Kaohsiung J Med Sci September 2006 • Vol 22 • No 9 437 Dementia has been a major public health problem of
the aging population in developed countries for decades. The elderly population aged 65 years and above has increased rapidly in Taiwan, from 7.1% in 1993 to 9.5% in 2004 [1]. It is estimated that there will be about 23.9% of people older than 65 years by 2051
in Taiwan [2]. Recent studies in Taiwan have shown that the prevalence of dementia among people aged 65 years and above is 2–4.4% [3–5]. Few illnesses associated with aging are as devastating to the patient or family as dementia. Characterized by chronic and often progressive cognitive deterioration, dementia causes patients to lose their functional capacity for independence and personal care [6]. It also affects the quality of life of both patients and caregivers and is directly linked to costs of care [7,8]. Although hospi-talization or long-term care facilities often resolve patients’ health problem, the heavy financial burden Received: October 24, 2005 Accepted: June 6, 2006
Address correspondence and reprint requests to: Professor Ching-Kuan Liu, Department of Neurology, Kaohsiung Medical University Hospital, 100 Tzyou 1stRoad, Kaohsiung 807, Taiwan. E-mail: [email protected]
F
UNCTIONAL
P
ERFORMANCE OF
A
LZHEIMER
’
S
D
ISEASE AND
V
ASCULAR
D
EMENTIA IN
S
OUTHERN
T
AIWAN
Mei-Yuh Shiau, Lifa Yu,1Hui-Shin Yuan,2Jau-Hong Lin,3and Ching-Kuan Liu4
Departments of Healthcare Management, and 2Nursing, Tajen University, Pingtung, Faculties of 1Psychology and 3Physical Therapy, Kaohsiung Medical University, and 4Department of Neurology,
Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
This study investigated the functional performance of two major subtypes of dementia, Alzheimer’s disease (AD) and vascular dementia (VaD), by the Functional Independence Measure (FIM), and to understand the need for assistance in performing activities of daily living. The subjects comprised 64 AD and 21 VaD patients who were recruited from two epidemiologic studies of dementia with a total of 3,931 community residents aged 65 years and above in southern Taiwan. The results showed that the severity of dementia was similar between the two groups. The mean score for AD was 82.7 and for VaD was 56.5 for total FIM (p< 0.05), 61.6 and 41.7 for the motor dimension (p< 0.05), and 21.1 and 15.7 for the cognitive dimension (p<0.05). There were significant differences (p<0.01) between AD and VaD in six FIM items and borderline or marginal significance (p <0.05) in most of the FIM items. For AD patients, stairs, lower dressing, bathing, and tub/shower transfer were the most difficult items in the motor dimension, and it was memory in the cognitive dimen-sion. For VaD patients, bathing, upper and lower dressing, and grooming were the most difficult items in the motor dimension, and it was problem solving in the cognitive dimension. VaD patients were more dependent on all FIM items and required more assistance than AD patients. The func-tional performances of dementia patients were significantly associated with dementia severity and subtypes, together accounting for 40% of the variability in total FIM. In conclusion, most dementia patients are dependent in daily activities and different types and severity of dementia lead to different disability profiles; individualized care is, therefore, most appropriate.
Key Words:Alzheimer’s disease, Functional Independence Measure, vascular dementia (Kaohsiung J Med Sci 2006;22:437–46)
has a serious impact on the family and society. In any case, home care of the elderly is traditional in Taiwan. Dementia, therefore, has increasingly significant eco-nomic and social impacts on families and societies in Taiwan.
Dementia is a clinical syndrome of biopsychoso-cial components that produces disruption in behavior, cognition, and affect. Assessing the levels of func-tional abilities of these demented elderly is essential for understanding their needs and level of assistance required in order to provide them with adequate functional skills or aids. The performance of the activities of daily living (ADL) is influenced by pro-gressive cognitive impairment in the demented eld-erly. The Functional Independence Measure (FIM) is a reliable, valid, sensitive, simple, practical, and effi-cient instrument to assess a patient’s daily function-ing [9–11]. The FIM, which is a part of the Uniform Data System for Medical Rehabilitation, has been developed to measure physical disability [12,13], to assess the outcomes of medical rehabilitation [14] and to estimate the burden of care [15]. In addition to ADL and mobility, the FIM also assesses communica-tion and cognitive skills and has gained widespread popularity in the United States and other countries [16,17]. Since the daily activities of dementia patients are highly influenced by cognitive deficits as well as motor dysfunction, the FIM should be very suitable for assessing functional performance in dementia patients. However, FIM has seldom been used on demented elderly. The purpose of this study was to investigate the functional performance in two major types of dementia, Alzheimer’s disease (AD) and vascular dementia (VaD), using FIM, and to under-stand the need for assistance in performing ADL for these two patient groups on the FIM items.
