Which factors increase informal care hours and societal costs among caregivers of people with dementia? A systematic review of Resource Utilization in Dementia (RUD)

Renira C Angeles, Line I Berge, Marie H Gedde, Egil Kjerstad, Maarja Vislapuu, Nathalie G Puaschitz, Bettina S Husebo, Renira C Angeles, Line I Berge, Marie H Gedde, Egil Kjerstad, Maarja Vislapuu, Nathalie G Puaschitz, Bettina S Husebo

Abstract

Background: Nearly 19 million people across OECD countries are living with dementia, and millions of family caregivers are affected by the disease. The costs of informal care are estimated to represent 40-75% of the total dementia cost exceeding formal care time and medical costs.

Objective: To conduct a systematic review to evaluate the methodological quality and factors associated with high informal care hours per month that increase societal costs, and to identify what type of interventions may alleviate the entire burden of informal and formal caregiving.

Methods: The systematic review was registered at PROSPERO (15.12.2020). A search in Medline, Embase, PsycINFO, and web of science for observational studies, cost-effectiveness, and cost of illness (COI) analyses on resource utilization in dementia (RUD) was conducted on 1 December 2020. Our inclusion criteria included a requirement that studies had to use the original RUD, RUD-FOCA or RUD lite in terms of hours or days per month, and costs as primary or secondary outcome, OECD countries, within the last 20 years and a sample population comprising persons with dementia (PwD) ≥65 years and their caregivers. We followed the PRISMA, GRADE, PICO guidelines and Drummond criteria to assess the methodology and quality of the studies.

Results: Of 307 studies, 26 cross-sectional and 3 longitudinal cohort studies were included in the analyses. Two studies had a randomized controlled trial (RCT) design. The methods and cost categories in each study varied widely. Disease severity, caregiver factors, and behavioural and psychological symptoms of dementia (BPSD) were associated with high informal care hours and societal cost. One RCT found no effect of a non-pharmacological intervention on informal care hours, yet another RCT found a cost-effective impact of an in-home respite care programme reducing informal care burden and costs.

Conclusion: The divergent use of the RUD components within included studies encourage more harmonized analyses. There are only two RCTs on RUD, one of which shows a significant treatment effect. Larger sample sizes and longer follow-up periods are required in future RCTs with dedicated focus on cost-enhancing and resource intensive factors such as disease severity and BPSD. Novel interventions must diversify between caregiver and PwD groups.

Prospero registration: CRD42021226388 .

Keywords: Cost of illness; Cost-effectiveness; Family caregivers; Informal caregivers; Resource utility dementia.

Conflict of interest statement

MHG, LIB, BSH, MV, EK and RCA declare no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Flow diagram of RUD study selection

