Quality of life in chronic diseases of the aged: the importance of cognitive deterioration

Archives of Gerontology and Geriatrics 22 (1996) 195-205

ELSEVIER

ARCHIVES OF GERONTOLOGY AND GERIATRICS

Quality of life in chronic diseases of the aged: the importance of cognitive deterioration Mario Fioravanti a'*, Guido Zavattini b, Ann E. Buckely ~ aDepartment of Psychiatric Science and Psychological Medicine, University of Rome 'La Sapienza', 00185 Rome, Italy bR and D Department, Poli Industria Chimica, Milan, Italy ¢Consultant Psychologist, Rome, Italy

Received 7 August 1995; accepted 23 November 1995

Abstract The interference of a chronic disease on the aging process reduces patients efficiency in confronting everyday life events and their Quality of Life (QOL). The purpose of this study was to examine the interaction between cognitive problems and emotional difficulties as related to several chronic diseases commonly present among aged patients in contributing to their QOL reduction. Diseases considered were: chronic cerebro-vascular disorders non-insulin dependent diabetes mellitus and hypertension. Memory characteristics and subjective evaluation of several areas of daily living where problems could be present were assessed. Severity of cognitive and behavioral deterioration emerged as a major component independent from type of disease, contributing to reduction of QOL. Disease type determined the different risk of presence of an objective reduction of memory efficiency. The QOL of aged patients was identified as a multidimensional array of different components among which cognitive deterioration assumes a primary role. These results, together with analogous findings from previous studies, underline the importance of considering cognitive efficiency in aged patients even with chronic diseases not directly affecting CNS in order to evaluate their needs. Keywords: Cognitive deterioration; Quality of Life; Chronic diseases; Aging

* Corresponding author. 0167-4943/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved SSDI 0167-4943(95)00693-1

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1. Introduction

The progression of chronological age in older adults is accompanied by a series of biological, functional and psychological modifications, together with economical and social changes that require complex adjustment by the individual in order to maintain a competent efficiency in his/her daily activities. Various types of chronic diseases which typically affect older persons can further complicate this continuous process of adjustment to aging (Koff, 1988). Emotional and cognitive characteristics are the two of the most salient components of adjustment process to aging, and in the presence of chronic diseases become the most sensitive elements of maladjustment. These two components often make the difference between a functioning and valid aged person and someone without those essential resources necessary for continuing with competence in his/her involvement in usual daily activities (Feuerstein et al., 1988). The multidimensionality of this adjustment process reflects the multidimensionality of the Quality of Life (QOL) in the aged. QOL encompasses both the environmental (external to the individual) and the biological and psychological (internal to the individual) perspectives (Williams, 1990; Pearlman and Uhlmann, 1991). Hence, the presence of chronic diseases in the aged patients and their consequences become important factor which need to be considered when the needs of an aged population is evaluated. A relationship between cognitive impairment due to a chronic disease and adjustment to disease of aged patients has already been found to play a relevant role in determining QOL in chronic obstructive pulmonary disease patients (COPD) (Fioravanti et al., 1993, 1994, 1995). The present study examines the relationship among cognitive, emotional and QOL impairment in other types of chronic diseases common among the aged: chronic cerebro-vascular disorders (CVD), hypertension (HYP), and non-insulin dependent diabetes meUitus (NIDDM). The choice of these three clinical groups was based on the evidence that suggests cognitive deficits are associated with these diseases (Gradman et al., 1993; Richardson, 1990; Fioravanti et al., 1991a; Fioravanti et al., 1991b; Van Swieten et al., 1991; Waldestein et al., 1991; Blumental et al., 1993; Desmond et al., 1993; Breteler et al., 1994). The aim of this study, a cross-sectional comparative survey, was to evaluate the role of possible cognitive and emotional problems in the structuring of difficulties in Quality of Life of aged people in these three diagnostic groups.