M
ATERIALS ANDM
ETHODSSubjects
All subjects were obtained from the two dementia studies in southern Taiwan conducted by Liu et al [4] and Lin et al [5] and underwent annual follow-up for 3 years parallel to the current study. In total, 3,931 elderly subjects aged 65 years and above were sam-pled by a multistep stratified random method from Kaohsiung city, Kaohsiung county, and Pingtung county. The ascertainment of dementia cases was
done using a two-phase study design. In the screen-ing phase (Phase 1), a culturally adapted version of the Chinese Mini Mental State Examination [18], Blessed Dementia Rating Scale [19], and a question-naire regarding detailed demographic data and past medical history were administered by specially trained interviewers. In Phase 2, the CERAD (Consortium to Establish a Registry of Alzheimer’s Disease) neu-ropsychologic test battery [20] was performed by neuropsychologists, and comprehensive neurobehav-ioral examinations, including Clinical Dementia Rating Scale (CDR) [21] and Hachinski Ischemia Scale [22], were administered by senior neurologists. The ICD-10NA, DSM-III-R criteria for dementia, NINCDS-ADRDA guidelines for AD [23], and NINDS-AIREN criteria [24] for VaD were employed to identify the subtypes of dementia. Severity of dementia was clas-sified by the CDR, and CDR= 1, 2, 3–5 represented mild, moderate, and severe, respectively. From the two studies, the total number of demented elderly was 153. Of these 153 demented elderly, 30 died, seven moved, and 14 could not be traced. Consequently, the remaining 102 subjects were enrolled. Of these 102 demented patients, 64 (62.7%) were classified as hav-ing AD, 21 (20.6%) as havhav-ing VaD, eight (7.8%) as having a mixture of AD and VaD, two (2.0%) as hav-ing Parkinson’s disease, and seven (6.9%) as havhav-ing other disorders. Only 85 patients with AD and VaD were included in the analysis.
Instrument
Structured interview of 18 FIM items was used in this study. For each of the 18 FIM items, specific scaling descriptions are listed and used. The FIM was devel-oped from the Barthel Index by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Task Force. This instrument was translated into Chinese and val-idated using Taiwanese subjects by Guo et al [25]. The FIM is an 18-item ordinal scale; each item is scored with a seven-level ordinal scale to assess the patient’s need for assistance or devices in order to accomplish daily activities. The 18 items of the FIM are classified into six subscales and assess two dimensions: motor and cognitive. The motor dimension consists of self-care (eating, grooming, bathing, upper and lower dressing, toileting), sphincter control (bladder and bowel management), mobility (bed/chair, toilet, and tub/shower transfer), and locomotion (walking or
using wheelchair, stairs). The cognitive dimension con-sists of communication (comprehension, expression) and social cognition (social interaction, problem solv-ing, memory). For each of the 18 FIM items, specific scaling descriptors are used. Degree of dependency is classified into three levels of functioning [9,16–17,26]: independence with no helper (ID), modified depend-ence on a helper (MD), and complete dependdepend-ence on a helper (CD). Each item is rated on a seven-point scale. A score of 1 or 2 indicates CD; a score of 1 means requiring total assistance and 2 means maximal assis-tance. A score of 3, 4, or 5 indicates MD; a score of 3 means requiring moderate assistance, 4 minimal assis-tance, and 5 supervision. A score of 6 or 7 indicates ID; a score of 6 means modified independence and 7 means complete independence [9,16–17,26]. Scores on the FIM range from 18 to 126. A higher FIM score means a higher level of independence and better functional performance of the patient. The interrater reliability of this instrument ranges from 0.88 to 0.93 and the internal consistency reliability is 0.97.
