Studies On Instrumental Activities Of Daily Living Assessment For Screening Dementia Among Rural Elderly Of Shandong Province

Background:Dementia is a common cause of dysfunction in the elderly.The epidemiological survey of dementia in China shows that the total number of dementia patients reached 3.68 million in 1990(of which 1.93 million were Alzheimer's patients),and the total number of dementia patients increased to 9.19 million in 2010(of which Alzheimer's disease Patients account for 5.69 million),costing approximately $ 47.5 billion annually and is expected to rise to about $ 70 billion by 2020.Especially with the rapid economic development,social change,and aging of the population in China in recent years,the prevalence of dementia and Alzheimer's disease has been increasing year by year,and more than 10%of the elderly have different degrees cognitive impairment.In stark contrast to this,in the past 20-30 years,the incidence of dementia in European countries has remained stable.According to the analysis,the important reasons are that early screening and related effective prevention and control of risk factors.Although early detection of the disease may help slow functional decline and related care costs,in low-and middle-income countries,diagnostic coverage for dementia is as low as 5%to 10%.In China,nearly 60%of the elderly live in rural areas.Epidemiological surveys show that the prevalence of dementia in rural elderly is significantly higher than that of urban elderly.However,due to the lack of professional doctors in rural areas,more patients with dementia are not adequately diagnosed and identified.In order to diagnose dementia early and reliably,effective screening strategies are needed.The accurate diagnosis of dementia is both complicated and difficult.It requires comprehensive clinical,neuropsychological,imaging and laboratory tests,which is difficult to achieve because of the limited economic and medical conditions in rural areas.Therefore,in primary health care,especially in rural areas,a simple procedure is needed to screen for dementiaThere are already many validated screening tests and self-assessment questionnaires commonly used to assess cognitive function,including the Mini-mental State Examination Scale(MMSE)and the Ascertain Dementia 8-item Informant Questionnaire(AD8).MMSE is the most widely used cognitive screening scale.It is often recommended for the screening of dementia,and it covers orientation,memory,attention,computing,language ability,and visual space ability.The AD8 test is an eight-item questionnaire developed by the University of Washington's Alzheimer's Disease Research Center in 2005 to identify changes in individual judgment,memory,orientation,and function because such changes may be related to Early cognitive decline is related to a self-assessment questionnaire or a caregiver to provide the above changes.The results of AD8 have a certain degree of correlation with the results of MMSE.MMSE or AD8 is used as a screening tool.When one of them tests positive,it may indicate cognitive impairment,but the final diagnosis of dementia requires further evaluation in combination with medical history and neuropsychological tests.In low-and middle-income countries,high illiteracy rates and limited education may further complicate cognitive screening,and complex neuropsychological tests,including MMSE,are difficult for rural healthcare professionals to become proficient at grasp.Therefore,there is a need for an alternative simple tool that is more suitable for rural useImpaired ability of daily living is one of the core symptoms of dementia.The activities of daily living include two aspects:basic activities of daily living and instrumental activities of daily living.Studies have shown that the decline in instrumental activities of daily living is a feature of the early stage of dementia.Instrumental activities of daily living include a range of complex daily or social activities,such as the ability to manage finances,work,cook,use tools,travel,and do housework.The early stages of dementia are manifested as a decline in instrumental activities of daily living because these activities require complex cognitive activities.The instrumental ability for daily living is an effective tool for screening dementia in the population,with sensitivity and specificity of 87.2%-95.1%and 74.7%-90.3%,respectively.As the disease progresses,the decline in basic daily living abilities such as eating,toileting,self-care and mobility will become apparent in the later stages of dementia.Therefore,the assessment of the decline in instrumental activities of daily living can be an effective means of screening for dementia,and many validated instrumental activities of daily living scales have been developed to identify dysfunctions related to dementiaThe Pfeffer Functional Assessment Questionnaire(FAQ)and Lawton's Instrumental Activities of Daily Living Scale of Lawton(IADL)are commonly used instrumental assessment tools for daily living functions,which are usually used to quantify instrumental activities of daily living capabilities.Pfeffer et al.Found that the sensitivity and specificity of the Functional