RESULTS: The findings highlighted the positive experiences, for example, meaningful connection with patients and the challenges, for example, managing challenging behaviour in providing PCC. The initial challenges were due to a lack of prior knowledge and experience. Through formal and informal learning, the nurses built confidence and competence, and also provided support to one other. They emphasized the importance of teamwork and camaraderie in the CAMIE team but raised concerns about the negative perceptions of non-CAMIE nurses on the value of their work. CONCLUSION: Despite the challenges, adequate knowledge and robust organizational level support are the key support for nurses to embrace PCC as their care ethos in the acute care setting.

Feasibility and validity of EQ-5D-5L proxy by nurses in measuring health-related quality of life of nursing home residents.

OBJECTIVE: Our study examined the feasibility and validity of the EQ-5D-5L proxy questionnaire in measuring health-related quality of life (HRQoL) of nursing home residents. METHODS: Twenty-four nurses and 229 residents from 3 nursing homes in Singapore participated in this cross-sectional study. Nurses assessed residents under their care with the EQ-5D-5L proxy questionnaire. Two experienced mappers conducted Dementia Care Mapping (DCM) within 1 month in a subsample of the residents. Feasibility was evaluated according to percentage of unanswered EQ-5D-5L items and proportion of nurses who failed to respond to all items. Convergent validity was assessed by examining the correlation between EQ-5D-5L measures and DCM scores. Known-groups validity was assessed by comparing differences in EQ-5D-5L scores for residents with varying communication abilities and physical functions. RESULTS: The nurses' mean age was 35.4 years while the residents' was 73.4 years. Most residents were female (51.3%) and had the ability to communicate (81.3%). For 6 of the 229 residents (2.6%), not all items in the EQ-5D-5L were completed. The EQ-5D-5L index score correlated positively and moderately with the DCM's well/ill-being score (r = 0.433, n = 90, P < 0.01). Residents who were able to communicate effectively or had better physical function were assessed to have less severe health problems and better EQ-5D-5L scores. CONCLUSION: The EQ-5D-5L proxy questionnaire has adequate feasibility and validity when used by nurses to assess the HRQoL of nursing home residents. As it is brief and can be conveniently administered, it can be deployed on a larger scale to assess HRQoL of nursing home residents.

Physiological and Cognitive Determinants of Dual-Task Costs for Gait Parameters: The Yishun Study.

BACKGROUND: Studies indicate that physiological and cognitive aging are causally related and functionally interdependent. However, the relative contribution of physiological factors and cognition to dual-task costs (DTC) of gait parameters has not been well studied. In this cross-sectional study, we examined the trajectory of DTC of gait parameters across the adult age spectrum for both sexes and identified the contributions of physical and cognitive performance to DTC of gait. METHODS: A total of 492 community-dwelling adults, aged 21-90 years, were randomly recruited into the study. Participants were divided into 7 age groups, with 10-year age range for each group. Demographic data, height, body mass, education level, and information on comorbidities were recorded. Cognition was measured using the Repeatable Battery for the Assessment of Neuropsychological Status. Physical performance included visual contrast sensitivity, postural sway, hand reaction time, handgrip strength, knee extensor strength, and single-task and dual-task gait assessments. Stepwise multivariable regression was used to examine the association between physical and cognitive performance with DTC of gait parameters. RESULTS: Women were found to have significantly higher DTC of gait speed (p = 0.01), cadence (p < 0.01), and double support time (p < 0.01) than men. However, significant aging effect on DTC of gait speed (p = 0.01), step length (p = 0.01), and double support time (p = 0.01) was observed in men but not in women. Immediate memory was the primary determinant for the DTC of gait speed (ß = -0.25, p < 0.01), step length (ß = -0.22, p < 0.01), and cadence (ß = -0.15, p = 0.03) in men. Besides immediate memory, postural sway (ß = -0.13, p = 0.03) and hand reaction (ß = 0.14, p = 0.02) were also significantly associated with DTC of step length and cadence, respectively, in women. CONCLUSION: There were sex differences in the amplitude and trajectories of DTC of gait parameters. The DTC increased with age in men but not in women. Immediate memory was the primary determinant of DTC of gait parameters in men while immediate memory, postural sway, and reaction time were associated with DTC of gait in women. Future studies should investigate the clinical implications of the sex differences in the DTC with fall risks.

Burden of informal care in stroke survivors and its determinants: a prospective observational study in an Asian setting.