References

    1. Wimo A, Reed CC, Dodel R, Belger M, Jones RW, Happich M, Argimon JM, Bruno G, Novick D, Vellas B, Haro JM. The GERAS study: a prospective observational study of costs and resource use in community dwellers with Alzheimer's disease in three European countries - study design and baseline findings. J Alzheimers Dis. 2013;36(2):385–399. doi: 10.3233/JAD-122392.
    1. Wimo A. Global estimates of informal care. London: Alzheimer’s Disease International and Karolinska Institutet; 2018.
    1. Junfang X, et al. Global and regional economic costs of dementia: a systematic review. Lancet. 2017;390:S47. doi: 10.1016/S0140-6736(17)33185-9.
    1. El-Hayek YH, et al. Tip of the iceberg: assessing the global socioeconomic costs of Alzheimer’s disease and related dementias and strategic implications for stakeholders. J Alzheimers Dis. 2019;70(2):323–341. doi: 10.3233/JAD-190426.
    1. OECD . Care needed. improving the lives of people with dementia. 2018.
    1. Bonsang E. Does informal care from children to their elderly parents substitute for formal care in Europe? J Health Econ. 2009;28(1):143–154. doi: 10.1016/j.jhealeco.2008.09.002.
    1. Brodaty H, Thomson C, Thompson C, Fine M. Why caregivers of people with dementia and memory loss don't use services - Brodaty - 2005 - International Journal of Geriatric Psychiatry - Wiley Online Library. Int J Geriatric Psychiatry. 2005;20(6):537–546. doi: 10.1002/gps.1322.
    1. Van Houtven CH, Norton EC. Informal care and health care use of older adults. J Health Econ. 2004;23(6):1159–1180. doi: 10.1016/j.jhealeco.2004.04.008.
    1. Jönsson L, Wimo A. The cost of dementia in Europe: a review of the evidence, and methodological considerations. Pharmacoeconomics. 2009;27(5):391–403. doi: 10.2165/00019053-200927050-00004.
    1. Schaller S, Mauskopf J, Kriza C, Wahlster P, Kolominsky-Rabas PL. The main cost drivers in dementia: a systematic review. Int J Geriatr Psychiatry. 2015;30(2):111–129. doi: 10.1002/gps.4198.
    1. Prince M, et al. World Alzheimer Report 2016. Improving healthcare for people living with dementia. Coverage, quality and costs now and in the future. London: Alzheimer Disease International (ADI); 2016.
    1. Eska K, Graessel E, Donath C, Schwarzkopf L, Lauterberg J, Holle R. Predictors of institutionalization of dementia patients in mild and moderate stages: a 4-year prospective analysis. Dement Geriatr Cogn Dis Extra. 2013;3(1):426–445. doi: 10.1159/000355079.
    1. Pinquart M, Sorensen S. Differences between caregivers and noncaregivers in psychological health and physical health: a meta-analysis. Psychol Aging. 2003;18(2):250–267. doi: 10.1037/0882-7974.18.2.250.
    1. Conde-Sala JL, Turró-Garriga O, Calvó-Perxas L, Vilalta-Franch J, Lopez-Pousa S, Garre-Olmo J. Three-year trajectories of caregiver burden in Alzheimer's disease. J Alzheimers Dis. 2014;42(2):623–633. doi: 10.3233/JAD-140360.
    1. Wimo A, Gauthier S, Prince M. World Alzheimer report. London: Alzheimer's disease international (ADI) and Karolinska Institute; 2018. Global estimates of informal care.
    1. Le Bihan B, Martin C. Diversification of care policy measures supporting older people: towards greater flexibility for carers? Eur J Ageing. 2012;9(2):141–150. doi: 10.1007/s10433-012-0228-6.
    1. Wimo A, et al. Application of Resource Utilization in Dementia (RUD) instrument in a global setting. Alzheimers Dement. 2013;9(4):429–435.e17. doi: 10.1016/j.jalz.2012.06.008.
    1. Wimo A, Jonsson L, Zbrozek A. The resource utilization in dementia (RUD) instrument is valid for assessing informal care time in community-living patients with dementia. J Nutr Health Aging. 2010;14(8):685–690. doi: 10.1007/s12603-010-0316-2.
    1. Cantarero-Prieto D, et al. The economic cost of dementia: a systematic review. Dementia. 2019;0:1–21. 10.1177/1471301219837776.