Assessment Questionnaire(FAQ)were 0.85 and 0.81 in distinguishing between patients with and without dementia,respectively.Because the Functional Assessment Questionnaire(FAQ)and Lawton's Instrumental Ability for Daily Living(IADL)can distinguish healthy individuals from those with cognitive impairments,their use in screening for dementia would be valuable.Although empirical evidence for this use is limited,it does show a degree of specificity in population-based studies.However,the effectiveness of the instrumental activities of daily living assessment in screening dementia among rural residents in China has not been evaluated.In this study,we attempted to assess whether the modified Chinese version of the Functional Assessment Questionnaire(FAQ)and the Lawton Instrumental Ability for Daily Living Ability(IADL)can be used to distinguish dementia between rural elderly populations to find a simple dementia screening program for the rural elderly.Objectives:To investigate the prevalence of dementia among the elderly in Yanlou Town,Shandong Province,to explore the screening power of FAQ and IADL for dementia,and to identify risk factors for dementia.Methods and Results:Part I:Screening power of FAQ for dementia in rural high-risk elderly population of Shandong ProvinceMethods:Relying on the Science and Technology Benefiting People Program of Shandong Province,our team conducted epidemiological survey of dementia for residents aged 65 and over in 53 villages of Yanlou,Liaocheng.The survey was conducted in two phases.The first stage is mainly to collect general conditions,lifestyle,disease history and preliminary screening of cognitive impairment.The survey tools include general information questionnaire,lifestyle behavior questionnaire,past medical history and current illness questionnaire,social support.Social support rating scale(SSR).Cognitive assessment screening using AD8 and MMSE).Positive by MMSE and/or AD8 screening test suggesting that there may be cognitive impairment,the second stage of investigation is recommended;in the second stage,further detailed dementia investigation and research are conducted on some participants with positive MMSE and/or AD8 screening in the first stage to collect a history of cognitive impairment(including the main complaint and current medical history),physical examination,and a series of complex neuropsychological tests and assessment of daily living ability,depression,vascular factors,mental behavior,etc.The survey tools include medical history collection form,daily cognitive scale(Everyday Cognition(ECog),verbal fluency test(VFT)(animals,fruits,vegetables),Boston naming test(BNT),auditory verbal learning test(AVLT),Fuld object memory test(FOM),WISC block design(BD),digit span test(DST),trail making test(TMT),clock drawing test(CDT),functional assessment questionnaire(FAQ),Hamilton depression scale(HAMD),Hachinski ischemic scale(HIS),clinical dementia rating scale(CDR),neuropsychiatric inventory questionnaire(NPI),etc.Among them,the FAQ is used to evaluate the instrumental ability of daily living,including 10 daily activities.This study eventually included 961 participants with positive MMSE and/or AD8 screening tests.The diagnosis of dementia among the participants was based on DSM-IV diagnostic criteria.The receiver operating characteristic curve(ROC)analysis was used to determine the optimal cutoff value of functional activity questionnaire(FAQ)screening for dementia,and stratified according to age,gender,and education level.Further analysis of FAQ screening for dementia in different strata Ability.The relationship between FAQ and MMSE or AD8 and the risk factors of dementia were analyzed.Results:Of the 961 participants finally included,84(8.7%)were clinically diagnosed with dementia and classified into the dementia group;the remaining 877(91.3%)were classified into the non-dementia group.The average score of MMSE in the dementia group was significantly lower than that in the non-dementia group,and the average score of AD 8 and FAQ were significantly higher than those in the non-dementia group.After controlling for the influence of factors such as gender,age,education level,marital status,smoking,and drinking,Spearman correlation analysis found that the total FAQ score was moderately inversely related to the MMSE score(r=-0.302,P<0.001);The FAQ total score was weakly positively correlated with the AD8 score(r=0.221,P<0.001).Multivariate logistic regression analysis found that FAQ was related to dementia,OR(95%CI)=1.21(1.17?1.25),P<0.001;after correcting other risk factors,OR(95%CI)?1.13(1.08?1.18),P<0.001,that is,increasing every 1 point of the FAQ,increased the risk of having dementia 1.13(1.08-1.18)times.The cutoff score of the FAQ scale was 5/6 points to determine dementia(determined as dementia with?6 points):area under the curve=0.899;sensitivity=94.1%;specificity=75.1%.The optimal cutoff for FAQs varies with age,gender,and education.In the illiterate population,the discrimination ability is slightly worse(AUC=0.891,sensitivity=96.7%,specificity=68.8%),high sensitivity and poor specificity,which may lead to excessive screening due to a high false positive rate.Logistic regression analysis was performed to screen for the risk factors of dementia,and it was found that increased age(P<0.001,OR=1.093),history of cerebral infarction(P<0.001,OR=3.078),and illiteracy(P<0.01,OR=7.646)were dementia Risk factors.Part ? Screening power of IADL for dementia in rural elderly population of Shandong ProvinceMethods:Relying on the Ministry of Science and Technology's "Thirteenth Five-Year Plan"National Key Research and Development plan-a major research project on the prevention and control of major chronic non-communicable diseases-a randomized controlled multimodal intervention study to delay dementia and disability in China(MIND-CHINA)project,from March to September 2018,our team conducted epidemiological survey of dementia for residents aged 60 and over in 53 villages of Yanlou,Liaocheng.The collected information includes general information,lifestyle,history of cognitive impairment,history of other diseases,physical examination and neuropsychological tests.The survey tools include general information questionnaires,lifestyle behavior questionnaires,medical history and current illness questionnaires.Social support rating scale(SSR);cognitive assessment using subjective memory loss questionnaire,subjective memory loss self-rating scale,AD8,MMSE,Verbal fluency test(VFT)(animal,fruit,vegetable),auditory verbal learning test(AVLT),digit span test(DST),clock drawing test(CDT),trail making test(TMT);assessment of daily living ability is based on Zhang Mingyuan's modified version of activities of daily living scale(ADL);depression state is used in the elderly depression state assessment scale(Geriatric depression scale,GDS);using the Hakinski ischemia scale(HIS)evaluation vascular factors;walking speed testing for physical evaluation.Among them,the Instrumental Activities of Daily Living Scale(IADL)in Zhang Mingyuan's improved Activities of Daily Living Scale(ADL)is used to assess instrumental daily living abilities,including 12 daily activity items.The diagnosis of dementia among the participants was based on DSM-IV diagnostic criteria.Receiver operator characteristic curve(ROC)analysis is used to determine the best cutoff value for IADL screening for dementia,and it is stratified according to age,gender and education level years,and further analysis of IADL screening ability in different strata.The correlation between IADL and MMSE or AD8 and the risk factors of dementia were analyzed.Results:The study finally included 5173 participants.The diagnosis of dementia among participants was based on DSM-? diagnostic criteria.Of the 5173 participants finally included,147(2.8%)were clinically diagnosed with dementia and were included in the dementia group;the remaining 5026(97.2%)were included in the non-dementia group.The average MMSE score of the dementia group was significantly lower than that of the non-dementia group.The average score of AD8 and IADL were significantly higher than that of the non-dementia group.The difference between the two groups was statistically significant(P<0.01).The IADL scale score was divided into 15 points to determine dementia(IADL?15 points were determined to be dementia):area under the curve=0.921;sensitivity=81.0%;specificity=90.9%.IADL's optimal cut-off value and discriminative power for identifying dementia vary little with age,gender,and education level.Among people aged 75 and over,IADL's discriminative power is slightly worse.After controlling for the influence of factors such as gender,age,education level,marital status,smoking,and drinking,Pearson correlation analysis found that the IADL score and the MMSE score were moderately negatively correlated(r=-0.407,P<0.001);the IADL score was positively correlated with the AD8 score(r=0.478,P<0.001).Multivariate logistic regression analysis found that dementia was related to IADL,OR(95%CI)=1.9(1.8 to 2.1),P<0.001;after correcting other related factors,dementia was still related to IADL,OR(95%CI)=1.4(1.2 to 1.5),P<0.001.For every 1point increase in IADL,the likelihood of suffering from dementia increases 1.4(1.2 to 1.5)times.Logistic regression analysis was used to screen for risk factors for dementia,and aging(P<0.001,OR=1.10)and history of cerebral infarction(P<0.05,OR=1.81)were risk factors for dementia,and the number of years of education increased(P<0.05,OR=0.90)is a protective factor for dementia.Conclusions:The instrumental activities of daily living are related to cognition.There is a decline in instrumental daily living abilities of patients with dementia.The instrumental activities of daily living assessment can be used to distinguish dementia patients in the rural elderly population of Shandong Province.It has high sensitivity,specificity and overall efficacy.It can be used to simplify dementia screening procedures in rural areas and improve the detection rate of dementia.Both the FAQ scale and the IADL scale can be used for dementia screening in rural elderly of Shandong Province.Ageing,low education level,and cerebral infarction are the risk factors for dementia.In the rural areas,active science education should be carried out to control the risk factors,which is expected to reduce the incidence of dementia.