Louise Demers

Development of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST)

This studys purpose was to develop a clinical instrument designed to evaluate user satisfaction with assistive technology devices. This paper describes the methodology used to develop the instrument entitled the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Based on the theoretical and practical foundations of assistive technology as well as on the concept of satisfaction, preliminary versions of the instrument were created and examined by a panel of team participants. After the panels recommendations were incorporated, a pretest of the revised instrument was conducted and the final French version of QUEST emerged. The originality of QUEST lies in its inter-activeness and user-directed approach to assessing satisfaction with assistive technology. From a set of 27 variables, the user is asked to indicate the degree of importance he/she attributes to each of the satisfaction variables and then to rate his/her degree of satisfaction with each of the variables considered (quite or very) important. While QUEST remains a clinical instrument undergoing pilot testing, it holds much promise in our quest for a reliable and valid means of assessing assistive technology outcome from the users perspective.

Item Analysis of the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST)

The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) is an outcomes assessment tool designed to measure satisfaction with assistive technology in a structured and standardized way. The purpose of this article is to present the results of an analysis of the 24 items comprising QUEST and to explain how a subset of items demonstrating optimal measurement performance was selected. The criteria against which the items were measured were general acceptability, content validity, contribution to internal consistency, test–retest stability, and sensitivity. The items that ranked best in terms of these measurement properties were submitted to factorial analysis in order to complete the item selection. The first series of analyses reduced the item pool approximately by half, and the second series of analyses led to the final selection of 12 items. Factor analysis results suggested a bidimensional structure of satisfaction with assistive technology related to the assistive technology device (eight items) and services (four items). The 12-item revised version that will result from this study should prove to be a reliable and valid instrument for measuring outcomes in the field of assistive technology.

Short-Term Changes in and Predictors of Participation of Older Adults After Stroke Following Acute Care or Rehabilitation

Background. Stroke can lead to restrictions in participation in daily activities and social roles. Although considered an important rehabilitation outcome, little is known about participation after stroke and its predictors, and about the differences associated with the types of services provided following stroke. Objective . The aims of this study were 1) to follow and compare changes in participation of older adults discharged home after stroke from acute care or postacute rehabilitation, and 2) to identify the best predictors of participation after stroke from physical, cognitive, perceptual, and psychological ability measures taken shortly after discharge. Methods. Level of participation in daily activities and social roles of 197 older adults who had a stroke was evaluated at 2 to 3 weeks (T1), 3 months (T2), and 6 months (T3) after being discharged home from acute care (n = 86) or rehabilitation (n = 111). Physical, cognitive, perceptual, and psychological abilities were assessed at T1. Results. A significant increase in participation was found over time for both groups, mainly in the first 3 months. The best predictors of participation differed between the groups and between the daily activities and social roles domains. Walking and acceptance of the stroke or fewer depressive symptoms were the best predictors of the level of participation after stroke. Conclusions . Participation was not optimal at discharge because it continued to increase after the return home. The importance of psychological factors in participation after stroke is undeniable. Many predictors are amenable to interventions.

Powered Mobility for Middle-aged and Older Adults: Systematic Review of Outcomes and Appraisal of Published Evidence

Auger C, Demers L, Gélinas I, Jutai J, Fuhrer MJ, DeRuyter F: Powered mobility for middle-aged and older adults: systematic review of outcomes and appraisal of published evidence. Am J Phys Med Rehabil 2008;87:666–680. Objective:To identify the outcomes of power mobility devices for middle-aged and older adult users, and to critically appraise the research evidence. Design:Systematic review of primary source studies involving adults aged 50 and over using power mobility devices (1996–2007). Articles were (i) mapped to the Taxonomy of Assistive Technology Device Outcomes, which describes categories of impact of assistive devices from the vantages of effectiveness, social significance, and subjective well-being; and (ii) appraised using the Grading of Recommendations, Assessment, Development, and Evaluation criteria. Results:This review retained 19 studies and identified 52 different categories of impacts of power mobility devices spanning the three vantages of the taxonomy. The coverage of outcome dimensions was not as extensive for adults age 50 and over as it was for mixed-age groups. Most of the research designs were assigned very low evidence grades. Three studies were low to moderate in quality of evidence, among which one was a randomized trial. Conclusions:A vast array of potential impacts of powered mobility devices have been described in the last decade. The level of quality of this evidence is improving, but most of these studies were not designed to verify causal relationships, and this is largely responsible for the absence of unequivocal evidence for directly attributing benefits to devices themselves and for quantifying relationships between power mobility device intervention and outcome. To raise the level of evidence about power mobility device interventions in older adults, studies are needed that use prospective designs, better-defined user groups, and well-grounded conceptual frameworks for measuring interventions and outcomes.

Donepezil and rivastigmine in the treatment of Alzheimer's disease: a best-evidence synthesis of the published data on their efficacy and cost-effectiveness

BACKGROUND Various drugs have been approved for the treatment of Alzheimers disease (AD) in the United States and Canada, including donepezil and rivastigmine, although questions remain as to their efficacy, effectiveness, and long-term benefits. OBJECTIVE The goal of this study was to conduct a best-evidence synthesis of data on the efficacy and cost-effectiveness of donepezil and rivastigmine in the treatment of AD. METHODS Relevant published randomized controlled trials (RCTs) and Phase IV open-label extension studies (excluding abstracts) were identified through searches of MEDLINE, HealthSTAR, and PsycINFO for the period January 1984 to October 2001. The bibliographies of retrieved articles were searched for additional publications. For inclusion in the best-evidence synthesis, clinical trials had to pass a blinded quality assessment (score > or =5 on the Jadad scale) and use National Institute of Neurological and Communicative Disease and Stroke-Alzheimers Disease and Related Disorders Association diagnostic criteria. Economic studies were selected using National Health Service Centre for Reviews and Dissemination criteria for reporting critical summaries of economic evaluations. RESULTS Nine RCTs of donepezil and 2 of rivastigmine were identified and met inclusion criteria for the best-evidence synthesis. Eight donepezil trials and both rivastigmine trials included patients with mild AD (Mini-Mental State Examination [MMSE] score, 15-27) or moderate AD (MMSE score, 8-14); 1 donepezil trial included patients with moderate or severe AD (MMSE score, 0-7). In the RCTs of donepezil, the mean decrease in scores on the Alzheimers Disease Assessment Scale-cognitive subscale (ADAS-cog) was greater with active treatment than with placebo (lower scores indicate less cognitive deterioration). In the RCTs of rivastigmine, ADAS-cog scores decreased over the follow-up period with both active treatment and placebo; however, scores decreased more with active treatment. Three Phase IV studies of donepezil and I Phase IV study of rivastigmine were identified. Their results were consistent with those of the RCTs. Ten economic studies (7 donepezil, 3 rivastigmine) were identified and reviewed. In 4 of the donepezil studies and all 3 rivastigmine studies, use of the drug cost less than a no-drug strategy. CONCLUSIONS The efficacy data indicate that both donepezil and rivastigmine can delay cognitive impairment and deterioration in global health for at least 6 months in patients with mild to moderate AD. Patients receiving active treatment will have more favorable ADAS-cog scores for at least 6 months, after which their scores will begin to converge with those of patients receiving placebo. Differences in methodology, types of direct or indirect costs included, and sources of cost data made it difficult to compare and synthesize findings of the economic studies; therefore, the cost-effectiveness data are inconclusive.

Burden of Caregivers of People with Stroke: Evolution and Predictors

Background: Caregiver burden differs according to the amount of care, but no study has really focused on that point. This study compares the evolution of burden of two groups of caregivers of people with a recent stroke who returned home after discharge from two different types of health care facilities. Methods: Burden was assessed at 3 weeks and 3 and 6 months after discharge. The two groups of people with stroke and their caregivers were recruited from acute care (n = 69) and rehabilitation facilities (n = 89). Caregivers completed a questionnaire with three dimensions. In addition to sociodemographic characteristics, we assessed variables pertaining to the clinical, physical and cognitive functioning of the people with stroke. Results: Differences in burden were noted. The best predictors of burden were the caregivers’ characteristics, i.e. gender (female), occupation (retired), schooling (low), age (older) and hours of care given, and the stroke survivors’ characteristics, i.e. depressive symptoms, poor motor function (leg), verbal comprehension deficits, difficulty walking and neurological deficits. Conclusion: These results reinforce the view that services (information, training and support) should be tailored to the needs of caregivers, depending on whether or not the recipient of care has received rehabilitation services.

