K.Y. Yamashita, E.S. Deol, S.J. Elliott, J.E. Morley, T.K. Malmstrom
Saint Louis University School of Medicine, Saint Louis, USA
Corresponding Author: K.Y. Yamashita, Saint Louis University School of Medicine, Saint Louis, USA, firstname.lastname@example.org
J Prev Alz Dis 2022;
Published online June 16, 2022, http://dx.doi.org/10.14283/jpad.2022.60
Background/Objectives: Alzheimer’s disease (AD) is the most common cause of dementia and negatively impacts individuals’ quality of life (QOL). One essential component of disease management in older adults with AD is the maintenance and improvement of QOL. The QOL-AD is a tool that can be administered to evaluate QOL in AD patients, but it can take too long to administer in a patient visit. The purpose of this study was to investigate the validity of a more brief, 6-item QOL questionnaire, LIFEAD, comparing it to the QOL-AD in older adults with mild to moderate cognitive dysfunction.
Design: Prospective validation study.
Setting: Participants were patients presenting to internal medicine and geriatrics outpatient clinics and a nursing home.
Participants: 285 adults 65 and older with mild to moderate cognitive impairment. Measurements: QOL was assessed using LIFEAD and the QOL-AD. Demographic data were collected and level of depression was determined through a demographic questionnaire and the PHQ-8, respectively.
Results: QOL-AD mean item scores ranged from 2.27-3.32 with an average scale total of 36.28 ± 6.48. LIFEAD mean item scores ranged from 2.26-2.51 with an average scale total of 14.28 ± 2.87. A majority (68%) of patients rated all items on LIFEAD as either average or good. The correlation between LIFEAD and the QOL-AD was 0.71 (p<0.001). Both LIFEAD and the QOL-AD showed strong internal consistency with a Cronbach’s alpha of 0.82 and 0.87, respectively.
Conclusion: This study validated LIFEAD and exhibited LIFEAD can assess QOL in older adults with mild to moderate cognitive dysfunction in the clinic or nursing home. LIFEAD is a short, practical questionnaire and is easily administered in approximately 1 minute. Further research on LIFEAD could be done with larger samples, in different clinical populations, and including persons of other ethnic backgrounds.
Key words: Quality of life, Alzheimer’s disease, LIFEAD.
Alzheimer’s disease (AD) is a neurodegenerative disorder, advancing overtime to affect one’s memory, behavior, and capacity (1). AD is prevalent in the United States with a predicted 7.1 million adults over 65 years old with AD in 2025 (2). As the baby-boomer generation turned 65 in 2011, the amount of people at risk for AD will continue to grow significantly (2). By 2050, around 13 million people over 65 years old will have AD (2). AD is the most common cause of dementia, and along with a decline in cognitive function can come a negative impact on quality of life (QOL) for individuals (3). One important component of disease management among older people with AD is the evaluation and maintenance of QOL.
The concept of QOL is broad and multi-dimensional (4). QOL affects an individual’s physical health, psychological state, level of independence, personal beliefs, and relationships with others and the environment (5). QOL includes an individual’s self-perception in the context of a culture and value system (5). Treatment and management for AD includes pharmacological, behavioral, educational, and environmental interventions (2, 3, 6). Evaluations of cognitive, psycho-behavioral, and functional ability can be made to determine the impact of treatments on AD patients, but the assessments do not encompass patients’ perceptions of the disease’s effect on themselves (1). Evaluation of QOL is important in the context of disease progression and management due to its association with unfavorable conditions such as depression and frailty (7, 8). However, the assessment of QOL among patients with dementia can be difficult due to its complexity, as it may require use of cognition, memory, and introspection (7).
The QOL-AD is a well-known tool available to evaluate QOL in patients and consists of 13 items on a 4-point scale, but this tool may take too long to administer during a clinic visit. A more functional, concise measure of QOL in patients with AD is needed.
The purpose of this study is to investigate the validity of a brief, 6-item QOL questionnaire, LIFEAD, developed for use in clinical settings and community programs. To do this, we compared LIFEAD to the QOL-AD measure in a sample of older adults with mild to moderate cognitive dysfunction.
LIFEAD is a brief clinical assessment tool designed to measure QOL in patients with AD (see Figure 1). LIFEAD includes 6-items and asks patients to rate quality of life, ability to tolerate illnesses, functional ability, energy, level of anxiety, and level of happiness on a 3-point Likert scale (poor=1, average=2 and good=3) (6-18 total points). LIFEAD is based on self-report and administration time is approximately one minute.
Answers are poor, average or good.
The QOL-AD is a validated, widely used measure to assess QOL in patients with AD and includes 13 items rated on a 4-point Likert scale (poor=1, fair=2, good=3, excellent=4) (1-52 total points) (9). Items evaluate aspects of one’s relationships, finances, physical ability, memory, mood, and health (10). The QOL-AD takes approximately three minutes to administer.
The Saint Louis University Mental Status (SLUMS) examination is a 30-point, 11-item scale that evaluates cognitive function, requiring completion of tasks involving things like recall, attention to detail, numeric calculation, and clock drawing (11).
The PHQ-8 is a widely used measure for major depression and has 8 items scored using a 4-point Likert scale (not at all=0, several days=1, more than half the days=2, nearly every day=3) (12).
The demographic questionnaire administered captures age, marital status, highest level of education, and self-identified gender, race, and ethnicity.
Inclusion criteria were ages 65+, ability and willingness to provide written informed consent, and SLUMS scores. Patients were recruited from outpatient clinics and a nursing home.