2. Patients and methods 2.1. P a r t i c i p a n t s

Subjects were recruited in a nationwide network of clinical centers dealing mainly with aged patients. All participants were voluntary. In order to be considered for inclusion (screening phase) patients had to be over 60 years of age, have a Global Deterioration Scale score (GDS) (Reisberg et al., 1982) between 2 (very mild

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deterioration) and 4 (moderate deterioration), and an educational level of at least 3 years of schooling. Patients with one or more of the following characteristics were excluded from this study: chronic pathologies accompanied by functional sensorial and/or motor limitations; severe heart, kidney or liver insufficiency; unbalanced metabolic or disendocrine conditions; severe blood disorders; other pathologies interfering with daily activity; recent surgery; recent admission to an hospital for disturbances other than the inclusion criteria; living in an institution. After screening, only those patients diagnosed as CVD, HYP and N I D D M were included in the study. The first diagnosis to be verified was that of CVD. Patients with a positive history of focal cerebrovascular disturbances (RINDT, TIA, STROKE), a positive history of vascular risk factors, and an Ischemic Score of the Hachinski Scale > 4 were included in this group. If this diagnosis was not applicable, the other two diagnoses were tested: N I D D M or HYP. The diagnosis of N I D D M was confirmed when a stable or variable hyperglycemia ( > 140 mg/1 in venous plasma; > 120 mg/1 in venous blood) was found after the age of 40 years together with the conventional symptoms of diabetes (polyuria, polydipsia, polyphagia, chetonuria and quick loss of weight) or an elevated glycemia was repeatedly found after oral sugar load together with the conventional symptoms of diabetes. The diagnosis of HYP was confirmed when: a diastolic blood pressure > 90 mmHg was found (from 90 to 104 mmHg, mild hypertension according to WHO classification, from 105 to 114 mmHg, moderate hypertension, over 114 mmHg, severe hypertension). All patients not classified in one of these three diagnostic groups were excluded from the study.

2.2. Measures All patients responded to questionnaires and were tested for their cognitive efficiency. The Questionnaire for the Adjustment to Chronic Disease (QACD) (Fioravanti et al., 1995) and the Questionnaire of Memory Disorders (QMD) (Fioravanti et al., 1995), which have already been validated for the Italian population and are furnished with norms for age, educational level and sex differences were used. Objective cognitive evaluation included a Serial Learning task (16 common words of concrete meaning presented orally to subjects and recalled immediately after presentation and again after 20 min), a Rote Learning task (20 words constituting a story, recalled immediately after presentation in verbatim mode and again after 20 min in gist mode) and a Digit Recall task (forward and backward). All cognitive tasks have norms for age differences and the serial learning and the rote learning tasks are part of the Memory Efficiency Test (MET) (Fioravanti et al., 1992).

2.3. Analysis of data Scores from questionnaires and cognitive tasks were analyzed in order to identify differences associated with the type of diagnosis, severity of deterioration, course of

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disease, and other factors which hypothetically could be related to cognitive functioning and QOL. Differences were tested by ANOVA. Discriminant analysis was employed to verify the possible differences between diagnostic groups using a multivariate method. Finally, a factor analysis was attempted on a selected combination of variables, from the objective and subjective measures in order to identify different dimensions which could account for the relationships between the cognitive measures and those more directly related to QOL.

3. Results

After inclusion 537 patients remained in the study. Of them, 285 (53%) are males and 252 (47%) females with a mean age of 71.54 years. (S.D. 6.48), ranging between 60 and 90 years. The educational level is primary school for 56% of all cases, junior high school for 19%, high school for 19% and university level for 6%. In Table 1 there is the description of cases divided by diagnosis.

3. I. Differences by diagnosis Chronological age (F(2,536) 3.85, P < 0.03), age at the beginning of disease (F(2,37s) 34.37, P < 0.001), and length of disease (F(2,536) 76.06, P < 0.001) had significant differences between clinical groups. CVD patients were older than all others and demonstrated an older age at the disease onset with a shorter length of disease. The Hachinski Ischemic Score was significantly higher in CVD patients (F(2,334) 39.34, P < 0.001) and in males (F(I,534) 5.70, P < 0.02). Blood pressure parameters were significantly lower in NIDDM patients than in all others (respectively, for systolic blood pressure F(2,534 ) 10.77, P < 0.001, and for diastolic blood pressure F(2,534 ) 17.81, P < 0.001) (see Table 1). No other differences other than severity of deterioration emerged in the description of all cases when compared by diagnosis. CVD patients presented higher degrees of deterioration more frequently than other groups (see Table 2). Table 1 Description of cases

Age Age at the beginning of disease Length of disease (years) Hachinski lschemic Score Systolic blood pressure Diastolic blood pressure

C V D ( n = 340)

N I D D M (n -

69)

H Y P ( n = 128)

M

SD

M

SD

M

SD

72.13 67.18 4.48 8.31 152.34 87.48

6.51 7.10 3.00 2.29 17.46 9.78

70.49 60.07 9.14 2.76 146.23 83.16

6.65 8.76 5.19 1.14 14.99 7.19

70.55 60.39 9.39 2.92 157.66 91.30

6.16 9.18 6,48 0.86 14.18 8.87

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Table 2 Distribution of patients of the three diagnostic groups according to their deterioration level GDS

Very mild Mild Moderate

QMD

High level Medium-high level Medium level Low-medium level Low level

CVD

NIDDM

HYP

GDS

QMD

GDS

QMD

GDS

QMD

--30% 47% 23%

-3% 56% 31% 10%

--62% 28% 10%

3% 9% 65% 22% 1%

--69% 29% 2%

2% 11% 75% 10% 2%

Frequencies of patients in each category expressed as a percentage of the same diagnostic group. The two classifications of deterioration levels are respectively based on the Global Deterioration Scale (GDS), and on the level of functioning score of the Questionnaire of Memory Disorders (QMD).

3.2. Differences by severity of cognitive and behavioral deterioration Severity of deterioration as measured by the GDS was associated with age (F(2,534) 6.17, P < 0.002). This relationship between age and cognitive deterioration was not related to type of diagnosis and/or length of disease. Of all patients, 43% were classified with a very mild deterioration, 40% with a mild deterioration and 17% with a moderate deterioration. Distribution of cases by diagnosis, based on the three levels of deterioration from GDS is reported in Table 2. The QMD provides a score which reflects deterioration. This subjective evaluation, made by the patient on the QMD, has a wider range that the GDS score where the objective evaluation is made by the clinician. Five degrees of deterioration were present in the patients under study (see Table 2). As expected, CVD patients demonstrated the most severe degree of deterioration (Z~s) 55.20, P < 0.01). The QMD allows for the classification of respondents in a four-class typology based on the intensity of the two different components of subjective memory problems: the cognitive component and the emotional component. CVD patients presented significantly different results from those evidenced by the other two diagnostic groups (Z~6) 61.08, P < 0.001) when this classification was utilized (see Table 3). CVD patients presented generally more subjective memory problems than Table 3 Distribution of patients of the three diagnostic groups according to their type of memory problems

High emotional/high cognitive Low emotional/high cognitive High emotional/low cognitive Low emotional/tow cognitive

CVD

NIDDM

HYP

55% 6% 6% 33%

24% 3% 17% 56%

21% 11% 7% 61%

Frequencies of different types of subjective memory problems in the three diagnostic groups.

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Table 4 Scores of the QMD in the three diagnostic groups CVD

Feelings of insecurity Feelings of confusion Feelings of impediment Feelings of decline

NIDDM

HYP

Mean

S.D.

Mean

S.D.

Mean

S.D.

52.47 52.31 51.90 52.63

10.51 10.24 10.50 10.29

46.01 46.18 46.29 45.73

8.54 8.96 8.75 7.80

45.64 45.77 46.08 45.04

7.72 8.38 8.36 7.03

Values are means and S.D.s of the scores of the Questionnaire of Memory Disturbances. Scores are standardized by age, sex and educational level. The reference mean is 50 and 1 S.D. is 10 points. The higher the score the more problematized is the area of memory functioning described by the score. the other patients and, in particular, their problems were more frequently characterized by both cognitive and emotional characteristics (see Table 4). The presence of subjective memory problems was different in the three diagnostic categories with one out of four N I D D M patients (26%), one out of three H Y P patients (32%), and two out of three CVD patients (61%) reporting concern about their memory functioning.