    1. Costa N, Derumeaux H, Rapp T, Garnault V, Ferlicoq L, Gillette S, Andrieu S, Vellas B, Lamure M, Grand A, Molinier L. Methodological considerations in cost of illness studies on Alzheimer disease. Health Econ Rev. 2012;2(1):18. doi: 10.1186/2191-1991-2-18.
    1. Leicht H, König HH, Stuhldreher N, Bachmann C, Bickel H, Fuchs A, et al. Predictors of costs in dementia in a longitudinal perspective. PLoS One. 2013;8(7). 10.1371/journal.pone.0070018.
    1. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions, version 5.1.0. Oxford: The Cochrane Collaboration; 2013.
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. doi: 10.1371/journal.pmed.1000100.
    1. Wimo A, Winblad B. Resource utilization in dementia: RUD lite. Brain Aging. 2003;3(1):48–50.
    1. Luttenberger K, Graessel E. Recording care time in nursing homes: development and validation of the “RUD-FOCA” (resource utilization in dementia – formal care) Int Psychogeriatr. 2010;22(8):1291–1300. doi: 10.1017/S1041610210000487.
    1. Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. BMJ. 1996;313(7052):275. doi: 10.1136/bmj.313.7052.275.
    1. König HH, Leicht H, Brettschneider C, Bachmann C, Bickel H, Fuchs A, Jessen F, Köhler M, Luppa M, Mösch E, Pentzek M, Werle J, Weyerer S, Wiese B, Scherer M, Maier W, Riedel-Heller SG, AgeCoDe Study Group The costs of dementia from the societal perspective: is care provided in the community really cheaper than nursing home care? J Am Med Dir Assoc. 2014;15(2):117–126. doi: 10.1016/j.jamda.2013.10.003.
    1. Wimo A, Nordberg G. Validity and reliability of assessments of time. Comparisons of direct observations and estimates of time by the use of the resource utilization in dementia (RUD)-instrument. Arch Gerontol Geriatr. 2007;44(1):71–81. doi: 10.1016/j.archger.2006.03.001.
    1. Wimo A, von Strauss E, Nordberg G, Sassi F, Johansson L. Time spent on informal and formal care giving for persons with dementia in Sweden. Health Policy. 2002;61(3):255–268. doi: 10.1016/S0168-8510(02)00010-6.
    1. Evers S, Goossens M, de Vet H, van Tulder M, Ament A. Criteria list for assessment of methodological quality of economic evaluations: consensus on health economic criteria. Int J Technol Assess Health Care. 2005;21(2):240–245. doi: 10.1017/S0266462305050324.
    1. Larg A, Moss JR. Cost-of-illness studies: a guide to critical evaluation. Pharmacoeconomics. 2011;29(8):653–671. doi: 10.2165/11588380-000000000-00000.
    1. Molinier L, Bauvin E, Combescure C, Castelli C, Rebillard X, Soulié M, Daurès JP, Grosclaude P. Methodological considerations in cost of prostate cancer studies: a systematic review. Value Health. 2008;11(5):878–885. doi: 10.1111/j.1524-4733.2008.00327.x.
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926. doi: 10.1136/.
    1. Drummond MF, et al. Methods for the economic evaluation of health care programmes. 4. United Kingdom: Oxford University Press; 2015.
    1. Teipel SJ, Thyrian JR, Hertel J, Eichler T, Wucherer D, Michalowsky B, Kilimann I, Hoffmann W. Neuropsychiatric symptoms in people screened positive for dementia in primary care. Int Psychogeriatr. 2015;27(1):39–48. doi: 10.1017/S1041610214001987.
    1. Neubauer S, Holle R, Menn P, Grossfeld-Schmitz M, Graesel E. Measurement of informal care time in a study of patients with dementia. Int Psychogeriatr. 2008;20(6):1160–1176. doi: 10.1017/S1041610208007564.
    1. Nordberg G, von Strauss E, Kåreholt I, Johansson L, Wimo A. The amount of informal and formal care among non-demented and demented elderly persons—results from a Swedish population-based study. Int J Geriatr Psychiatry. 2005;20(9):862–871. doi: 10.1002/gps.1371.
