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Introduction: The study aimed to determine the room for improvement of a perfect cerebrospinal fluid (CSF) biomarker and the societal incremental net monetary benefit of CSF in subjects with mild cognitive impairment (MCI) assuming a hypothetical disease-modifying Alzheimer's disease (AD) treatment., Methods: A decision model compared current practice to a perfect biomarker and to two strategies positioning CSF as add-on test when current practice concluded the presence or absence of AD., Results: The simulated MCI population was aged on average 68.3 and 49% had AD. The room for improvement by the perfect CSF test was 0.39 quality adjusted life years, €33,622 ($43,372) savings, 2.0 potential beneficial treatment years, and 1.3-year delay in dementia conversion., Discussion: The results indicated more potential benefit from a biomarker positioned to verify subjects who are not expected to have AD (i.e., to prevent undertreatment) rather than to verify subjects expected to have AD (prevent overtreatment). Sensitivity analyses explored different CSF positions., (Copyright © 2015 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.)

Background: The aim of the study was to evaluate whether adding a geriatric nurse practitioner (GNP) to an outpatient diagnostic multidisciplinary facility for patients with cognitive disorders (Diagnostic Observation Center for PsychoGeriatry, DOC-PG) could improve quality of care. DOC-PG combines hospital diagnostics and care assessment from a community mental health team and provides the general practitioner (GP) with advice for treatment and management. In a previous study, we found that 28.7% of the advice made by this service was not followed up on by the GP., Methods: Two cohorts were studied: a group of patients with added GNP (n = 114) and a historical reference sample (n = 137). Both groups followed the same diagnostic protocol and care approach, but, in the GNP group, a care coordinator was added in order to communicate the advice from the DOC-PG to the GP. The primary outcome was the concordance rate of GPs regarding the advice. At the patient level, health-related quality of life (HRQoL) was assessed. Self-Rated Burden and care-related quality of life were measured at the informal caregiver level. Measures were conducted immediately after DOC-PG diagnosis and after 6 and 12 months. Univariate analyses, logistic regression analyses, and mixed model multilevel analyses were used to test differences between both groups., Results: Total concordance rates were significantly higher in the GNP group compared to the reference sample (82.1 and 71.3%, respectively; p < 0.001). No improvement in patient HRQoL was identified. Among the informal caregivers, a significant reduction of Self-Rated Burden was found in the GNP group at 12 months (adjusted mean difference -1.724, 95% CI -2.582 to -0.866; p < 0.001)., Conclusions: Adding a GNP to an outpatient diagnostic multidisciplinary facility for patients with cognitive disorders may improve the GP concordance rate of the advice from the DOC-PG and reduce subjective burden of the informal caregiver.

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 ($34,505 or £17,775) and &OV0556;11,931 ($15,749 or £8113) for patient and family. The analyses indicated that cognitive functioning, caregiver burden, patient sex, and instrumental activities of daily living were significantly associated with care costs independently., Conclusions: Cognitive functioning and instrumental activities of daily living are important variables to include in health care decision models. We recommend also including caregiver burden and patient sex in decision models for health policy decision makers to fully reflect the heterogeneity of the disease progression of cognitive disorders.

Background: Examination of clinical practice reveals that current treatment options are often not sufficiently utilized by patients suffering from dementia or mild cognitive impairment., Objective: This study aimed to investigate to what extent and in what way these patients utilize the available treatment options, as well as to identify factors and reasons that play a role in the non-utilization of these options., Methods: Semi-structured interviews by telephone were held with the patients' caregivers., Results: Counseling, medication, activities and home care were the options that were most frequently utilized by the 252 patients and caregivers who were included in the study. Group guidance and admissions were the main treatment categories that had not been utilized (although they were proposed). The most important reasons given were refusal by the patient and the fact that help was not necessary yet according to the caregiver. Burden of care and cognition were the most important factors in predicting which of the treatment options were not utilized., Conclusions: Most patients and caregivers are not aware of the treatment options available to them. Awareness of these options is necessary to avoid situations in which patients and caregivers find themselves with their backs against the wall and the need for care support has become an acute necessity. Health care professionals should play an important role with regard to this empowerment., (Copyright © 2010 John Wiley & Sons, Ltd.)

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., ((c) 2007 S. Karger AG, Basel.)

Background: The 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., Methods: Data from the MEDICIE study (n = 196) were used, in which all questionnaires were rated by proxies., Results: Regarding 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., Conclusion: We 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.

Background: Neuropsychological testing has long been embedded in daily clinical practice at memory clinics but the added value of a complete neuropsychological assessment (NPA) to standard clinical evaluation is unknown.Objective: To evaluate the added diagnostic and prognostic value of NPA to clinical evaluation only in memory clinic patients.Methods: In 221 memory clinic patients of a prospective cohort study, clinical experts diagnosed clinical syndrome (subjective cognitive impairment (SCI), mild cognitive impairment (MCI), or dementia) and etiology (Alzheimer's disease (AD) or no AD), and provided a prognosis of disease course (decline or no decline) before and after results of NPA were made available. The reference standard was a panel consensus based on all clinical information at baseline and up to 2 follow-up assessments.Results: With NPA data available, clinicians changed their initial syndromal diagnosis in 22% of patients, and the etiological diagnosis as well as the prognosis in 15%. This led to an increase in correctly classified cases of 18% for syndromal diagnosis, 5% for etiological diagnosis, and 1% for prognosis. NPA data resulted in the largest improvement in patients initially classified as SCI (syndrome: 93.3% (n = 14) correctly reclassified, etiology: net reclassification improvement [NRI] = 0.61, prognosis: NRI = 0.13) or MCI (syndrome: 89.3% (n = 23) correctly reclassified, etiology: NRI = 0.17, prognosis: NRI = 0.14), while there was no improvement in patients with dementia (syndrome: 100% (n = 1) correctly reclassified, etiology: NRI = -0.05, prognosis: NRI = -0.06). Overall, inclusion of NPA in the diagnostic process increased confidence in all diagnoses with 6-7%.Conclusion: Administration of a complete NPA after standard clinical evaluation has added value for diagnosing cognitive syndrome and its underlying etiology in patients regarded as non-demented based on the first clinical impression. [ABSTRACT FROM AUTHOR]

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. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]