Procedures
The patients and their families were contacted by telephone to ask if they were interested in participat-ing in the study. Those who had no telephones were informed by mail. During home visit, a specially trained nurse evaluated the patient’s performance on the FIM by observation and interviews of patients
and their caregivers. Health education for caregivers was also conducted to enhance their knowledge about dementia, safety of environment, and skills of care. Five registered nurses participated in this study. A home visit was conducted for each patient. Each home visit took about 1–2 hours.
Statistical analyses
Background characteristics of subjects were analyzed with the χ2 test to examine the differences between
AD and VaD. The age and FIM score were analyzed by Student’s t test. Multiple regression analysis was used to determine the importance of various predict-ing factors. Significance was defined as p< 0.01 and borderline significance as p< 0.05 because of multiple comparisons. Statistical analysis was performed with SPSS version 8.0 (SPSS Inc., Chicago, IL, USA). Data were analyzed with percentage, χ2test, mean, standard
deviation, Student’s t test, and multiple regressions.
R
ESULTSBackground characteristics of subjects are shown in Table 1. This study consisted of 64 (75.3%) AD and 21 (24.7%) VaD patients. Mean age was 80.3± 7.4 years for AD patients, and 75.3± 6.2 years for VaD patients (t= 2.82, p < 0.01). There were significant differences in gender (χ2= 5.58, p < 0.05) between the two groups.
Table 1. Background characteristics of subjects
Total (n= 85) AD (n= 64) VaD (n= 21) Statistical
Variables n (%) n (%) n (%) value
Gender χ2=5.58*
Male 34 (40.0) 21 (32.8) 13 (61.9)
Female 51 (60.0) 43 (67.2) 8 (38.0)
Mean age (yr) 78.93± 7.45 80.33± 7.39 75.29± 6.19 t= 2.82†
Education χ2= 3.81
Illiterate 59 (69.4) 48 (75.0) 11 (52.4)
Literate 3 (3.5) 3 (4.7) 0 (0.0)
Elementary school 15 (17.6) 9 (14.1) 6 (28.6)
Junior high school 2 (2.4) 1 (1.6) 1 (4.7)
Senior high school or above 6 (7.1) 3 (4.7) 3 (14.3)
Severity of dementia (CDR) χ2=4.19
Mild (CDR 1) 58 (68.2) 45 (70.4) 13 (61.9)
Moderate (CDR 2) 13 (15.3) 7 (10.9) 6 (28.6)
Severe (CDR 3, 4, 5) 14 (16.5) 12 (18.8) 2 (9.6) *p< 0.05; †p< 0.01. AD = Alzheimer’s disease; VaD = vascular dementia; CDR = Clinical Dementia Rating scale.
A higher percentage of dementia was found in lower educational groups. With regard to severity of demen-tia, 58 subjects (68.2%) had mild dementia (CDR= 1), 13 (15.3%) had moderate dementia (CDR= 2), and 14 (16.5%) had severe dementia (CDR= 3–5). However, there were no significant differences in education and severity of dementia (CDR score) between the two groups.
Table 2 shows the degree of dependence by FIM at different stages of dementia. In general, the degree of dependence was associated with the stage of dementia. The frequency of CD was 13.8–31.1% for mild demen-tia, 46.2–84.6% for moderate demendemen-tia, and 64.3–92.9% for severe dementia. For the 58 mild demented elderly (CDR=1), the four leading difficult motor items were bathing, stairs, lower dressing and walking or using a wheelchair. For the 13 moderate dementia patients, the four leading difficult motor items were upper dressing, bathing, lower dressing, and toileting, and the two most difficult cognitive items were memory (84.6%) and problem solving (61.5%). For the 14 severe demented elderly, grooming, bathing, upper dressing, and bladder management were the most difficult items, and 85.8% of them were completely dependent on a
helper in motor items. Memory, expression (both 92.9%), and social interaction (85.7%) were difficult in the cognitive dimension.
