Claire A. G. Wolfs

Impact of molecular imaging on the diagnostic process in a memory clinic

[11C]Pittsburgh compound B ([11C]PIB) and [18F]‐2‐fluoro‐2‐deoxy‐D‐glucose ([18F]FDG) PET measure fibrillar amyloid‐β load and glucose metabolism, respectively. We evaluated the impact of these tracers on the diagnostic process in a memory clinic population.

Performance of the EQ-5D and the EQ-5D+C in elderly patients with cognitive impairments

BackgroundThe EQ-5D is a reliable tool for measuring Health-Related Quality of Life (HRQoL). However, concern has been expressed that it may ignore elements of HRQoL, particularly cognition. In response to this concern, the EQ-5D has been extended with a cognitive dimension (EQ-5D+C). The aim of this study was to compare the performance of the EQ-5D and the EQ-5D+C in elderly patients with cognitive impairments by assessing their construct validity and responsiveness.MethodsData from the MEDICIE study (n = 196) were used, in which all questionnaires were rated by proxies.ResultsRegarding construct validity, we found similar correlations between the EQ-5D and the Mini Mental State Examination (MMSE) and between the EQ-5D+C and the MMSE. Furthermore, both the EQ-5D and the EQ-5D+C were responsive to changes in the MMSE, with the EQ-5D performing slightly better.ConclusionWe conclude that the EQ-5D performs well for evaluating HRQoL in a population with cognitive impairments. Based on the results of this explorative study, it does not seem necessary to adjust the current classification system by adding a cognitive dimension. However, in order to compare both instruments regarding utility values, it is necessary to develop a new scoring algorithm for the EQ-5D+C by conducting a general population study. Considering the explorative nature of this study, it is recommended that more aspects of the validity of both the EQ-5D and the EQ-5D+C are explored in patients with cognitive impairments using a more tailored study design.

Effectiveness of dementia follow-up care by memory clinics or general practitioners: randomised controlled trial.

Objective To examine the effectiveness of post-diagnosis dementia treatment and coordination of care by memory clinics compared with general practitioners. Design Multicentre randomised controlled trial. Setting Nine memory clinics and 159 general practitioners in the Netherlands. Participants 175 patients with a new diagnosis of mild to moderate dementia living in the community and their informal caregivers. Interventions Usual care provided by memory clinic or general practitioner. Main outcome measures Caregiver rated quality of life of the patient measured with the quality of life in Alzheimer’s disease instrument and self perceived burden of the informal caregiver measured with the sense of competence questionnaire (intention to treat analysis). Results The quality of life of the patients in the memory clinic group was 0.5 (95% confidence interval −0.7 to 1.6) points higher than in the general practitioner group. Caregivers’ burden was 2.4 (−5.8 to 1.0) points lower in the memory clinic group than in the general practitioner group. Conclusion No evidence was found that memory clinics were more effective than general practitioners with regard to post-diagnosis treatment and coordination care for patients with dementia. Without further evidence on the effectiveness of these modalities, other arguments, such as cost minimisation, patients’ preferences, or regional health service planning, can determine which type of dementia care is offered. Trial registration Clinical trials NCT00554047.

Integrated multidisciplinary diagnostic approach for dementia care: randomised controlled trial

BACKGROUND An integrated multidisciplinary approach to dementia is often recommended but has rarely been evaluated. AIMS To evaluate the clinical effects of an integrated multidisciplinary diagnostic facility for psychogeriatric patients. METHOD Patients suspected of having complex psychogeriatric problems were randomly allocated to the intervention (n=137) or to treatment as usual (n=93). They were assessed at baseline, and at 6 months and 12 months follow-up by means of personal interviews with the patients proxy. The primary outcome was health-related quality of life, assessed using the visual analogue scale (VAS) of the EuroQd measure, EQ-5D. RESULTS Health-related quality of life had improved at 6 months in the intervention group, whereas that of the control group had decreased. Furthermore, more patients in the intervention group experienced a clinically relevant improvement of 10 points or more on the VAS at both follow-up measurements. CONCLUSIONS An integrated multidisciplinary approach improves dementia care.

Predictive factors for the objective burden of informal care in people with dementia: a systematic review.

Background:Informal care plays a substantial role in the provision of total care in dementia. Several reviews have been published on the predictive factors of subjective burden; however, such a review lacks information on objective burden, which refers to the amount and/or costs of informal care. Objectives:The objectives of this study were to (1) give an overview of the predictive factors that are associated with the objective burden of informal care; (2) discuss whether these factors are similar to the predictive factors of subjective burden; and (3) examine whether they are modifiable. Design:The literature in a number of international databases was systematically searched. Methodological quality and level of certainty were assessed. Results:Ten studies were identified as relevant for the purpose of this review, describing a total of 39 predictive factors. Three factors (behavioral problems and impairments regarding daily functioning and cognition) were considered to be predictors of objective burden. Three factors were not related; 12 were potential predictors; and the results of the remaining 22 factors were inconclusive. Conclusions:Many factors were found to be (potential) predictors of objective burden, reflecting its complex nature. Objective and subjective burdens are 2 different relevant aspects of informal care. Interventions aimed at countering behavioral problems and impairments regarding daily functioning could reduce objective burden.