3.3. Differences by subjective evaluation of memory problems The Q M D is composed o f four scored which have been standardized by age. They describe different areas of concern about memory functioning (see Table 4). Patients who retired from work for disability (respectively, F(1,362) 5.65, P < 0.02, and F(1,367 ) 5.93, P < 0.02) and those with a more severe deterioration (respectively, F(2,362 ) 46.10, P < 0.001, and F(2,367 ) 36.40, P < 0.001) presented a more troubled appraisal of their conditions in these areas of functioning as measured by scored Feelings of Insecurity and Feelings of Impediment. CVD patients (respectively, F(2,362 ) 3.56, P < 0.03, and F(2,367 ) 4.83, P < 0.009), patients retired for disability (respectively, F(1,362 ) 4.82, P < 0.03, and F(1,367 ) 7.92, P < 0.008) and those with a more severe deterioration (respectively, F(2,362) 39.11, P < 0.001, and F(2,367 ) 43.94, p < 0.001) presented the most difficulty in the areas of the scores on Feelings of Confusion and Feelings of Decline. An interaction between different factors (F(1,362) 4.01, P < 0.05) indicated that outpatients with a worsening course of disease presented the most troubled descriptions on the Feelings of Confusion score.

3.4. Differences by Quality o f Life The Q A C D includes several scores aimed at assessing different areas of concern which influence the patient's adjustment to his/her clinical condition and, as a consequence, can be expected to interfere with QOL. This multidimensional evaluation of different QOL components permits the identification of a complex pattern of relations between the clinical group and Q O L in our patients (see Table 5).

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The area defined by the Physical Limitation score evidenced a progressive and increasing reduction of adjustment in patients for the different clinical groups (F(2,374) 3.68, P < 0.03). HYP patients had the lowest Physical Limitations scores while CVD patients had the highest. The relevance of physical problems was also related to the degree of cognitive deterioration (F(2,374) 15.86, P < 0.001) and independent from the clinical diagnosis. The area defined by the Family Support score showed an interaction between the type of diagnosis and the presence of retirement for disability (F(2,374) 4.06, P < 0.02) indicating that N I D D M patients who retired from work for disability present more problems concerning support from their family when compared with patients from the two other diagnostic groups. The course of disease (F(2,374) 6.94, P < 0.009) and the degree of cognitive deterioration (F(2,374) 15.66, P < 0.001) independently affected the Social Interaction score of QOL without any interaction with other characteristics including the type of diagnosis. Patients with a stable course of disease in the previous year end/or with a more severe degree of cognitive deterioration presented more social problems when compared with others. The Emotional Reactivity score was related to the type of diagnosis (F(2,374) 4.13, P < 0.02) and the degree of deterioration (F(2,374) 11.52, P < 0.001). HYP patients were less concerned with emotional difficulties while CVD patients seemed to be the most concerned. At the same time, the higher the degree of deterioration the more concerned were the patients with their emotional difficulties. The degree of deterioration also interacting with the diagnosis emerged as a factor for emotional troubles (F(4,495) 4.72, P < 0.001). The Cognitive Efficiency score evidenced the most complex pattern of relations. Principally, the degree of deterioration was related to this kind of subjective Table 5 Scores of the QACD in the three diagnostic groups CVD

Physical limitation Familial support Social interaction Emotional reactivity Cognitive efficiency Well-being Adjustment to disease Social adjustment Quality of Life Index

NIDDM

HYP

M

S.D.

M

S.D.

M

S.D.

52.25 50.17 47.13 52.13 53.41 53.57 53.16 48.66 51.57

9.84 9.78 9.76 9.72 9.46 9.42 7.88 7.85 4.84

46.85 50.57 52.30 48.08 46.76 46.83 46.97 51.27 48.69

8.60 10.36 8.36 9.63 8.04 8.68 6.75 7.95 4.27

44.55 50.37 54.99 45.95 44.38 44.23 45.03 52.65 47.52

8.26 10.81 9.30 9.83 8.72 9.24 6.71 8.66 4.53

Values are means and S.D.s of the scores of the Questionnaire on Adjustment to Chronic Disease. Scores are standardized by age, sex and educational level. The reference mean is 50 and 1 S.D. is 10 points. The higher the score the more problematized is the area of Quality of Life described by the score.

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problem (F(2,374) 21.33,

P < 0.001) independent from any other factor. The type of diagnosis has also a relationship with this area of concern (F(2,348) 7.03, P < 0.001). HYP patients were the least pre-occupied and the CVD the most worried about their cognitive functioning. The type of diagnosis also interacted with the type of medical situation of patients (F(2,374) 4.69, P < 0.01). CVD inpatients were more worried than the outpatients of the same clinical group, while the outpatients in HYP and N I D D M groups were the most concerned about their cognitive functioning. In general, without any diagnostic distinction, those patients who presented a worsening of their clinical course in the previous year were more concerned than those with a stable condition (F(2,374) 4.87, P < 0.03). The clinical course also showed an interaction with the medical situation of patients (F(2,374) 9.98, P < 0.002). Among inpatients, those with a stable clinical course reported more concern about their cognitive functioning, and among the outpatients, those with a recent worsening of their clinical course showed the highest degree of concern. Finally, the effect of type of diagnosis and degree of cognitive deterioration in this area became stronger when age differences among patients were controlled. The Well-being score of QACD indicated more problems for CVD patients (F(2,345) 7.01, P < 0.001) and, without distinction of diagnosis, for inpatients (F0,345) 8.82 P < 0.003), for patients with a worsening clinical course (F(1,345) 7.64, P < 0.006), and for patients with a more severe cognitive deterioration (F(2,345) 6.18, P < 0.902). The concern about well-being was also related to an interaction between the course of disease and severity of cognitive deterioration (F(2,345) 3.12, P < 0.05). More deteriorated patients and with a stable clinical course were more concerned than the others. The strength of effects from severity of cognitive deterioration and diagnosis on this score augmented when the age differences of patients were controlled. Several factors related independently to the Adjustment to Disease score. CVD patients (F(2,345) 8.92, P < 0.001), inpatients (Fll,345) 6.18, P < 0.02), patients with a worsening course of disease (F(L,345~4.11, P < 0.05), patients with a more severe cognitive deterioration (F(2,345) 17.35, P < 0.001) were those who presented a worse adjustment to their clinical situation. When age differences were controlled, diagnosis and severity of cognitive deterioration strengthened their effects on adjustment to the disease. The Social Adjustment score was related to these factors with a different pattern. Patients with a stable clinical course (Flj,345) 4.36, P < 0.04) and those with a less severe cognitive deterioration (F(2,345) 7.99, P < 0.001) had more difficulties in their adjustment when the interaction with others is concerned. Finally, results of the Quality of Life Index, which is a score summarizing all other scores of QACD, showed that CVD patients (F(2,345) 7.64, P < 0.001), inpatients (F(I,345) 6.54, P < 0.02), and those with more severe cognitive deterioration (F(1,345) 8.06, P < 0.001) had a worse QOL. For inpatients there was also an interaction with the type of diagnosis; while CVD patients reduced their QOL when hospitalized, HYP patients improved their QOL when in hospital. Furthermore, only CVD patients had lower QOL in relation to the severity of cognitive deterioration while modifications of QOL of HYP patients seemed to be independent from the severity of cognitive deterioration.

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3.5. Differences by objective measures of memory efficiency The total score of Digit Span showed significant differences among diagnostic groups (F(2.362) 5.17, P < 0.006) with CVD patients with the worst performance. In general, once the age effect is removed, the mean score of the CVD group is below the normal level of performance found in the general population. These results are different from those found in a previous study of a COPD group of patients of comparable age. While the aged patients with chronic respiratory difficulties achieved a mean score at the Digit Span comparable to the general population but with a wider variance due to a subgroup of patients whose performance at this test is below the normal level, the entire distribution of results at this test obtained from CVD patients is 1 S.D. below the values of the normal population. The CVD's variance, on the other hand, is comparable to that of the normal population. Among CVD patients, the risk of presenting abnormal scores at the Digit Span is 6 times higher than in normal subjects of the same age. The results of N I D D M patients were instead, analogous to those described for COPD patients: only a subgroup have results below the normal level and the risk of finding abnormal scores among N I D D M patients is twice the one in the normal population. Other factors independently affecting the Digit Span score were course of disease (F(1,362) 8.58, P < 0.004), retirement for disability (F(1,362) 5.22, P < 0.03), and cognitive deterioration level (F(2,362) 13.93, P < 0.001). The Serial learning task and the Rote Learning task have two different scores: one for immediate recall and another for delayed recall. The immediate recall scores of both tasks present differences exclusively due to the severity of cognitive deterioration (for serial learning, F(2,326) 14.15, P < 0.001; for rote learning, (F(2,326) 12.13, P < 0.001). The delayed recall scores of both tasks present differences due to the interaction between severity of cognitive deterioration and course of disease (for serial learning, F(2,326) 3.97, P < 0.02; for rote learning, F(2,326) 4.91, P < 0.008). The poorest performance was associated with patients with the highest deterioration and a worsening course of disease independent from diagnosis.