As shown in Table 3, the VaD group had lower scores than the AD group on all six subscales (self-care, sphincter control, mobility, locomotion, com-munication, social cognition), the two dimensions (motor, cognitive), and total scores. The total mean FIM score for AD was 82.7 (65.6% of maximal score) and for VaD was 56.5 (44.8% of maximal score). The AD group obtained a mean score of 61.6 (67.6% of maximal score) and the VaD group a score of 41.7 (45.8% of maximal score) on the motor dimension. The AD group obtained a mean score of 21.1 (60.2% of maximal score) and the VaD group a score of 15.7 (44.9% of maximal score) on the cognitive dimension. We also found borderline significant differences in the motor and cognitive dimensions, and total FIM scores between the AD and VaD groups. Most of the FIM items were significantly different between AD and VaD, except bladder management, language com-prehension, and memory. Among the motor dimen-sion items, the six most significantly different items between AD and VaD were bed/chair transfer (t=3.18,
Table 2. Degree of dependency in various dementia severities by Functional Independence Measure (FIM) items Mild (n= 58) Moderate (n= 13) Severe (n= 14)
(CDR 1) (CDR 2) (CDR 3, 4, 5) Total (n= 85) FIM items % % % % ID MD CD ID MD CD ID MD CD ID MD CD Eating 69.0 8.7 22.3 15.4 23.1 61.5 21.4 14.3 64.3 52.9 11.8 35.3 Grooming 69.0 3.4 27.6 15.4 15.4 69.2 7.1 7.1 85.8 50.6 5.9 43.5 Bathing 63.7 5.1 31.1 15.4 7.7 76.9 7.1 7.1 85.8 47.0 5.9 47.0 Upper dressing 67.3 5.1 27.6 15.4 0.0 84.6 0.0 14.2 85.8 49.4 4.7 45.9 Lower dressing 65.5 5.1 29.3 15.4 7.7 76.9 7.1 14.3 78.6 48.2 5.9 45.9 Toileting 67.3 6.8 25.9 15.4 7.7 76.9 21.4 0.0 78.6 51.8 5.9 42.3 Bladder management 69.0 12.1 18.9 15.4 23.1 61.5 14.3 0.0 85.7 51.8 11.8 36.4 Bowel management 69.0 13.9 17.1 30.8 15.4 53.8 21.4 0.0 78.6 55.3 11.8 32.9 Bed/chair transfer 65.5 8.6 25.9 23.1 15.4 61.5 28.6 7.1 64.3 52.9 9.4 37.7 Toilet transfer 63.8 10.3 25.9 30.8 7.7 61.5 28.6 0.0 71.4 52.9 8.3 38.8 Tub/shower transfer 62.0 10.4 27.6 23.1 15.4 61.5 14.3 7.1 78.6 48.2 10.6 41.2 Walk or wheelchair 67.3 3.4 29.3 30.8 7.7 61.5 28.6 0.0 71.4 55.3 3.5 41.2 Stairs 64.1 5.7 30.2 16.6 16.6 66.8 21.4 7.1 71.4 49.4 7.6 43.0 Comprehension 37.9 44.9 17.2 30.7 23.1 46.2 7.1 14.3 78.6 31.8 36.4 31.8 Expression 50.0 31.0 19.0 30.7 23.1 46.2 0.0 7.1 92.9 38.8 25.9 35.3 Social interaction 51.7 34.5 13.8 30.7 23.1 46.2 0.0 14.3 85.7 40.0 29.4 30.6 Problem solving 37.9 39.7 22.4 15.4 23.1 61.5 0.0 35.7 64.3 28.2 36.4 35.3 Memory 29.3 46.6 24.1 7.7 7.7 84.6 0.0 7.1 92.9 21.2 34.1 44.7 CDR = Clinical Dementia Rating scale; ID (independence) = complete independence or modified independence; MD (modified depen-dence) = levels of assistance required supervision, minimal contact assistance or moderate assistance; CD (complete dependepen-dence) = maximal assistance or total assistance.
p< 0.01), upper dressing (t = 3.14, p < 0.01), problem
solving (t= 2.99, p < 0.01), bathing (t = 2.75, p < 0.01), eating (t= 2.67, p < 0.01), and lower dressing (t = 2.65,
p< 0.01). Of the 18 FIM items, the scores were around
4–5 points (minimal assistance to supervision) for AD (except for memory) and 2–4 points (maximal to minimal assistance) for VaD.
We applied multiple regression analysis to deter-mine the important factors in predicting the perform-ance on FIM. It was found that CDR had the highest predictive ability, followed by subtypes of dementia, for motor dimension, cognitive dimension, and total FIM scores. These two predictors together accounted for 36.7% of the variability in motor FIM scores, 38% in cognitive FIM scores and 40% in total FIM scores (Table 4).
D
ISCUSSIONThis study was conducted in the community and the investigators examined the patients in their homes and were able to observe their environment and actual performance. Also, the subjects were recruited from community surveys and could represent the real picture of dementia care status in Taiwan, com-pared to most hospital studies. Severity of dementia was determined with the CDR [21], which proved to be very useful in assessing the need for support serv-ices. Figure 1 shows that higher CDR score indicates more dependence on caregivers and need for more assistance in daily activities. Among patients with mild dementia, one third were dependent in motor dimension activities, and only half to one third were
Table 3. Comparison of the Functional Independence Measure (FIM) scores between Alzheimer’s disease (AD) and vascular dementia (VaD)
AD VaD FIM items (n= 64) (n= 21) t M± SD M± SD Motor dimension 61.6± 33.1 41.7± 30.7 2.44* Self-care subscale 28.6± 15.3 18.4± 14.7 2.76† Eating 5.2± 2.3 3.6± 2.3 2.67† Grooming 4.7± 2.8 2.9± 2.6 2.58* Bathing 4.6± 2.7 2.8± 2.5 2.75† Upper dressing 4.7± 2.7 2.7± 2.4 3.14† Lower dressing 4.6± 2.7 2.9± 2.6 2.65† Toileting 4.8± 2.7 3.2± 2.6 2.40*
Sphincter control subscale 9.9± 5.2 7.5± 5.2 1.97
Bladder management 4.8± 2.7 3.6± 2.6 1.76 Bowel management 5.1± 2.6 3.7± 2.6 2.14* Mobility subscale 14.4± 7.7 9.6± 7.5 2.63† Bed/chair transfer 5.0± 2.6 3.0± 2.4 3.18† Toilet transfer 4.8± 2.7 3.2± 2.6 2.46* Tub/shower transfer 4.6± 2.7 3.1± 2.5 2.15* Locomotion subscale 9.3± 5.4 6.2± 5.2 2.15* Walk/wheelchair 4.8± 2.8 3.1± 2.7 2.37* Stairs 4.5± 2.7 3.0± 2.6 2.09* Cognitive dimension 21.1± 9.9 15.7± 9.5 2.08* Communication subscale 8.9± 4.3 6.9± 4.3 1.73 Comprehension 4.3± 2.1 4.0± 2.5 0.69 Expression 4.6± 2.3 3.1± 2.2 2.59*
Social cognition subscale 12.2± 5.9 8.8± 5.4 2.24*
Social interaction 4.6± 2.2 3.4± 2.1 2.19*
Problem solving 4.0± 2.2 2.6± 1.8 2.99†
Memory 3.5± 2.0 2.9± 2.0 1.24
Total FIM scores 82.7± 41.4 56.5± 38.9 2.46*
*p< 0.05; †p< 0.01. M = mean; SD = standard deviation. Note: Levels of functioning and their scores: 7 = complete independence; 6 = modified independence; 5 = supervision; 4 = minimal assistance (at least 75% independent); 3 = moderate assistance (at least 50% independence); 2 = maximal assistance (at least 25% independent); 1 = total assistance (< 25% independence).
independent in various cognitive functioning activi-ties. In general, the functional performance of FIM is significantly associated with severity and subtype of dementia. Galasko reported that AD patients demon-strate a similar deterioration course in functional loss, starting from forgetting, to inability to use household appliances, dressing, locomotion, and finally eating [27]. In motor function, self-care was the most diffi-cult subscale, and 61.5–85.8% of patients with moder-ate to severe dementia were completely dependent in this area. The four most difficult motor items for the 85 demented elderly were bathing, upper dressing, lower dressing, and grooming. Most patients with severe dementia are completely dependent on a helper and need to be fed, are incontinent, or bedridden [21]. However, the deterioration course of various motor activities varied a lot, which may be a result of different progression courses of dementia in both AD and VaD and the various proportions of AD to VaD at
different dementia stages in this sample. In contrast, the deterioration in cognitive functioning was more consistent and homogeneous with the progression of dementia because the staging of dementia, regard-less of the subtype, was based mainly on cognitive dysfunction.
