Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial.

OBJECTIVES: To investigate the effect of self-management group rehabilitation for persons with dementia (PwD) and their spouses on their health-related quality of life (HRQoL), the cognition of the PwD, and the costs of health and social services. DESIGN: A randomized controlled trial. SETTING: Primary care and memory clinics in the Helsinki metropolitan area, Finland. PARTICIPANTS: PwD (N = 136) and their spouses (N = 136). INTERVENTION: Couples were randomized to usual care or eight-session self-management groups for PwD and concurrently for their spouses. Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support. MEASUREMENTS: The primary outcome measures were the HRQoL of PwD (measured using a generic, comprehensive (15-dimensional), self-administered instrument (15D)) and spouses (measured using the RAND-36) and the spousal Sense of Competence Questionnaire (SCQ). Secondary outcome measures were PwD cognition (Verbal Fluency (VF), Clock Drawing Test (CDT)) and costs of health and social services during 24 months. RESULTS: At 3 months, the spouse physical component of the RAND-36 improved (mean change 1.0, 95% confidence interval (CI) = -0.5 to 2.4) for those undergoing the intervention and worsened for controls (mean change -2.0, 95% CI = -3.5 to -0.4) (P = .006 adjusted for age, sex, baseline value of the physical component of the RAND-36). There were no differences between the groups on the mental component of the RAND-36, the SCQ, or the 15D. At 9 months, PwD change in VF was -0.38 (95% CI = -1.03 to 0.27) in intervention group and -1.60 (95% CI = -2.26 to -0.94) for controls (P = .011 adjusted for age, sex, baseline MMSE score). CDT changes were similar to VF changes. Differences in incremental costs between the groups was -436 € per person per year (95% CI = -4,986 to 4,115) for PwD (P = .35 adjusted for age, CDR) and -896 € per person per year (95% CI = -3,657 to 1,864) for spouses (P = .51 adjusted for PwD age, CDR). CONCLUSIONS: The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12611001173987.

Psychosocial group intervention to enhance self-management skills of people with dementia and their caregivers: study protocol for a randomized controlled trial.

BACKGROUND: After diagnosis of a dementing illness, patients and their spouses have many concerns related to the disease and their future. This often leads to poor psychological well-being and reduced health-related quality of life (HRQoL) of the family. Support for self-management skills has been proven to be an effective method to improve prognosis of asthma, heart failure and osteoarthritis. However, self-management interventions have not been studied in dementia. Therefore, our aim was to examine, in an objective-oriented group intervention, the efficacy of self-management support program (SMP) on the HRQoL of dementia patients and their spousal caregivers as well as on the sense of competence and psychological well-being of caregivers. METHODS: During the years 2011 to 12, 160 dementia patients and their spouses will be recruited from memory clinics and randomized into two arms: 80 patients for group-based SMP sessions including topics selected by the participants, 80 patients will serve as controls in usual community care. Sessions may include topics on dementia, community services, active lifestyle and prevention for cognitive decline, spousal relationship, future planning and emotional well-being. The patients and spouses will have their separate group sessions (ten participants per group) once a week for eight weeks. Main outcome measures will be patients' HRQoL (15D) and spousal caregivers' HRQoL (RAND-36), and sense of competence (SCQ). Secondary measures will be caregivers' psychological well-being (GHQ-12) and coping resources, patients' depression, cognition and signs of frailty. Data concerning admissions to institutional care and the use and costs of health and social services will be collected during a two-year follow-up. DISCUSSION: This is a 'proof-of-concept' study to explore the efficacy of group support for self-management skills among dementia families. It will also provide data on cost-effectiveness of the intervention. TRIAL REGISTRATION: ACTRN12611001173987.

Apathy: prevalence, associated factors, and prognostic value among frail, older inpatients.

OBJECTIVES: The association of apathy with Alzheimer disease and other dementias and caregiver burden has been examined in a number of studies; however, less is known about its relationship with delirium and mortality. We aimed to investigate the prevalence, relationship with delirium and dementia, and prognostic value of apathy in an elderly and frail inpatient population. SETTING AND PARTICIPANTS: The cohort included 425 patients in acute geriatric wards and in 7 nursing homes in Helsinki (1999-2000). Demographic factors, physical functioning, diagnoses, and drugs were assessed with special reference for dementia, delirium, and apathy. Mortality was registered from central registers. RESULTS: Of the patients, 98 (23.1%) suffered from apathy, and it was more frequent among men (32% versus 21% women, P = .037 ). There was no difference in mean age, number of comorbidities, or in the mean number of medications between those with and without apathy; however, those with apathy had lower mean MMSE points (9.2 versus 14.0 without apathy, P < .001), more often severe dementia according to Clinical Dementia Rating, and higher dependence in activities of daily living (P = .001). Furthermore, patients with apathy were more often suffering from delirium (37.8% versus 21.1%, P ≤ .001). Mortality during the 1-year follow-up was 34.7% (n = 34) and 22.0% (n = 72) among individuals with and without apathy, respectively (P = .011). In the Cox proportional hazard model with age, gender, activities of daily living, and delirium as covariates, apathy significantly predicted mortality (HR 1.89, 95% CI 1.24 to 2.89; P = .003). CONCLUSIONS: Apathy is a common and serious neuropsychiatric symptom associated with cognitive decline, delirium, and disability, and it also independently predicts mortality.

The overlap of delirium with neuropsychiatric symptoms among patients with dementia.

OBJECTIVES: To study the frequency of overlapping of delirium with neuropsychiatric symptoms (NPS) among patients with dementia, and to investigate the prognostic value of delirium, multiple NPS without delirium, or neither during a 2-year follow-up. METHODS: We assessed 425 consecutive patients in acute geriatric wards and in seven nursing homes in Helsinki. Those 255 suffering from dementia were examined for NPS of dementia described in the Neuropsychiatric Inventory (delusions, hallucinations, agitation/aggression, depression/low mood, anxiety, euphoria/elation, apathy, disinhibition, irritability/mood changes, and aberrant motor behavior) and for delirium criteria according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Patients were categorized into three groups: delirium with or without multiple NPS (delirium group), multiple NPS without delirium (multiple NPS group), or having neither delirium nor multiple NPS (zero or only one NPS group). RESULTS: A total of 66 patients suffered from delirium according to the DSM-IV, 127 had multiple NPS without delirium, and 62 had neither multiple NPS nor delirium. In the delirium group 61 individuals (92.4%) were deceased or residing in permanent institutional care at the end of the 2-year follow up period, compared to 100 individuals (78.7%) in the multiple NPS group and 48 (77.4%) in the zero or one NPS group (Pearson χ² = 6.64, df 2, p = 0.036). In logistic regression analysis adjusted for age, sex, and comorbidities, delirium was an independent predictor of this composite outcome (OR: 4.3, 95% CI: 1.4-13.6). CONCLUSIONS: Patient groups with symptoms of delirium and multiple NPS are highly overlapping. The presence of delirium indicates poor prognosis.