Economic Evaluation of an Integrated Diagnostic Approach for Psychogeriatric Patients: Results of a Randomized Controlled Trial

CONTEXT Because of the increasing number of elderly people with dementia, the costs of dementia and dementia care are expected to grow rapidly in the coming decades. Cost-effectiveness results are relevant for decision making about new strategies in dementia care. OBJECTIVE To evaluate the cost-effectiveness of an integrated multidisciplinary diagnostic facility for diagnosing dementia in ambulatory psychogeriatric patients. DESIGN Randomized controlled trial with an economic evaluation component. SETTING The Maastricht Evaluation of a Diagnostic Intervention for Cognitively Impaired Elderly, Maastricht University Hospital, Maastricht, the Netherlands. PATIENTS A total of 137 patients who received care in the multidisciplinary diagnostic facility and 93 who received usual care. MAIN OUTCOME MEASURES Quality-adjusted life-years (QALYs) as the main outcome measure and cognition and behavioral problems as secondary outcome measures. RESULTS Compared with patients receiving usual care, patients who visited the diagnostic facility gained a mean 0.05 QALY at the extra cost of euro65. The incremental cost per QALY amounted to euro1267. This point estimate lies beneath commonly accepted thresholds and is within an acceptable range of uncertainty. With regard to the secondary analyses, cost-effectiveness results showed a substantial amount of uncertainty and were therefore indecisive. CONCLUSION On the basis of the main cost-per-QALY analysis, the use of the integrated multidisciplinary diagnostic facility is cost-effective for the diagnosis and management of dementia in ambulatory patients.

Relationship between Measures of Dementia Severity and Observation of Daily Life Functioning as Measured with the Assessment of Motor and Process Skills (AMPS)

Background: Cognitive impairment is mostly regarded as the core symptom of dementia, but several other domains (such as daily functioning) are equally relevant to assess the severity of dementia. The relationship between these domains is unclear. The Assessment of Motor and Process Skills (AMPS) is a relatively unexplored instrument in people with dementia, measuring severity by direct observation. Objective: To study the relationship between the AMPS and scores on several commonly used outcome measures for the assessment of dementia severity, and to examine the possible influence of neuropsychiatric symptoms on these relationships in patients with cognitive disorders. Methods: Cross-sectional data of 118 patients with cognitive disorders were used; data on cognition (Mini-Mental State Examination, MMSE; CAMCOG), global severity (Global Deterioration Scale, GDS), daily life functioning (Instrumental Activities of Daily Living, IADL), and neuropsychiatric symptoms (Neuropsychiatric Inventory, NPI) were collected and analyzed using correlation and regression analyses. Different combinations of the severity measures were tested for their ability to predict the AMPS process ability scores. Results: Scores on the MMSE, CAMCOG and GDS were moderately associated with the AMPS process ability score. These measures explained between 27 and 44% of the variance in the AMPS score. The presence of apathy influenced the association between the cognitive measures and the AMPS score. Conclusion: Commonly used measures of dementia severity are only moderately associated with observation of performance on daily activities. This underlines the need for direct observation of daily activities in dementia patients. This relationship between several approaches of assessing dementia severity needs further study.

Qualitative study on needs and wishes of early-stage dementia caregivers: the paradox between needing and accepting help

BACKGROUND Early individualized interventions for informal dementia caregivers can prevent overburdening in the later stages. However, the needs of early-stage dementia caregivers (EDC) remain largely unknown. This study aimed to explore the needs and wishes and need for care of EDC to maximize the benefit of potential programs for EDC and tailor interventions accordingly. METHODS Four focus group interviews with 28 informal caregivers of people with dementia (PwD) were analyzed using inductive content analysis. Both EDC and caregivers in the later stages were included to compare perceived EDC needs from different points in the caregiver career. RESULTS Four themes were identified: the early-stage needs paradox, barriers in acceptance, facilitators in acceptance, and a transition from loss to adaptation. The retrospective view provided by later-stage caregivers differed from the view of EDC; EDC struggled with acknowledging needs due to fear of stigma and low acceptance. EDC stressed the importance of acceptance as a prerequisite for adequate adaptation, but were hindered by lack of knowledge, difficulty acknowledging changes, and focus on loss. In contrast, better understanding of the disease, increasing personal time, structuring ones day, and using appropriate humor can reduce negative communication, increase positive encounters and caregiver-confidence, contributing to positive interaction with the care recipient and an increase in well-being. CONCLUSIONS Early therapeutic interventions could help caregivers identify their needs, increase knowledge about changes in roles and relationship reciprocity, and focus on enhancement of the positive, intact experiences to prevent caregiver burden.

Determinants of care costs of patients with dementia or cognitive impairment

Introduction:Dementia causes a high burden on patients, caregivers, and societies. Decision analytic models to support allocation of resources are often developed making use of cost-of-illness (COI) studies. However, current COI study estimates are highly variable due to care setting and methodological issues. We aim to explore variables explaining the variation of (formal and informal) health care costs of cognitive disorders, using a broad spectrum of variables, including patient, caregiver, and social context variables. Methods:A bottom-up COI study design was used in which a societal viewpoint and a validated method to measure and value informal care was applied. Data were analyzed using univariate, multivariate, and forward regression analyses. Results:The average 1-year health care sector costs were &OV0556;26,140 (

Empowered or overpowered? Service use, needs, wants and demands in elderly patients with cognitive impairments.

34,505 or £17,775) and &OV0556;11,931 (