There were significant differences in age and gen-der between AD and VaD patients; however, age and gender were not significantly associated with FIM score. VaD patients were more dependent than AD patients in all 18 FIM items [28] and vascular demen-tia, causally related to stroke, always induced physical disability such as paralysis, limb rigidity, spasticity, and gait abnormality [29], which is consistent with Chen et al’s report that VaD patients have more phys-ical and severe functional disabilities compared to AD patients [30]. The most significant differences between AD and VaD groups in the 18 FIM items were activi-ties involving locomotion, which resulted from motor
Table 4. Multiple regression analysis predicting Functional Independence Measure (FIM) scores in dementia Unstandardized Standardized
Dependent variables Independent variables regression regression F R2
coefficients coefficients
Motor dimension CDR (stage 1/others) −16.72 −0.49* 8.48 0.37
scores Subtype of dementia −28.79 −0.36*
(AD vs. VaD)
Gender (male vs. female) −10.93 −0.16
Age (yr) −0.56 −0.13
Level of education (illiterate/ −0.78 0.03 literate elementary, junior
high school, senior high school, and above)
Cognitive dimension CDR (stage 1/others) −5.43 −0.53† 9.68 0.38
scores Subtype of dementia −7.44 −0.32*
(AD vs. VaD)
Gender (male vs. female) −3.31 −0.16
Age (yr) −0.07 −0.05
Level of education 0.99 0.14
(illiterate/literate elementary, junior high school, senior high school and above)
Total FIM scores CDR (stage 1/others) −22.14 −0.52† 9.75 0.40
Subtype of dementia −36.86 −0.37* (AD vs. VaD)
Gender (male vs. female) −13.58 −0.16
Age (yr) −0.67 0.12
Level of education 1.85 0.07
(illiterate/literate elementary, junior high school, senior high school and above)
disability via stroke. Going up or down stairs was the most difficult item for AD patients, which might result from gait apraxia [31]. This probably was the cause of fall accidents. Thus, the AD patients always performed better in ADL and were more independent than the VaD patients except for bladder management, com-prehension, and memory, which are highly related to dementia severity. Both types of dementia patients had large ranges of FIM performance, especially VaD patients, indicating high heterogeneity in functioning among dementia patients.
Several studies [16,25,32–34] have shown that eat-ing is the easiest self-care item in both groups. The AD patients could complete this task under supervision, while the VaD patients needed moderate to minimal assistance. In self-care items, bathing and dressing were the most difficult for AD patients, resulting from complicated procedures [35], while upper dressing was the most difficult for VaD patients, probably relat-ing to hemiparesis. These neurologic dysfunction and neurobehavioral impairments influenced ADL performance, and causes of impaired functioning in dementia patients were often complicated. We con-sider sphincter control as an example. Bladder man-agement was more difficult than bowel manman-agement. Urge incontinence in AD may relate to dysfunction of
sphincter control and forgetfulness from central degen-erations. However, stroke can cause bladder dysfunc-tion, resulting in neurogenic bladder and uninhibited bladder, causing incontinence, which may be aggra-vated by memory lapses, inattention, emotional fac-tors, inability to communicate, and impaired physical mobility [36].
In general, there were no significant differences in global cognitive impairment between the two groups, because dementia was defined, according to DSM-IV [37], as multiple cognitive deficits [37]. Nevertheless, there was significant difference in some specific cognitive domain between the two groups. Figure 2 and Table 3 show that AD had better functional performance than VaD. VaD patients required moderate assistance, while AD patients ranged from requiring supervision to minimal assis-tance. This result may reflect the fact that VaD patients have expressive, receptive aphasia as well as dysarthria while AD patients have difficulty mainly in understanding (comprehension deficit) until the late stage [29]. VaD patients also had much difficulty in problem solving, which may be due to the fact that VaD patients frequently have frontal dysfunc-tion and physical disability to conduct the task. These reflect that the disabilities of dementia patients 0 20 40 60 80 100 % CDR1 CDR2 CDR3 FIM items Eating Grooming Bathing
Upper dressingLower dressing Toileting
Bladder managementBowel managementBed/chair transfer Toilet transfer
Tub/shower transferWalk or wheelchair Stairs Comprehension
Expression
Social interactionProblem solving Memory
Figure 1.Complete dependence in Alzheimer’s disease and vascular dementia by Functional Independence Measure (FIM) items. CDR= Clinical Dementia Rating scale.
are very heterogeneous regarding cause, severity and individual difference.