BACKGROUND: Informal caregiving is an integral part of post-stroke recovery with strenuous caregiving demands often resulting in caregiving burden, threatening sustainability of caregiving and potentially impacting stroke survivor's outcomes. Our study aimed to examine and quantify objective and subjective informal care burden after stroke; and to explore the factors associated with informal care burden in Singapore. METHODS: Stroke patients and their informal caregivers were recruited from all five tertiary hospitals in Singapore from December 2010 to September 2013. Informal care comprised of assistance provided by informal caregivers with any of the activities of daily living. Informal care burden was measured by patients' likelihood of requiring informal care, hours of informal care required, and informal caregivers' Zarit's Burden Score. We examined informal care burden at 3-months and 12-months post-stroke. Generalized linear regressions were applied with control variables including patients' and informal caregivers' demographic characteristics, arrangement of informal care, and patients' health status including stroke severity (measured using National Institute of Health Stroke Scale), functional status (measured using Modified Rankin Scale), self-reported depression, and common comorbidities. RESULTS: Three hundred and five patients and 263 patients were examined at 3-months and 12-months. Around 35% were female and 60% were Chinese. Sixty three percent and 49% of the patients required informal care at 3-months and 12-months point, respectively. Among those who required informal care, average hours required per week were 64.3 h at 3-months and 76.6 h at 12-months point. Patients with higher functional dependency were more likely to require informal care at both time points, and required more hours of informal care at 3-months point. Female informal caregivers and those caring for patients with higher functional dependency reported higher Zarit's Burden. While informal caregivers who worked full-time reported higher burden, those caring for married stroke patients reported lower burden at 3-months point. Informal caregivers who co-cared with foreign domestic workers, i.e.: stay-in migrant female waged domestic workers, reported lower burden. CONCLUSIONS: Informal care burden remains high up to 12-months post-stroke. Factors such as functional dependency, stroke severity, informal caregiver gender and co-caring with foreign domestic workers were associated with informal care burden.

Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore.

BACKGROUND: Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke. METHOD: Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0-3 months (early) and 4-12 months (late) post-stroke. RESULTS: For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits. CONCLUSION: We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.

The three dimensions of caregiver grief in dementia caregiving: Validity and utility of the subscales of the Marwit-Meuser Caregiver Grief Inventory.

BACKGROUND: The experience of grief in family caregivers as they provide care for persons with dementia is often overlooked. The Marwit-Meuser Caregiver Grief Inventory (MM-CGI) is one among the few scales that capture such experiences. In a recent study, MM-CGI was found to contain three subscales identifying dimensions of loss in caregivers-Personal-Sacrifice Burden (PSB), Heartfelt Sadness, Longing, and Worry (HSLW), and Felt Isolation (FI). We aimed to evaluate the validity and utility of these dimensions in a multiethnic Asian population. METHODS: Family caregivers (n = 394) completed MM-CGI and scales assessing caregiver burden, depression, and gains. Internal consistency reliability was examined using Cronbach α; test-retest reliability using intraclass correlation coefficient; and construct validity using Pearson correlation coefficient. The utility of the MM-CGI dimensions was evaluated by comparing caregivers with high subscale scores across dementia stages and caregiving relationship. RESULTS: The three dimensions of MM-CGI exhibited adequate internal consistency, test-retest reliability, construct validity, and known-group validity. PSB correlated most strongly with caregiver burden (r = 0.78); HSLW with caregiver depression (r = 0.75); and FI with caregiver burden and caregiver depression (r = 0.60, respectively). Caregivers with high total grief scores tended to experience most difficulty with HSLW (90.8%), followed by PSB (75.4%) and FI (46.2%). The three dimensions also increased across the dementia stages, with FI higher in mild dementia, PSB higher in moderate dementia, and HSLW higher in severe dementia. Spousal caregivers experienced most difficulty in HSLW, whereas children caregivers experienced similar levels of difficulty across the dimensions. CONCLUSIONS: The three dimensions of MM-CGI captured distinct aspects of caregiver grief in a multiethnic Asian population and would enable more individualized assessments and interventions for caregiver grief.

Validity and Utility of the Center for Epidemiological Studies Depression Scale for Detecting Depression in Family Caregivers of Persons with Dementia.

BACKGROUND/AIMS: The psychometric properties of Center for Epidemiological Studies Depression Scale (CES-D) have never been substantively investigated in caregivers of persons with dementia (PwD). We evaluated the validity and reliability of CES-D for detecting caregiver depression in dementia, and assessed whether CES-D could provide added utility beyond Zarit Burden Interview (ZBI). METHOD: Family caregivers of community-dwelling PwD (n = 394) completed self-administered questionnaires containing CES-D. Factorial validity was evaluated with confirmatory factor analysis; convergent and discriminant validity with Pearson's correlation coefficient; known-group validity by comparing across key variables; and internal consistency reliability with Cronbach's α. Cohen's κ was used to compare the agreement between those with depression (CES-D ≥16) and those with high caregiver burden (ZBI >60). RESULTS: CES-D demonstrated convergent, discriminant and known-group validity, consistent with a priori hypotheses. The original four-factor model of CES-D produced the best model-fit indices. Internal consistency reliability was good for the CES-D total scale (α = 0.92), but lower for the Positive affect and Interpersonal problems subscales (α = 0.70-0.74). Forty-five percent of the caregivers had depression as identified by CES-D (95% CI 40-50%), but most of them were not identified by high ZBI scores (κ = 0.16). CONCLUSIONS: CES-D is a valid and reliable scale for detecting caregiver depression in dementia. It has added utility, beyond that of a caregiver burden scale, in identifying a subgroup of caregivers with depression but not burden. However, two subscales (Positive affect and Interpersonal problems) may require caution in interpretation among non-Caucasian caregivers.

Dyadic approach to post-stroke hospitalizations: role of caregiver and patient characteristics.

AIM: To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3-12 months post-stroke in Singapore. METHODS: Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome. RESULTS: Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3-12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization. CONCLUSION: Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.