    1. Nordberg G, Wimo A, Jönsson L, Kåreholt I, Sjölund BM, Lagergren M, von Strauss E. Time use and costs of institutionalised elderly persons with or without dementia: results from the Nordanstig cohort in the Kungsholmen project—a population based study in Sweden. Int J Geriatr Psychiatry. 2007;22(7):639–648. doi: 10.1002/gps.1724.
    1. Luttenberger K, Donath C, Uter W, Graessel E. Effects of multimodal nondrug therapy on dementia symptoms and need for care in nursing home residents with degenerative dementia: a randomized-controlled study with 6-month follow-up. J Am Geriatr Soc. 2012;60(5):830–840. doi: 10.1111/j.1532-5415.2012.03938.x.
    1. Parrotta I, et al. Depression in people with dementia and caregiver outcomes: results from the European right time place care study. J Am Med Dir Assoc. 2020;21(6):872–878.e1. doi: 10.1016/j.jamda.2020.02.023.
    1. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198. doi: 10.1016/0022-3956(75)90026-6.
    1. Sköldunger A, Wimo A, Sjögren K, Björk S, Backman A, Sandman PO, Edvardsson D. Resource use and its association to cognitive impairment, ADL functions, and behavior in residents of Swedish nursing homes: results from the U-age program (SWENIS study) Int J Geriatr Psychiatry. 2019;34(1):130–136. doi: 10.1002/gps.5000.
    1. Reisberg B, Ferris SH, de Leon MJ, Crook T. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982;139(9):1136–1139. doi: 10.1176/ajp.139.9.1136.
    1. Neubauer S, Holle R, Menn P, Gräßel E. A valid instrument for measuring informal care time for people with dementia. Int J Geriatr Psychiatry. 2009;24(3):275–282. doi: 10.1002/gps.2103.
    1. Hajek A, Brettschneider C, Ernst A, Posselt T, Wiese B, Prokein J, Weyerer S, Werle J, Fuchs A, Pentzek M, Stein J, Riedel-Heller SG, Bickel H, Mösch E, Heser K, Jessen F, Maier W, Scherer M, König HH. Longitudinal predictors of informal and formal caregiving time in community-dwelling dementia patients. Soc Psychiatry Psychiatr Epidemiol. 2016;51(4):607–616. doi: 10.1007/s00127-015-1138-7.
    1. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for depression in dementia. Biol Psychiatry. 1988;23(3):271–284. doi: 10.1016/0006-3223(88)90038-8.
    1. Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: correlates of feelings of burden. Gerontologist. 1980;20(6):649–655. doi: 10.1093/geront/20.6.649.
    1. Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994;44(12):2308–2314. doi: 10.1212/WNL.44.12.2308.
    1. Vossius C, Selbæk G, Benth JŠ, Wimo A, Engedal K, Kirkevold Ø, Rokstad AMM. Cost analysis of day care centres in Norway. PLoS One. 2019;14(8):e0219568. doi: 10.1371/journal.pone.0219568.
    1. Boström F, Jönsson L, Minthon L, Londos E. Patients with Lewy body dementia use more resources than those with Alzheimer's disease. Int J Geriatr Psychiatry. 2007;22(8):713–719. doi: 10.1002/gps.1738.
    1. Nakabe T, Sasaki N, Uematsu H, Kunisawa S, Wimo A, Imanaka Y. Classification tree model of the personal economic burden of dementia care by related factors of both people with dementia and caregivers in Japan: a cross-sectional online survey. BMJ Open. 2019;9(7):e026733. doi: 10.1136/bmjopen-2018-026733.
    1. Nakabe T, Sasaki N, Uematsu H, Kunisawa S, Wimo A, Imanaka Y. The personal cost of dementia care in Japan: a comparative analysis of residence types. Int J Geriatr Psychiatry. 2018;33(9):1243–1252. doi: 10.1002/gps.4916.
    1. Hojman DA, Duarte F, Ruiz-Tagle J, Budnich M, Delgado C, Slachevsky A. The cost of dementia in an unequal country: the case of Chile. PLoS One. 2017;12(3):e0172204. doi: 10.1371/journal.pone.0172204.
    1. Vandepitte S, Putman K, van den Noortgate N, Verhaeghe N, Annemans L. Cost-effectiveness of an in-home respite care program to support informal caregivers of persons with dementia: a model-based analysis. Int J Geriatr Psychiatry. 2020;35(6):601–609. doi: 10.1002/gps.5276.