This study explored the functional performance of dementia patients in Southern Taiwan and showed prominent functional impairment that was diverse between two major types of dementia and which changes with disease progression. Due to the high heterogeneity of dementia, disabilities in various types and severity of dementia are quite different. Detailed assessment of functional performance for every dementia patient is essential for adequate care, and an individualized plan of care for each patient is mandatory for better care. Future studies should recruit more subjects so that the dementia patients can be divided into more groups, in addition to severity and type. In addition, simultaneous assessment of cogni-tive function, behavioral problem, and CDR score may bring out more fruitful findings. Public education about knowledge and home care of dementia, efforts to reduce incidence of head trauma, prevention of stroke, and treatment of risk factors would benefit in the care of demented elderly and in controlling its severity. The results of this study provide references in caring for dementia patients.
A
CKNOWLEDGMENTSThis work was supported by a research grant from the National Science Council of Taiwan (NSC 85-2413-H-037001). We also wish to acknowledge Yong-Yuan Chang, ScD, for assistance in data analysis.
R
EFERENCES1. Department of Statistics, Ministry of the Interior of the Republic of China. Public Database of Department of
Household Registration Affairs, Ministry of the Interior.
Available at http://www.ris.gov.tw and http://www. moi.gov.tw/stat/ [Accessed: August 10, 2005]
2. Manpower Planning Department, Council for Economic Planning and Development. Projection of the Population of
Taiwan, Republic of China, 1998–2051. [In Chinese]
3. Liu HC, Lin KN, Teng EL, et al. Prevalence and sub-types of dementia in Taiwan: a community survey of 5297 individuals. J Am Geriatr Soc 1995;43:1–6.
4. Liu CK, Lin RT, Chen YF, et al. Prevalence of dementia in an urban area in Taiwan. J Formos Med Assoc 1996; 95:762–8.
5. Lin RT, Lai CL, Tai CT, et al. Prevalence and subtypes of dementia in southern Taiwan: impact of age, sex, edu-cation, and urbanization. J Neurol Sci 1998;160:67–75. 0 20 40 60 80 100 FIM items % GroomingBathing Upper dressing Stairs Comprehension Eating Lower dressing Toileting
Bladder managementBowel managementBed/chair transfer Toilet transfer
Tub/shower transferWalk or wheelchair
Expression
Social interactionProblem solving Memory
AD VaD
Figure 2.Modified dependence and complete dependence in Alzheimer’s disease (AD) and vascular dementia (VaD) by Functional Independence Measure (FIM) items.
6. Rankin ED, Haut MW, Keefover RW. Clinical assessment of family caregivers in dementia. Gerontologist 1992;32: 813–21.
7. Kurz X, Scuvee-Moreau J, Rive B, et al. A new approach to the qualitative evaluation of functional disability in dementia. Int J Geriatr Psychiatry 2003;18:1050–5. 8. Albert SM, Sano M, Bell K, et al. Hourly care received by
people with Alzheimer’s disease: result from an urban community survey. Gerontologist 1998;38:704–14. 9. Hamilton BB, Granger CV. Disability outcomes
follow-ing inpatient rehabilitation for stroke. Phys Ther 1994; 74:494–503.
10. Heinemann AW, Linacre JM, Wright BD, et al. Relation-ships between impairment and physical disability as measured by the Functional Independence Measure.
Arch Phys Med Rehabil 1993;74:566–73.
11. Ring H, Feder M, Schwartz G. Functional measures of first stroke rehabilitation inpatient: usefulness of the Functional Independence Measure total score with a clinical rationale. Arch Phys Med Rehabil 1997;78:630–5. 12. Kemal N, Ali G, Remzi C, et al. The relationship between
physical impairment and disability during stroke reha-bilitation: effect of cognitive status. Int J Rehabil Res 2004;27:181–4.
13. Sooyen K, Abraham GH, Pamela WD, et al. Disability measurements in stroke: relationship among the Barthel Index, the Functional Independence Measure, and the modified Rankin Scale. Stroke 2004;35:918–23.
14. Chae J, Zorowitz RD, Johnston MV. Functional outcome of hemorrhagic and nonhemorrhagic stroke patients after in-patient rehabilitation: a matched comparison.
Am J Phys Med Rehabil 1996;75:177–82.
15. Disler PB, Roy CW, Smith BP. Predicting hours of care need. Arch Phys Med Rehabil 1993;74:139–43.
16. Tsuji T, Sonoda S, Domen K, et al. ADL structure for stroke patients in Japan based on the Functional Independence Measure. Am J Phys Med Rehabil 1995;74: 432–8.
17. Black TM, Soltis T, Bartlett C. Using the Functional Independence Measure instrument to predict stroke rehabilitation outcomes. Rehabil Nurs 1999;24:109–21. 18. Chen YF. Validation of Chinese version of Mini-Mental
Status Examination in the field study. Kaohsiung, Taiwan:
Kaohsiung Medical College, 1994. [Masters thesis. In Chinese]
19. Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral gray matter of elderly subjects. Br J Psychiatry 1968;114:797–811.
20. Morris JC, Heyman A, Mohs RC, et al. The Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Part I: clinical and neuropsychological assessment of Alzheimer’s disease. Neurology 1989;39:1159–65. 21. Hughes CP, Berg L, Danziger WL, et al. A new clinical
scale for the staging of dementia. Br J Psychiatry 1982; 140:566–72.
22. Hachinski VC, Iliff LD, Zilhka E, et al. Cerebral blood flow in dementia. Arch Neurol 1975;32:632–7.
23. McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer’s disease: report of the NINCDR-ADRDA Work Group under the auspices of Depart-ment of Health and Human Services Task Force on Alzheimer’s disease. Neurology 1994;34:939–44. 24. Roman GC, Tatemichi TK, Erkinjuntti T, et al. Vascular
dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop. Neurology 1993;43:250–60.
25. Guo NW, Yeh SH, Lin JH, et al. A study on structural analysis of Functional Independence Measure in Taiwan.
J Rehabil Med Repub China 1999;27:217–26. [In Chinese]
26. Linacre JM, Heinemann AW, Wright BD, et al. The structure and stability of the Functional Independence Measure. Arch Phys Med Rehabil 1994;75:127–32. 27. Galasko D. An integrated approach to the management
of Alzheimer’s disease: assessing cognition, function and behaviour. Eur J Neurol 1998;5:S9–17
28. Arai Y, Zarit SH, Kumamoto K, et al. Are there inequities in the assessment of dementia under Japan’s LTC insur-ance system? Int J Geriatr Psychiatry 2003;18:346–52. 29. Cummings JL, Benson DF. Dementia: A Clinical Approach,
2ndedition. Boston: Butterworth-Heinemann, 1992:1–8,
152–3.
30. Chen X, Zhang ZX, Huang JB, et al. Comparative study on the features of Alzheimer’s disease and vascular dementia. Chung-Kuo I Hsueh Ko Hsueh Yuan Hsueh Pao 2004;26:122–7.
31. Della SS, Spinnler H, Venneri A. Walking difficulties in patient with Alzheimer’s disease might originate from gait apraxia. J Neurol Neurosurg Psychiatry 2004;75:196–201. 32. Cotter EM, Burgio LD, Stevens AB, et al. Correspondence
of the Functional Independence Measure (FIM) self-care subscale with real-time observation of dementia patients’s ADL performance in the home. Clin Rehabil 2002;16:36–45.
33. Wu SC, Hsu HC, Chuang YC, et al. Application of func-tional assessment in estimating long-term care need among non-institutionalized elderly adults in Taiwan.
J Health Med Repub China 1996;15:533–44. [In Chinese]
34. Gerdner LA, Hall GR. Chronic confusion. In: Maas ML, Buckwalter KC, Hardy MD, et al (eds). Nursing Care of
Older Adults: Diagnoses, Outcomes and Interventions, 2nd
edition. St Louis: Mosby, 2001:421–41.
35. Rogers JC, Holm MB, Burgio LD, et al. Excess disabil-ity during morning care in nursing home residents with dementia. Int Psychogeriatr 2000;12:267–82.
36. Black JM, Hawks JH, Keene AM. Management of clients with degenerative neurologic disorders. In: Medical-Surgical Nursing, 6th edition. New York: WB
Saunders, 2001:1953–81, 2002–13.
37. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington DC: American Psychiatric
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