Consenting subjects were administered the SLUMS examination to assess cognitive function (11). It was used to determine eligibility for participation in the study. Patients scoring 10-20 on the SLUMS indicated mild to moderate cognitive impairment and were included in the study. Those who didn’t satisfy these criteria—such as patients with severe cognitive dysfunction with a SLUMS score of <10 or patients without mild to moderate cognitive dysfunction with a SLUMS score of >20—were excluded and not administered any other study measures. Once eligible, participant characteristics were obtained using a demographic questionnaire, and participants were then administered the PHQ-8, the QOL-AD, and LIFEAD.
Data were analyzed using IBM SPSS Statistics, version 23 (Somers, NY). Descriptive statistics are reported as means ± standard deviations or percentages (see Table 1). Cronbach’s alpha coefficients were used to examine the internal consistency reliability of the QOL-AD and LIFEAD. Convergent and divergent validity of LIFEAD through correlation with the QOL-AD was analyzed using Spearman’s correlation.
Patients 65 and older (n=285) were recruited from internal medicine and geriatrics outpatient clinics (n=253) and a nursing home (n=32). Of the 285 adults, 107 adults met the inclusion criteria for this study with a SLUMS score of 10-20. Of the 285 adults, 16 were excluded with a SLUMS score of <10. Participant characteristics are shown in Table 1. Participants were ages 65-100 with a mean of 75.9 ± 8.3 and 58.9% (n=63) were female. The patient population included 35.5% (n=38) White, 57.9% (n=62) Black, and 6.6% (n=7) other or refused. Marriage demographics consisted of 21.5% (n=23) married, 28.0% (n=30) divorced, 29.9% (n=32) widowed, and 20.6% (n=22) separated or never married.
QOL-AD mean item scores ranged from 2.27-3.32 with an average scale total of 36.28 ± 6.48. LIFEAD mean item scores ranged from 2.26-2.51 with an average scale total of 14.28 ± 2.87. A majority (68%) of patients rated all items on LIFEAD as either average or good (see Table 2).
The correlation between LIFEAD and the QOL-AD was 0.71 (p<0.001). LIFEAD and SLUMS Exam scores did not correlate with one another, with a correlation of -0.06 (p=0.55). The correlation between LIFEAD and PHQ-8 scores was -0.24 (p=0.01). Both LIFEAD and the QOL-AD showed strong internal consistency with a Cronbach’s alpha of 0.82 and 0.87, respectively. LIFEAD internal consistency reliability was highest when all items were included in the scale. Cronbach’s alpha scores were all <0.82 if an item was removed from the composite.
SD, standard deviation.
SD, standard deviation.
LIFEAD is a valid and reliable measure to assess quality of life in the clinic or nursing home across a range of older persons with cognitive dysfunction, including mild cognitive impairment and mild to moderate AD. LIFEAD exhibited good convergent validity with the QOL-AD and good divergent validity with the SLUMS Exam. LIFEAD also exhibited convergence with the PHQ-8, but as predicted, the association was modest because the measures assess different constructs (i.e., quality of life vs. depression, respectively). LIFEAD also exhibited satisfactory internal consistency reliability, with no questions in LIFEAD showing redundancy, indicating good inter-item correlation. LIFEAD is a short, easily comprehensible questionnaire, making it practical for use in clinical settings. LIFEAD can be administered in approximately 1 minute.
LIFEAD can be used as a valid measure to assess QOL in individuals with cognitive impairment in interventions supported by the Geriatrics Workforce Enhancement Program at Saint Louis University such as Cognitive Stimulation Therapy (CST) (13). CST is a non-pharmacological treatment for dementia conducted with patients who have mild to moderate dementia in sessions of evidence-based treatment activities like singing, yoga, and stimulating discussions (13-15). Saint Louis University is currently North America’s designated training site for CST, and looking at the pre- and post-CST LIFEAD scores in patients involved in CST would efficiently and effectively evaluate QOL improvement after intervention (13).
Limitations of this study include participant recruitment from one geographic area and a moderate sample size. Study methodology is another limitation, as the same investigators administered the questionnaires to determine if patients were cognitively impaired. In addition, the study sample included primarily White or Black older adults. Further research on LIFEAD could be conducted with larger samples, in different clinical populations, and including persons of other ethnic backgrounds.
It’s essential to assess QOL in patients with AD, particularly since the growing population of individuals over 65 years old with AD may face a negative impact on quality of life with the decline in cognitive function. Hence, LIFEAD is a valid, reliable, and clinic-friendly measure for use in outpatient clinics and nursing homes to assess and then address poor QOL in patients with AD.
Disclosures and Author Responsibilities: Ms. Yamashita has nothing to disclose. Mr. Deol has nothing to disclose. Ms. Elliott has nothing to disclose. Dr. Morley has nothing to disclose. Dr. Malmstrom has nothing to disclose. Author responsibilities were as follows. KYY: study design, patient recruitment, patient assessment, data analysis, manuscript writing and revision. ESD: patient recruitment, patient assessment, manuscript revision. SJE: patient recruitment, patient assessment, manuscript revision. JEM: study design, manuscript revision. TKM: study design, data analysis, manuscript revision.
Impact Statement: We certify that this work is novel clinical research. It is a validation of a new quality of life questionnaire for patients with Alzheimer’s disease.
Ethical Standards: This study was approved by the Saint Louis University School of Medicine Institutional Review Board and abided by all local and federal laws.
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