Tau Ming Liew

Predicting Gains in Dementia Caregiving

Background: Caregiver gain is an important yet less-explored phenomenon. Being conceptually distinct from burden, factors associated with burden and gain can differ. This study aims to explore factors associated with the experience of gains in dementia caregiving. Method: Cross-sectional study involving caregivers recruited from a tertiary hospital dementia clinic and the local Alzheimer’s Association. Caregivers completed a questionnaire containing the following scales: gain in Alzheimer’s care Instrument (GAIN), General Health Questionnaire (GHQ-28), Dementia Management Strategies Scale (DMSS), Revised Memory and Behavioral Problems Checklist (RMBPC) and Zarit Burden Interview (ZBI). Demographic information for the person with dementia (PWD) and the caregiver was also recorded. Initial screening with univariate analyses (t tests, ANOVAs, Pearson’s correlations) was performed to identify significant (p < 0.05) variables, which were then entered into a multiple regression model to identify variables associated with gain. Result: The final sample comprised 334 caregivers with a mean age of 51.5 years (SD = 10.9, range = 22–85), the majority of whom where Chinese (94.6%) females (71%). Mean GAIN score was 30 (SD = 6.6, range = 7–40). Regression analysis identified 3 factors significantly associated with gains (adjusted R2 32.3%): mental well-being of the caregiver, use of active management as a caregiving strategy, and participation in caregiver educational and support group programmes. Conclusion: The results have important implications for caregiver interventions. Interventions should target maintaining mental well-being, encouraging participation in educational and support programmes, and teaching appropriate coping and dementia specific management strategies to derive good outcomes.

Montreal Cognitive Assessment for Screening Mild Cognitive Impairment: Variations in Test Performance and Scores by Education in Singapore

Background: The Montreal Cognitive Assessment (MoCA) was developed as a screening instrument for mild cognitive impairment (MCI). We evaluated the MoCAs test performance by educational groups among older Singaporean Chinese adults. Method: The MoCA and Mini-Mental State Examination (MMSE) were evaluated in two independent studies (clinic-based sample and community-based sample) of MCI and normal cognition (NC) controls, using receiver operating characteristic curve analyses: area under the curve (AUC), sensitivity (Sn), and specificity (Sp). Results: The MoCA modestly discriminated MCI from NC in both study samples (AUC = 0.63 and 0.65): Sn = 0.64 and Sp = 0.36 at a cut-off of 28/29 in the clinic-based sample, and Sn = 0.65 and Sp = 0.55 at a cut-off of 22/23 in the community-based sample. The MoCAs test performance was least satisfactory in the highest (>6 years) education group: AUC = 0.50 (p = 0.98), Sn = 0.54, and Sp = 0.51 at a cut-off of 27/28. Overall, the MoCAs test performance was not better than that of the MMSE. In multivariate analyses controlling for age and gender, MCI diagnosis was associated with a <1-point decrement in MoCA score (η2 = 0.010), but lower (1-6 years) and no education was associated with a 3- to 5-point decrement (η2 = 0.115 and η2 = 0.162, respectively). Conclusion: The MoCAs ability to discriminate MCI from NC was modest in this Chinese population, because it was far more sensitive to the effect of education than MCI diagnosis.

Detecting Predeath Grief in Family Caregivers of Persons With Dementia: Validity and Utility of the Marwit-Meuser Caregiver Grief Inventory in a Multiethnic Asian Population

Abstract Background and Objectives Coping with predeath grief (PDG) is an unmet need in caregivers of persons with dementia (PWD). The Marwit-Meuser Caregiver Grief Inventory (MM-CGI) and its abbreviated MM-CGI-Short-Form (MM-CGI-SF) are among the few empirically developed scales that detect PDG, yet they have not been substantially validated outside United States. We evaluated the reliability and validity of the PDG scales in a multiethnic Asian population distinct from that of United States. Research Design and Methods Family caregivers of community-dwelling PWD (n = 300) completed self-administered questionnaires containing MM-CGI and other scales of related construct. Sixty percent of the participants repeated the questionnaires 1 week later for test-retest reliability. Internal-consistency reliability was assessed by Cronbach’s α, test-retest reliability by intraclass-correlation-coefficient, construct validity by Spearman’s correlation-coefficient, and factorial validity by confirmatory factor analysis (CFA). Cohen’s κ was used to compare the agreement between MM-CGI and a commonly-used caregiver burden scale (Zarit Burden Interview). Results MM-CGI and MM-CGI-SF demonstrated internal-consistency reliability, test-retest reliability, construct validity, and known-group validity. In CFA, MM-CGI showed modest model-fit (comparative-fit-index, CFI = .80; Tucker-Lewis-index, TLI = .79), whereas MM-CGI-SF showed better model-fit (CFI = .91; TLI = .90). Eighty-six percent of the caregivers reported average or high levels of PDG, with 18% reporting high PDG. High scores in the caregiver burden scale only showed modest agreement with high scores in MM-CGI (κ = .47). Discussion and Implications MM-CGI and MM-CGI-SF demonstrated adequate psychometric properties and utility, beyond that of a caregiver burden scale, in detecting high PDG in a multiethnic Asian population. They open the way for PDG intervention in clinical care, as well as further exploration in caregiver research.

