1. Do Instrumental Activities of Daily Living Predict Dementia at 1- and 2- Year Follow-Up? Findings from the Development of Screening Guidelines and Diagnostic Criteria for Predementia Alzheimer’s Disease Study Sietske A. M. Sikkes, PhD, Pieter Jelle Visser, MD, PhD, Dirk L. Knol, PhD, et al. JAGS; December 2011, vol 59, No. 12 Payal Patel Mercer University, College of Pharmacy and Health Sciences RTR Medical Group 1/31/2012

2. Background & study purpose Dementia is the most common disease in later life Diagnosis is based on decline in scales that assess disabilities in activities of daily living (ADLs) ADL refers to basic activity of daily living (BADL) and instrumental activities of daily living (IADL) Complex activities are more sensitive to cognitive decline in early stages of dementia IADL assessment can play an important role in screening/diagnosing dementia

3. Background & study purpose Several studies have investigated the use of IADL scales in diagnosing dementia Previous studies showed variable results from no correlation to strong association Difficult to compare because the selection of items and participants vary This study investigates whether interference in IADLs can predict dementia at 1 and 2 year follow-up in a memory clinic setting

4. Study Design and Population Prospective cohort study Participants selected from DESCRIPA study which was done by the European Alzheimer’s Disease Consortium Participants recruited from 20 memory clinics across Europe between January 2003 and June 2005

5. Study Design and Population Inclusion Criteria: Age 55 and older with a new referral due to cognitive complaints Exclusion Criteria: patients with cognitive impairment due to somatic, psychiatric or neurological disorder

6. Outcome Measures Instrumental Activities of Daily Living Different IADL scales were used between the study centers: 16 centers used an IADL scale 9 used Lawton IADL scale 3 used Blessed Dementia scale and Bayer ADL scale 1 used Alzheimer’s Disease Cooperative study ADL scale 1 used Bristol ADL scale

7. Primary outcome All questionnaires completed by informant of the participant Items related to IADLs were chosen from the questionnaires Item content that overlapped between the different tests was selected to pool IADLs Responses were dichotomized to ‘no problems’ or ‘slight to severe problems’

8. Outcome Measures Cognitive Examination – MMSE – Memory tests – Varied between the centers Primarily Rey Auditory Verbal Learning Test – Depression Different scales between the centers Scores dichotomized for clinically significant depressive symptoms in each of the scales

9. Statistical method Statistical analysis were performed using M- Plus version 6.1 and SPSS Differences between participants with and without dementia were analyzed with independent t tests or chi square

10. Statistical methods Item response theory was used to model the dimensional structure of IADLs The relationship between IADL and the diagnosis of dementia, depression, and memory were modeled using SEM P<0.05 was considered statistically significant

11. Results sample size = 616 participants 1 st year = 531 2 nd year = 481 Nine items were chosen: shopping, telephone use, housekeeping, transport, finances, medication, food/drink preparation, laundry, handling money 13 % developed dementia in 1 year with most common cause being Alzheimer’s 20.8 % patients had developed dementia in 2 years

12. Results Participants with at least one IADL problem had a higher rate of having dementia after 1 year (15.9%) compared to participants without IADL problems (P = 0.04) Participants with IADL disabilities at baseline also had a higher rate of dementia at 2 years (24.4%) compared to participants who did not have IADL problems (P = 0.04)

13. Results Participants who developed dementia were mostly older (p = 0.02) with lower MMSE scores ( p < 0.001) and greater memory impairments (p < = 0.001) at baseline Depression was not found to be a risk factor for developing dementia

14. Results CharacteristicN = 531Dementia (n = 69) at 1 year No Dementia (n = 462) at 1 year P value Age, mean +/- SD69.6 +/- 7.571.5 +/- 7.869.3 +/- 7.40.02 Female, n (%)315 (59.3)46 (66.7)269 (58.2)0.18 Education, n Primary201271740.95 Secondary20125176 >Secondary12917112 MMSE score, median (range) 28 (26-29)27 (25-28)28 (27-29)< 0.001 Memory Z –score, mean +/- SD -1.08 +/- 1.34-2.04 +/- 1.08-0.94 +/- 1.32<0.001 Depressed, n (%)50 (10.0)3 (4.4)47 (10.8)0.10

15. Conclusion IADL disability can be a useful tool in predicting dementia at 1 and 2 year follow-up along with other commonly used clinical measures such as MMSE and memory IADL problems are the border between the preclinical stages of dementia and dementia Depression is not a risk factor for developing dementia

16. Comments Strengths: – Sample size – Prospective design Weaknesses: – Pooled IADL items from different questionnaires Items might not be closely comparable – Difficult to say which IADL questionnaire should be used – Many patients did not complete the questionnaires completely Limited use in clinical practice – Most of the scales were developed to evaluate patients over time and not for diagnostic purposes Underestimation of the true diagnostic value of IADL problems – In some countries or regions, people may visit a memory clinic later in the disease course compared to others