    1. Carter L, O’Neill S, Keogh F, Pierce M, O’Shea E. Intensive home care supports, informal care and private provision for people with dementia in Ireland. Dementia. 2019:1471301219863580. 10.1177/1471301219863580.
    1. Gervès C, Chauvin P, Bellanger MM. Evaluation of full costs of care for patients with Alzheimer's disease in France: the predominant role of informal care. Health Policy. 2014;116(1):114–122. doi: 10.1016/j.healthpol.2014.01.001.
    1. Åkerborg Ö, Lang A, Wimo A, Sköldunger A, Fratiglioni L, Gaudig M, Rosenlund M. Cost of dementia and its correlation with dependence. J Aging Health. 2016;28(8):1448–1464. doi: 10.1177/0898264315624899.
    1. Érsek K, Kovács T, Wimo A, Kárpati K, Brodszky V, Péntek M, Jönsson L, Gustavsson A, McDaid D, Kenigsberg PA, Valtonen H, Gulácsi L. Costs of dementia in Hungary. J Nutr Health Aging. 2010;14(8):633–639. doi: 10.1007/s12603-010-0309-1.
    1. Farré M, Kostov B, Haro JM, Cabrera E, Risco E, Alvira MC, Miguel S, Zabalegui A. Costs and burden associated with loss of labor productivity in informal caregivers of people with dementia: results from Spain. J Occup Environ Med. 2018;60(5):456. doi: 10.1097/JOM.0000000000001229.
    1. Gustavsson A, Cattelin F, Jönsson L. Costs of care in a mild-to-moderate Alzheimer clinical trial sample: key resources and their determinants. Alzheimers Dement. 2011;7(4):466–473. doi: 10.1016/j.jalz.2010.06.002.
    1. Gustavsson A, Jonsson L, Rapp T, Reynish E, Ousset PJ, Andrieu S, Cantet C, Winblad B, Vellas B, Wimo A. Differences in resource use and costs of dementia care between European countries: baseline data from the ICTUS study. J Nutr Health Aging. 2010;14(8):648–654. doi: 10.1007/s12603-010-0311-7.
    1. Gustavsson A, Brinck P, Bergvall N, Kolasa K, Wimo A, Winblad B, Jönsson L. Predictors of costs of care in Alzheimer’s disease: a multinational sample of 1222 patients. Alzheimers Dement. 2011;7(3):318–327. doi: 10.1016/j.jalz.2010.09.001.
    1. Wübker A, Zwakhalen SMG, Challis D, Suhonen R, Karlsson S, Zabalegui A, Soto M, Saks K, Sauerland D. Costs of care for people with dementia just before and after nursing home placement: primary data from eight European countries. Eur J Health Econ. 2015;16(7):689–707. doi: 10.1007/s10198-014-0620-6.
    1. Handels RLH, et al. Quality of life, care resource use, and costs of dementia in 8 European countries in a cross-sectional cohort of the actifcare study. J Alzheimers Dis. 2018;66(3):1027–1040. doi: 10.3233/JAD-180275.
    1. Costa N, et al. Costs of care of agitation associated with dementia in 8 European countries: results from the RightTimePlaceCare study. J Am Med Dir Assoc. 2018;19(1):95.e1–95.e10. doi: 10.1016/j.jamda.2017.10.013.
    1. Clark CM, Ewbank DC. Performance of the dementia severity rating scale: a caregiver questionnaire for rating severity in Alzheimer disease. Alzheimer Dis Assoc Disord. 1996;10(1):31–39. doi: 10.1097/00002093-199603000-00006.
    1. Vandepitte S, van Wilder L, Putman K, van den Noortgate N, Verhaeghe S, Trybou J, Annemans L. Factors associated with costs of care in community-dwelling persons with dementia from a third party payer and societal perspective: a cross-sectional study. BMC Geriatr. 2020;20(1):18. doi: 10.1186/s12877-020-1414-6.
    1. Darbà J, Kaskens L, Lacey L. Relationship between global severity of patients with Alzheimer's disease and costs of care in Spain; results from the co-dependence study in Spain. Eur J Health Econ. 2015;16(8):895–905. doi: 10.1007/s10198-014-0642-0.
    1. Morris JC. The clinical dementia rating (CDR): current version and scoring rules. Neurology. 1993;43(11):2412–2414. doi: 10.1212/wnl.43.11.2412-a.
    1. Katz S, et al. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185(12):914–919. doi: 10.1001/jama.1963.03060120024016.