The optimal short version of the Zarit Burden Interview for dementia caregivers: diagnostic utility and externally validated cutoffs

ABSTRACT Objectives: Using a sample of dementia caregivers, we compared the diagnostic utility of the various short versions of the Zarit Burden Interview (ZBI) with the original scale to identify the most optimal one. Next, we established externally validated cutoffs for the various ZBI versions using probable depression cases as a reference standard. Methods: Caregivers (N = 394; 236 males; Agemean = 56 years) were administered the ZBI and a self-report depression measure. Participants who exceeded the cutoff for the latter were identified as probable depression cases. For each of the ZBI versions, a receiver operating characteristic (ROC) curve was plotted against probable depression cases. The area under these ROC curves between the short versions and the original were then compared using a non-parametric approach. Results: Compared to the original ZBI, the AUROC were similar for the 6-item, 7-item, and two 12-item versions, but significantly worse for the other short variants. The sensitivity and specificity of the cutoffs for all ZBI versions ranged from 77.3% to 85.2% and 60.1% to 79.8%, respectively. Conclusions: The original ZBI had good utility in identifying probable depression in caregivers, while the 6-item variant can be a useful alternative when short versions are preferred.

Neuropsychiatric and Cognitive Subtypes among Community-Dwelling Older Persons and the Association with DSM-5 Mild Neurocognitive Disorder: Latent Class Analysis

The differential diagnosis between Alzheimer’s disease (AD) and vascular dementia (VaD) are still roughly problematic in clinical practice, despite the widely used diagnostic criteria to differentiate between the two disorders. There is an increasing evidence that cerebrovascular dysfunction plays a role not only in vascular causes of cognitive alterations but also in AD. Cognitively patients, with AD, show sometimes mixed degrees of associated vascular lesions in 30-60% of AD cases. In opposition, AD pathology may be present in 40%-80% of VaD patients, thus impeding diagnosis accuracy. Therefore, to eliminate this bewilderment and discrepancies in the diagnosis between the AD and VaD, it is worthy to shed light firstly on a disease that is a microangiopathy and represents VaD with clear milestones and features as is the case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Studying CADASIL CSF biomarkers profile, will help in the differential diagnosis between both diseases sharing the coexisting neurodegeneration, furthermore, CADASIL is a dominantly inherited mid-adult life disorder causing ischemic strokes, which belongs to vasculopathies and symbolizes a genuine prototype of VaD that provides a valuable opportunity for studying its CSF biomarkers. Secondly, examining and evaluating the CSF biomarkers of AD compared to that of CADASIL. The pathogenesis similarities between CADASIL and early onset AD affecting the small vessels of the brain have suggested plausible molecular mechanisms involved in vascular damage and their impact on brain function and also come from the fact that in both diseases genetic mutations occur. CADASIL mutations in NOTCH3 gene generate toxic protein aggregates (Granular Osmiophilic Material- GOM) in the vicinity of vascular smooth muscle cells (VSMCs) causing degeneration and loss of VSMCs in small arteries and arterioles of white matter regions of the brain that lead to dementia, similar to those attributed to mutant forms of the Amyloid Precursor proteins (APP) and presenilins genes who cause overproduction and accumulations of the toxic Aβ42 protein in the brain and collapse of Aβ42 clearance mechanisms in AD. Despite the presumed pathological similarities, substantial differences between the two phenomena may exist especially in the CSF neurochemical phenotypes. To examine this aspect, which may help in the differential diagnosis, we carried out this review.

Response to the Letter from Lu et al, “Utility of Montreal Cognitive Assessment (Hong Kong Version) in the Diagnosis of Mild Neurocognitive Disorders (NCD): NCD Due to Alzheimer Disease (NCD-AD) and NCD Due to Vascular Disease (NCD-Vascular)”

with mild NCD. Hence, the linkage of HK MoCA and heterogeneity exemplified the ontogenetic changes in the structure of NCD subtypes and IIV. With regard to the DSM-5 criteria for subtypes of NCD, standardized neuropsychological testing, either computerbased test or paper-pencil test, demonstrated pros and cons. In this respect, the utility of cognitive assessments in NCD diagnoses would be rendering interpretation and implementation with described and measured variables in further exploration.