3.6. Multidimensional evaluations The best discrimination of CVD patients from those of different diagnostic groups was obtained by the combination of length of disease, course of disease in the previous year, and scores of Physical Limitation and Cognitive Efficiency from QACD. HYP patients were best characterized by the Digit Span backward score and age, while N I D D M patients were in an intermediate position between the other two groups. This combination of variables was highly correlated with the type of diagnosis (r = 0.63) accounting for 38% of the variance associated to the differences between types of diagnosis. A combination of five dimensions was extracted when different variables from objective, subjective and clinical evaluations were pooled together. These five dimensions, or factors, account for a remarkable 71% of the total variance expressed by all the variables considered. The first and most important dimension

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extracted, accounting for 36% of the total variance, was called Cognitive Decay, and includes the GDS score, the QACD score Cognitive Efficiency and all the scores from the QMD. This dimension is independent from diagnosis. The second dimension extracted accounted for 12% of variance and was called Cognitive Efficiency. It includes the Digit Span score, and all the scores from the others objective memory tasks. This dimension also, is independent of diagnosis. The third dimension accounted for 7% of variance and was called Psychological Difficulties. It includes some of the QACD scores (Physical Limitation, Social Interaction, Emotional Reactivity, Well-being) and is independent from the type of diagnosis. The fourth dimension accounted for 6% of variance and was called Clinical Factor including type of diagnosis, length of disease and the course of the disease. The fifth and the sixth dimensions respectively accounted for 6% and 5% of variance and were called Aging Factor and Family Support. The Aging Factor includes the GDS score and age, the last factor includes the QACD score Family Support. Both dimensions are independent from the type of diagnosis.

4. Discussion

This is a survey of three different diagnostic groups of aged patients with chronic disease (chronic cerebrovascular disorders, non-insulin dependent diabetes mellitus, and hypertension). Survey participants were included when they presented complaints but did not evidence severe clinical signs of cognitive decline. Our results evidence a different frequency of patients with objective cognitive impairment in each diagnostic group. This frequency is significantly superior to the risk present in a normal population of the same age. CVD patients with subjective, but not severe clinical signs of cognitive decline, present a risk of a cognitive deficit at an objective evaluation 6 times more than that present in normal aged subjects. The risk in NIDDM patients is reduced to twice that of normal subjects of the same age and to less than twice in hypertensive patients. Another difference between CVD, NIDDM and HYP patients can be seen in the general reduction of cognitive efficiency which was present in the entire group of CVD, but only in a subgroup of patients within each of the other diagnostic groups. However, diffuse in the three diagnostic groups, the presence of cognitive decline has repeatedly emerged in this study as strictly related to the psychological and behavioral adjustment of aged patients to chronic disease. Patients' cognitive status, as a factor in their adjustment to disease has also proved to be important in determining the kind of problems most common in their Quality of Life. These results emphasize the importance of considering the possibility of a decrease of cognitive efficiency in aged patients with different types of chronic disease. Cognitive decline can also be present in aged patients with chronic diseases not traditionally considered to have a direct and specific influence on the clinical condition of CNS. In fact, cognitive deterioration emerges as a key factor in determining the specific needs of aged patients. It accounts for many objective and

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behavioral deficits and is often responsible for difficulties that patients encounter in their usual daily tasks and in social and interpersonal events. Irrespective of diagnosis type, more severe cognitive difficulty relates to more pronounced difficulties for the patient in confronting his/her personal situation.

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