Comparison and correlates of participation in older adults without disabilities

This study was conducted to compare, by age group and gender, the level of participation of older adults who had no disabilities, and to determine which characteristics are most associated with participation. This study involved 350 randomly recruited community-dwelling older adults. Participation in daily activities and social roles were measured with the Assessment of Life Habits (LIFE-H). Demographic, health-related and environmental data were also collected. A decline with age was observed in four of the six daily activities domains and two of the four social roles domains of participation. However, these lower scores are mainly explained by the 85+ group, which consistently scored lower than the 65-69-year-old group. No differences were found between the 65-69, 70-74 and 75-79 years old groups. Some participation domains differed according to gender. Satisfaction with participation was high and did not differ between age groups. Characteristics most associated with participation vary according to the domains; generally, age and marital status are the best determinants of participation. This study found that most of older adults have an unrestricted level of participation which decreases only late in the aging process. This reduction in participation in very old adults was not accompanied by a decrease in satisfaction, supporting the hypothesis that they can participate satisfactorily in valued activities.

Review of Outcome Measurement Instruments in Alzheimer's Disease Drug Trials: Psychometric Properties of Functional and Quality of Life Scales:

The psychometric properties of functional and quality of life outcome measures that were used for the purpose of showing changes in antidementia drug trials for Alzheimers disease are described and critiqued. The seven functional scales reviewed for reliability, validity, and responsiveness to change included the Geriatric Evaluation by Relatives Rating Instrument, the Physical Self-Maintenance Scale, the Instrumental Activities of Daily Living, the Blessed Dementia Scale, Part 1 and its revised version, the Interview for Deterioration in Daily Living with Dementia, the Unified Activities of Daily Living, and the Dependence Scale. The Progressive Deterioration Scale and Quality of Life Assessment were classified as quality of life scales. The majority of the scales were found to exhibit serious limitations, such as incomplete reliability and validity assessment for the intended uses. The most pervasive problem was a lack of data on responsiveness to change. It is recommended that further research be conducted to develop new tools or enhance existing measures for the assessment of both quality of life and functional ability. (J Geriatr Psychiatry Neurol 2000; 13:170-180).

Life-Space Mobility of Middle-Aged and Older Adults at Various Stages of Usage of Power Mobility Devices

OBJECTIVE To examine whether the impact of power mobility devices (PMDs) varies as a function of stage of usage and to explore key factors associated with greater life-space mobility for middle-aged and older adults. DESIGN Multicohort study with respondents grouped as a function of stage of PMD usage (reference group with mobility impairments, n=42; initial users, 1-6mo, n=35; long-term users, 12-18mo, n=39). Cohorts were compared with respect to life-space mobility in a continuum of environments ranging from home to outside town, using analysis of variance and chi-square tests. Baseline personal, assistive device, intervention, and environmental factors associated with life-space mobility were explored with age-adjusted linear regression models. SETTING Four Canadian rehabilitation centers. PARTICIPANTS Random sample of middle-aged and older adults (N=116; 50-89y) living in the community or residential care. INTERVENTION Procurement of a powered wheelchair or scooter. MAIN OUTCOME MEASURE Life-Space Assessment composite score. RESULTS Cohort comparisons showed higher frequency of outings for PMD users in the neighborhood (P<.001) and around home (P<.05) and significantly greater Life-Space Assessment composite scores for initial and long-term users than for the reference group (P<.05). Factors such as sex, the nature of activities, and device type explained variances in Life-Space Assessment composite score ranging from 15.9% to 18.0% (P<.006). CONCLUSIONS Life-space mobility increases after PMD use and remains stable across the stages of initial and long-term use. To appreciate the impact of PMDs, clinicians should consider the environment and a combination of personal and device factors that are associated with the range of life-space mobility in the first 18 months after procurement.

Review of outcome measurement instruments in Alzheimer's disease drug trials: psychometric properties of behavior and mood scales.

This article reviews the reliability and validity of eight scales for behavior and mood problems that were identified in a comparative analysis ofAlzheimers disease (AD) drug trials. The scales are the Brief Psychiatric Rating Scale, the Alzheimers Disease Assessment Scale-noncognitive, the Relatives Assessment of Global Symptomatology, the Consortium to Establish a Registry for Alzheimers Disease-Behavior Rating Scale for Dementia, the Dementia Behavior Disturbance scale, the Neuropsychiatric Inventory, and two scales for depressive symptoms, the Cornell Scale for Depression in Dementia and the Dementia Mood Assessment Scale. This article also examines methodological limitations in the way the published literature has assessed the psychometric properties of these scales. The aim is to help clinicians and potential trial investigators select appropriate measurement instruments with which to assess behavior and mood problems in AD and to assist AD researchers in the evaluation of the psychometric properties of such scales. (J Geriatr Psychiatry Neurol 2000; 13:181-196).