    1. Jorm AF. A short form of the informant questionnaire on cognitive decline in the elderly (IQCODE): development and cross-validation. Psychol Med. 1994;24(1):145–153. doi: 10.1017/S003329170002691X.
    1. Michalowsky B, Flessa S, Eichler T, Hertel J, Dreier A, Zwingmann I, Wucherer D, Rau H, Thyrian JR, Hoffmann W. Healthcare utilization and costs in primary care patients with dementia: baseline results of the DelpHi-trial. Eur J Health Econ. 2018;19(1):87–102. doi: 10.1007/s10198-017-0869-7.
    1. Buylova Gola A, Morris S, Candy B, Davis S, King M, Kupeli N, Leavey G, Moore K, Nazareth I, Omar R, Vickerstaff V, Jones L, Sampson EL. Healthcare utilization and monetary costs associated with agitation in UK care home residents with advanced dementia: a prospective cohort study. Int Psychogeriatr. 2020;32(3):359–370. doi: 10.1017/S1041610219002059.
    1. Vandepitte S, van den Noortgate N, Putman K, Verhaeghe S, Annemans L. Effectiveness and cost-effectiveness of an in-home respite care program in supporting informal caregivers of people with dementia: design of a comparative study. BMC Geriatr. 2016;16(1):207. doi: 10.1186/s12877-016-0373-4.
    1. Guyatt G, Vist G, Falck-Ytter Y, Kunz R, Magrini N, Schunemann H. An emerging consensus on grading recommendations? Evid Based Med. 2006;11(1):2–4. doi: 10.1136/ebm.11.1.2-a.
    1. Michalowsky B, Eichler T, Thyrian JR, Hertel J, Wucherer D, Hoffmann W, Flessa S. Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany? Int Psychogeriatr. 2016;28(3):359–369. doi: 10.1017/S1041610215001453.
    1. Schwarzkopf L, Menn P, Kunz S, Holle R, Lauterberg J, Marx P, Mehlig H, Wunder S, Leidl R, Donath C, Graessel E. Costs of care for dementia patients in community setting: an analysis for mild and moderate disease stage. Value Health. 2011;14(6):827–835. doi: 10.1016/j.jval.2011.04.005.
    1. Bremer P, Cabrera E, Leino-Kilpi H, Lethin C, Saks K, Sutcliffe C, Soto M, Zwakhalen SM, Wübker A, RightTimePlaceCare Consortium Informal dementia care: consequences for caregivers’ health and health care use in 8 European countries. Health Policy. 2015;119(11):1459–1471. doi: 10.1016/j.healthpol.2015.09.014.
    1. Husebo BS, et al. LIVE@Home.Path—innovating the clinical pathway for home-dwelling people with dementia and their caregivers: study protocol for a mixed-method, stepped-wedge, randomized controlled trial. Trials. 2020;21(1):510. doi: 10.1186/s13063-020-04414-y.
    1. Husebø BS, Ballard C, Aarsland D, Selbaek G, Slettebo DD, Gulla C, Aasmul I, Habiger T, Elvegaard T, Testad I, Flo E. The effect of a multicomponent intervention on quality of life in residents of nursing homes: a randomized controlled trial (COSMOS) J Am Med Dir Assoc. 2019;20(3):330–339. doi: 10.1016/j.jamda.2018.11.006.
    1. Lee DA, Tirlea L, Haines TP. Non-pharmacological interventions to prevent hospital or nursing home admissions among community-dwelling older people with dementia: a systematic review and meta-analysis. Health Soc Care Community. 2020;28(5):1408–1429. doi: 10.1111/hsc.12984.
    1. Moore GF, et al. All interventions are complex, but some are more complex than others: using iCAT_SR to assess complexity. Cochrane Database Syst Rev. 2017;7:Ed000122.
    1. Greene JG, et al. Measuring behavioural disturbance of elderly demented patients in the community and its effects on relatives: a factor analytic study. Age Ageing. 1982;11(2):121–126. doi: 10.1093/ageing/11.2.121.
    1. Wahle M, Häller S, Spiegel R. Validation of the NOSGER (Nurses’ observation scale for geriatric patients): reliability and validity of a caregiver rating instrument. Int Psychogeriatr. 1996;8(4):525–547. doi: 10.1017/S1041610296002864.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere