quality of life of alzheimer’s disease patients, caregivers and evaluating the effectiveness of thenonpharmacologicalinterventions

MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF HEALTH

NATIONAL INSTITUTE OF EPIDEMIOLOGY AND HYGIENE

-----------------*-------------------

NGUYEN BICH NGOC

QUALITY OF LIFE OF ALZHEIMER’S DISEASE PATIENTS,
THEIR CAREGIVER AND EFFECTIVENESS ASSESSMENT OF
SOME NON-PHARMACOLOGICAL INTERVENTIONS

Specialization: Sociological Hygiene and Health Organization
Code: 62.72.01.64

SUMMARY OF THE DOCTORAL DISSERTATION

HA NOI – 2014


The work was completed in:
National Institute of Epidemiology and Hygiene

Thesis advisor:
1. Ass.Prof. Do Thi Khanh Hy
2. PhD Nguyen Thi Thuy Duong

Opponent 1: Ass.Prof. Pham Van Thao, PhD
(The Military Medical Institue)

Opponent 2: Prof. Nguyen Xuan Nghien
(Bach Mai Hospital)
Opponent 3: Ass.Prof. Nguyen Cong Hoan
(Hanoi Medical University)
The thesis will defensed at National Institute of Epidemiology and Hygiene
at .............., date ............. month .............. year 2014.

Full dissertation could be found at:
- National Library
- The Library of National Institute of Epidemiology and Hygiene


ACRONYM
AD:

Alzheimer’s Disease

ADL:

Activities of Daily Living

DSM- IV- TR: Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision)
GDS:

Geriatric Depression Scale

IADL:

Instrumental Activities of Daily Living scale

ICD-10:

International Classification of Diseases, 10threvision

MMSE:

Mini Mental State Exam

NINCDS-ADRDA: National Institute of Neurological and Communicative
Disorders and Stroke - Alzheimer’s Disease and Related Disorders
Association
QOL:

Quality of Life

QOL-AD:

Quality of Life–Alzheimer’s Disease

NPI:

NeuroPsychiatric Inventory

NGH :

National Geriatric Hospital

WHO:

World Health Organization


1

ABSTRACT OF THE DISSERTATION
1.

Background  

According to WHO (World Health Organization), global population is
gradually ageing. It is expected about 600 million people aged 60 years and
older. The number of the elderly is expected to double by 2025 and reached
approximately 3 billion in 2050. More than half of the world's elderly people
live in Asia.Survey data on population change and family planning by GSO
(General Statistics Office of Vietnam)on April 1st, 2012 showed the proportion
of population aged 60 and older was 10.2% and the proportion of population
over 65 was 7.1%. Vietnam officially entered the period known as "aging
population period".The time for Vietnam to change population structure from
"aging" to "aged population" would be only about 20 years,much shorter than
in many other countries.
Aging increased the risk of developing chronic and degenerative
diseasesincluding dementia which Alzheimer’s disease accounts for 50-70%. It
was really a tragedy for the elderly not only because of the high incidence in
this age group, but also due to diseases would affectmassive and long-lasting
in all aspects of the patient, their family and society, also reduce the quality of
life of patients and their caregivers.To ease these burden, in addition to
epidemiological studies andpharmaceutical, non-pharmacological therapies,
quality of life (QOL) and Alzheimer’spatient caring issues was being
researched in many parts of the world.In Vietnam, dementia and Alzheimer’s

disease was also begun to draw medical and social care attention. A number of
studies were conducted to find out the incidence, risk factors, screening criteria
and diagnosis of dementia and Alzheimer’s disease in Vietnam. However, the
amount of research on this disease was still limited, mainly focusing on
clinical studies, there was hardly any study focusing on the quality of life of
Alzheimer’spatients, their caregivers and supporting therapies. So, this study
wasaimed to cover the following mandates:
1. Describe the actual quality of life of Alzheimer’s patients being treated
at the National Geriatric Hospitalfrom 1/2011 to 6/2013, with the
caregiver’sburden andquality of life.
2. To assess the effectiveness of some non-pharmacological interventions to
improve the quality of life of Alzheimer’s patients and their caregivers.
2. New contributions of the thesis:
This dissertation was the first systematic study to have the actual quality of
life of Alzheimer’s disease patients; caregiving burden and health related
quality of life of their caregivers and to evaluate the effectiveness of a number
of non-pharmacological interventions.
International assessment scales were translated and adapted toVietnamese
and appliedsuccessfully to Vietnamese patients and their caregivers. These


2

tools would be applied to evaluate the quality of life of patients andcaregivers’
burden care in managing and caring Alzheimer’s patients programs.The thesis
studied 120 Alzheimer’s patients having multiple logical, feelings and
behavioral disorder symptoms, their quality of life was only about 50%
compared to the good level and closely linked to many elements related to the
condition of the disease. The study achieved result in quantifying the quality of
life of Alzheimer’s patients, the caregiver’s burden and quality of life and the

factors involved.
The dissertation proved the remarkable effectiveness of nonpharmacological interventions for Alzheimer’s patients and their
caregivers.Those applied in thesis were not only relatively simple andeasy to
implement,but alsoeffective and able to widely applied in practice fortreating
Alzheimer’sdisease patients and being as basisfor more extensive studies.
The results of this thesis gave new contributions for studies in the elderly
especially on dementia and Alzheimer’s diseaseand contributed materials for
policymaking on health care for the elderly in general and Alzheimer’s patients
in Vietnam in particular.
3. Scientific and practical Significance of this thesis
Scientific significance: The thesis used designed descriptive study through
observation a series of case studies and applied intervention on control group
then comparing before-afterin accordance with issues and study objectives.
Collecting information methods wereabundant and ensuring accuracy with the
standard questionnaire which wastested and assessed internal reliability,
concurrent use of multiple tools and assessment methods to increase test
accuracy
Practical significance: The results of the thesis provided evidence for the
actual quality of life of Alzheimer’s patients,caregivers' burden and quality of
life, the remarkable effectiveness of non-pharmacological interventionsto help
health care planners and policymakers on the topic of Alzheimer’s patients,
caregivers and the elderly and on applying intervention model for hospital
network and in general community.
4. How the report is structured
The study has 140 pages and 4 chapters, including Introduction: 2 pages,
Chapter 1. Overview: 31 pages, Chapter 2. Subject and methodology: 27
pages, Chapter 3. Findings: 40 pages, Chapter 4. Discussion: 37 pages,
Conclusion: 2 pages, Recommendations: 2 pages, 34 tables, 7 charts,
2diagrams, 1 image and 153 references, 17 in Vietnamese and 136 in English
updating to 2013. The appendix includes: the diagnostic criteria for

Alzheimer’s disease, research profile, questionnaires, exercises for patients and
patients studied list.


3

CHAPTER 1
OVERVIEW
1. Dementia and Alzheimer’sdisease
1.1. Clinical syndrome of dementia and Alzheimer’sdisease
- Syndrome of dementia
WHO (World Health Organization)Dementia is a syndrome – usually of a
chronic or progressive nature – in which there is deterioration in cognitive
function (i.e. the ability to process thought) beyond what might be expected
from normal ageing. It affects memory, thinking, orientation, comprehension,
calculation, learning capacity, language, and judgement. Consciousness is not
affected. The impairment in cognitive function is commonly accompanied, and
occasionally preceded, by deterioration in emotional control, social behavior,
or motivation.Dementia is one of the major causes of disability and
dependency among older people worldwide.
Dementia is caused by a variety of diseases and injuries that primarily or
secondarily affect the brain, such as Alzheimer’s disease or stroke accounting
for 50 to 70 percent and 20 to 30 percent respectively. However, later
researchers found that the overlap between the two types of dementia
particularly in the oldest age group.
- Alzheimer’s disease
It was first described by German psychiatrist and neuropathologistAlois
Alzheimer in 1906 and was named after him.He was the first to describe the
clinical and pathologic characteristics of disease included neurofibrillary
tangles and amyloid plaque.

Alzheimer's disease was a neurodegenerative disease, indicated by
memory loss, the most characteristic symptoms of disease and other cognitive
disorders such as Aphasia, apraxia, agnosia, lost the ability to synthesize
reasoning and dysfunction implementation, impaired ability to perform
activities, accompanied by the behavioral changes which were important
clinical manifestations such asdenial this disease, apathy, psychosis (delusions,
hallucinations), mood disorders (depression, anxiety), agitation activities,
seriously ... affecting professional and social of patients. Patients’ condition
got severe gradually and then not recoverable.
Diagnosis of Alzheimer
Definitive diagnosis Alzheimer based on pathology. Moderndigital
image diagnosis that would be diagnostic aid to probable Alzheimer's disease
cases such as MRI brain, PET scan and computed tomography single photon
SPECT.
Alzheimer's disease was diagnosed clinically based on the criteria of
DSM-IV-TR or ICD X or NINCDS-ADRDA.
1.2. Current status of dementia and Alzheimer in the world and Vietnam


4

1.2.1. Current status of dementia and Alzheimer in the world
The older you was, the more incidence of suffering dementia. Just after
every five years, the incidence of all dementia nearly doubled again, from
1.5% at age 60-69 to 40% at age 90. According to WHO, the number of people
currently suffering dementia worldwidewere about 35.6 million people. It was
estimated to double by 2030 (65.7 million) and increased over three times in
2050 (115.4 million). Alzheimer's situation is similar to that.
1.2.2. Current status of dementia and Alzheimer in Vietnam
According to a study from the National Geriatric Hospitalin Ba Vi district,

Hanoi (2005-2006) showed the percentage of people aged 60 years and older
living in the community suffering dementia was 4.63%, the morbidity rate
increased 1.78 times after every 5 years. In 2005, National Geriatric Hospital
has established "Research Unit of Memory and Dementia". Research in Hanoi
(2009 - 2010), the rate of dementia in ThanhXuan Commune -Soc Son was
5.1% of the elderly, in Phuong Mai Ward - Dong Da was 3.2%. Dementiaand
Alzheimer's disease situation in Vietnam are similar to other countries in the
region.
2. Quality of life of Alzheimer’s patients and that of their caregivers
2.1. Quality of life of Alzheimer’s patients
Quality of life should be considered as an important outlet to assess for
trials in Alzheimer's disease. There were many methods to assess the QOL of
Alzheimer's patients': patients’self-evaluation, caregivers gave evaluation and
direct observation on the behavior and activities related to the quality of life of
patients. Quality of life assessment in Alzheimer's disease (Quality of Life Alzheimer Disease / QOL-AD) was a broad set of tools, which structured
including objective and subjective indicators of quality of life and was the
most commonly used in research worldwide.
2.2. The caregiver’s burden and quality of life
Alzheimer's patients usually required a high level of caring. Taking care of
patients with Alzheimer's disease was more stressful than caring for people
with physical disabilities. Zarit BurdenInterview (ZBI) about
caregivers’burden was the tool that was most commonly used in the world.
Caregivers’ heath related quality of life also reduced, especially mental health.
3. Non-pharmacological interventions
So far, no medicine could cure Alzheimer's disease but only might slow
disease progression and reduce some of the symptoms. The nonpharmacological measures may improve cognitive function, daily activities,
reduce mental disorders and slow the behavioral disabilities and patients’
needs of hospitalized thereby improving the quality of life of Alzheimer's
patients and their caregivers.

5

CHAPTER 2
METHOD
The dissertation was carried out from January 1/2011 to January 6/2013 at
the NationalGeriatricHospital.
1. Objective 1
Describe the actual quality of life of diagnosed Alzheimer's patients at
Geriatric Hospital from 1/2011 to 6/2013, and their caregivers’ burden and
quality of life.
1.1. Research Subjects
1.1.1. Alzheimer's Patients
- Selection criteria: Patients with Alzheimer's was diagnosed according to
DSM-IV-TR in NationalGeriatricHospital.
- Exclusion criteria: Having medical condition or heavy surgical, not to
agree to participate in the study or the patient's family not to agree to
participate.
1.1.2. Caregivers
- Selection criteria: only selecting one primary caregiver of patient with
Alzheimer's disease to enroll in the study, aged 18 years and older, and able
to communicate.
- Exclusion criteria: not knowing how to read and write, having sensory
disabilities (deaf, blind), not to agree to participate in research
1.2. Study design: The study described through observation a series of cases.
1.3. Sample sizes and sampling methods
The total number of 120 patients diagnosed with Alzheimer's diease in
the period from January 1/2011 to January 6/2013 at National
GeriatricHospitaland 120 their primary caregivers ensuring the selection
criteria.

2. Objective 2
Assessing the effectiveness of several interventions non-pharmacological
to improve Alzheimer's patients and their caregivers' quality of life.
2.1. Research Subjects
a. Alzheimer's Patients
- Selection criteria: Patients with mild to moderate stages of Alzheimer's
(MMSE ≥ 10 points) were recruited in the observational study, agreed to
participate.
- Exclusion criteria: Patients with Alzheimer's disease having MMSE <10
points, not to agree to participate in the intervention program or monitoring
program.
b. Caregivers
- Selection criteria: As primary caregivers of Alzheimer's patients were
recruited into the study intervention.
- Exclusion criteria: not to agree to participate in research.


6

2.2. Study design: The study intervention control group, comparing after to
before.
2.3. Sample sizes and sampling methods
a. For Alzheimer's patients
- Intervention group: 30 patients consisting 20 patients with moderate level
Alzheimer's disease and 10 patients with mild level Alzheimer's disease.
- Control group: 56 patients consisting 25 patients with moderate level
Alzheimer's disease and 31 patients with mild level Alzheimer's disease.
All Alzheimer's patients in the intervention group and the control group
were treated outpatient according to general treatment protocol and managed
in dementia patients management program at National GeriatricHospital. In

addition to having the same treatment as the control group, the intervention
group was also treated coordinating with non-pharmacological measures:
Practicing awareness, stimulating memory, language, orientation reality;
occupational therapy andphysical activities.
b. CaregiversGroup
to each Alzheimer's disease patient to select a direct caregiver to patient.
Therefore, the intervention group of 30 caregivers (educated on health,
counseling, care instructions, communicate with patients) and control group
included 56 caregivers.
2.4. Research Index
a. Alzheimer's Patients
- General information (age, gender, education, marital status, time of
diagnosis).
- The results of the test and evaluation conditions.
- The internal reliability of the QOL-AD questionaire (Cronbach alpha
index).
- Quality of life according to patient and their caregivers evaluating (in
QOL-AD) and related factors (age, gender, cognitive impairment
condition, and mental state, psychological andpsychiatric tests).
b. Caregivers
- General information about their caregivers (age, gender, education, marital
status, employment status, relationship to the patient).
- The average burden of care per ZBI scale, according to some
characteristics of caregivers.
- Physical and mental health related quality of life in a number of related
factors.
Indicators interventioneffectiveness
- For Alzheimer’s disease patients: effectiveness on cognitive status
(MMSE), severity and impact of neuropsychiatric, behavioral symptoms,
activities of dailly living (ADL, IADL); quality of life rated by patient selfreport and caregiver proxy report.

7

- For caregivers:effectiveness on caregiver burden, Physical and mental
health related quality of life.
Intervention effectiveness = (Effectiveness index of intervention group) (Pre-post index of control group)
X 1 - X 2
x 100 (%) (of intervention
Effectiveness index (%) =
X 1
group)
Pre-post index of control group (%) = X 1 - X 2 x 100 (%) (of control
X 1
group)
2.5 Data collection tools
a. For Alzheimer's Patients
Including:research profile, questionnaires, Mini Mental State
Examination/MMSE, Neuropsychiatric Inventory (NPI), activities of dailly
living(ADL), activities of dailly living (IADL); Neuropsychological tests,
Quality of life in Alzheimer Disease (QOL-AD), The assessment of
participation, satisfaction levels of patients on exercise programs
b. For their caregivers
Including: The information collected by the caregivers, caregivers’
burden (ZBI), Quality of life related to health (MOS12-Item Short Form
Health Survey/SF-12)
2.6. The process of data collection
The study variables were collected from interviews of patients, their
caregivers follow the questionnaire in medical research, survey and gathered
from result of evaluation papers. After 24 weeks, the output information from

the control group and the intervention group were collected according to the
indicators.
2.2.7. The bias control measures
- Designed checklists, structured questionnaires, guidelines for interviews,
static gathering form data, and detailed instructions. Testing and
completing the questionnaire before the official data collection.
- Data wasrawprocessed, coded and entered into a computer by Epidata 3.1
software built specifically for this study include CHECK files. Data was
analyzed using STATA statistical software 10.0.
2.8. Ethics in Research
Research was acceptedby the Council Ethics in medical research from
the National Geriatric Hospital
CHAPTER 3
RESEARCH FINDING
3.1. Quality of life of Alzheimer's patients
3.1.1. The patient's general information
Research conducted on 120 patients with Alzheimer, average age 72.03 ±
8.7; mostly aged 60 or older (92.5%), 56.7% of women. The education level of


8

high school or less (55.9%), mainly former workers and farmers (45%).
Alzheimer’s disease detection time average of 2.73 ± 1.67 years.
3.1.2. Some clinical characteristics of patients with Alzheimer's
- The mean score of general cognitive status (MMSE) of 120 Alzheimer's
patients in the study was 14.71 ± 7.13.
- Grouping according to the degree of cognitive decline: 94 patients (88.3%)
in the level of moderate and mild cognitive impairment, 26 patients (11.7%)
severe cognitive impairment.

3.1.3. The actual quality of life of Alzheimer's patients and related factors
3.1.3.1. Different between patients with and without the ability to selfreport the quality of life
There were 95 patients (79.2%) self-report of their quality of life, 25 (20.8%)
patients did not answer the question.
Table 3.2: Some characteristics of patient self-report and not evaluated
quality of life (n = 120).
Characteristics
Gender (n (%)
Male
Female
Education (n (%))

Patient self- Patient could
report
not
(n=95)
answer(n=25)

p

46 (88.5)
49 (72.1)

6 (11.5)
19 (27.9)

0.028

High school or less
Intermediate /college

Undergraduate /postgraduate
Marital Status(n (%))

50 (74.6)
22 (84.6)
23 (85.2)

17 (23.4)
4 (15.4)
4 (14.8)

0.312

Married
Single /widowed /divorced /separated
Age (mean ± SD)
Time of diagnosis (mean ± SD)
Cognitive status (MMSE)
Activities of daily living (ADL)
Activities of daily living using instrument
or means (IADL)
The severityofNPI
The distressof NPI

73 (82.0)
22 (71.0)
70.8 ± 8.7
28.2 ± 16.7
17.7 ± 4.1
4.6 ± 1.5

16 (18.0)
9 (29.0)
76.8 ± 7.1
44.6 ± 23.9
2.8 ± 2.9
1.0 ± 1.4

4.5 ± 2.2

0.8 ± 1.2

0.001

5.8 ± 4.8
4.9 ± 5.8

10.2 ± 6.9
10.0 ± 8.2

0.003
0.001

0.192
0.002
0.001
0.001
0.001

Comment: Patients who were unable to complete the QOL-AD interview

had higher mean age, longer disease detected duration, more impaired
cognitive status and daily activities (ADL, IADL), more severe behavioral and
psychiatric symptoms than able self-report group (p <0.01).
3.1.3.2. Quality of life status of Alzheimer’s disease patients


9

Alzheimer’s disease patient quality of life score
Table 3.3. Alzheimer’s disease patient quality of life score
Quality of life
Cronbach
score
Subject
alpha
X
SD
Self-report patient (n=95)
27.5
4.1
0.82
Caregiver (n= 95)
24.7
4.3
0.82
The correlation coefficient between the
Rho = 0.67(p<0.001)
two assessments
Caregiver assessment for patients unable
18.2 ± 2.9 (p<0.01)

answer (n = 25)
X

: mean; SD: standard deviation

Comment: The quality of life (QOL) score of patients’ self-report were higher
than caregivers’ assessment (p <0.05) and only 52.9% and 47.5% compared to
the quality of life score at the best. QOL scores of patients who were unable
answer (18.2 ± 2.9) lower than that of patients with mild and moderate (p
<0.01) and reached only 35% compared to the best QOL. The QOL score
rating by patient and caregiver closely correlated (rho = 0.67, p <0.001).
Internal consistency reliability was excellent for both patient and caregiver
reports (Cronbach's alpha 0.82).
3.1.3.3. Patient quality of life and personal characteristics
Table 3.4: Patient quality of life and personal characteristics (n =95)
Characteristics

Patient able self-report
(n=95)
X ± SD
p

Age group
<60
28.44±5.34
60 - 69
27.09±4.31
0.261
70 - 79
27.95±3.82

≥80
26.60±3.60
Gender of patient
Female
25.56±7.55
0.242
Male
28.02±4.22
Cognitive impairment status based on MMSE score
MMSE = 9 points
24.0±2.8
MMSE from 10 - 19
26.2±6.0
points
0.102
MMSE from20 - 24
27.8±6.7
points
X : mean; SD: standard deviation

Caregiver (n= 95)
X

± SD

P

24.89±6.25
23.86±4.04
25.31±3.61

24.47±5.30

0.432

24.57±3.89
24.74±4.76

0.893

17.50±0.71
24.04±3.66
26.03±4.79

0.009


10

Comm
ments: Pat
tient qual
lity of lif scores were not significan
fe
ntly diffe
erent
between male and female p
d
patients, b
between th agegrou (p> 0
he

ups
0.05). Pati
ientD
did
iffer accor
rding to th degree of cogni
he
e
itive
reported QOL-AD ratings d not di
impairme
ent. But caregive
er-reported QOL-A rating were significa
d
AD
gs
antly
different with lo
ower QOL reporte among the low
L
ed
g
west cog
gnitive gr
roup
(p=0.009
9).
3.1.3.4. Alzheime
er’s pat
tient quality of life an

nd neur
ropsychia
atric
symptom (accord
ms
ding to NT assess
TP
sment)
ty
of
s
epression, indifferen
nce,abnor
rmal
Qualit of life scores o patients with de
nigh-time behavi
ioral sign
nificantly lower t
than thos withou sympto
se
ut
oms
(p<0.05). In additi
ion, patien change their ea
nts
ed
ating habi also red
its
duced qua
ality

of life.
3.1.3.5. Alzheime patie quality of life and psycho
er’s
ent
y
ological test
Quality of life of patien rated b caregiv were s
e
nts
by
ver
significan correla
ntly
ated
at mode
erate level with sp
l
peech diso
orders, lo of co
oss
oncentratio execu
on,
utive
dysfuncti
ion, activities of da living
aily
g(rho corr
relation co
oefficient from 0.30 to
0

0.45; p <
<0.05).
3.2. Caregiving burden and hea
alth-relate qualit of lif status of
ed
ty
fe
heimer’s d
disease ca
aregiver
Alzh
3.2.1. Ca
aregiver in
nformatio
on
Careg
givers in this study were m
y
mainly the children of patie
e
n
ents (59.2
2%);
35.8% w
were spous of pati
ses
ients, 66.7 % were women, 6
7
62.5 % we emplo
ere

oyed
and havin a stead income The mea age of c
ng
dy
e.
an
caregivers was 51.8 ± 15.1 years
s
8
old.
3.2.2. Ca
aregiver b
burden
3.2.2.1. Caregiving burde level fo
en
ollowing Z scale
ZBI
%
ver
n
e
nd
43.3% caregiv burden was in moderate level an 32.5% mild, 24.2%
caregiver burden in severity
r
n
y.
3.2.2.2. Caregive burden and pers
er
n

sonal cha
aracteristi
ics
Table 3.1 Caregi
11:
iver burde and per
en
rsonal cha
aracteristic (n=120)
cs
)
Careg
giver burd ZBI
den
Factor
Number
N
p
SD
Gender of caregi
r
iver
Male
40 (33.3%)
0
29.6
65
14.33
0.918
8

Female
F
80 (66.7%)
0
29.1
13
13.28
Age of caregiver
c
r
< 45 years
50
23.0
00
10.17
45 - 54 years
s
24
31.3
30
12.3
0.000
03
55 - 64 years
s
16
32.1
13
13.85
≥ 65 years

30
36.7
73
15.09
Labor status of caregiver
s
c
Stil working
ll
g
75
25.7
75
11.12
0.001
1
No working
o
g
45
35.2
22
15.27


11

Relationship of caregiver with patient
Spouses
43

36.72
Offspring/daughters71
25.30
in-law
Siblings/grandchildren
6
23.50
X

14.90
11.00

0.0002

10.46

: mean; SD: standard deviation

Comment: Caregivers aged 65 years and older had the caregiving burden
significantly higher (p = 0.0003). Unemployed and spouse caregiver groups in
our study had a higher burden (ZBI score was 36.72 ± 14.90) than offspring
and daughters-in-law caregiver group (25.30 ± 11.00) and other
caregivergroups (25.50 ± 10.46) with p ≤ 0.001.
3.2.2.3. Caregiver burden withpatient’s disease stage
Table 3.12: Caregiver burden with patient’s disease stage (n=120).
Caregiver burden
Cognitive impairment
p
X
SD

Severe/MMSE ≤ 9 (n = 26)
38.61
10.51
Moderate/MMSE from 10 – 19(n = 57)
27.35
12.18
0.0001
Mild/MMSE ≥ 20 (n = 37)
25.76
14.84
X

: mean; SD: standard deviation

Comment: Caregivers of patients with severe cognitive impairment
(MMSE) had much higher burden than caregivers of mild and moderate
patients group (p = 0.0001).
3.2.2.4. Correlation between caregiver burden and patient’s psychiatric
and behavioral symptoms
Severity, impact of psychiatric and behavioral symptoms of patients had
correlated relatively closely with caregiver burden ZBI (rho = 0.49 and 0.51, p
<0.005), which agitation or aggression, sleep behavior disorder were more
relevant than the other symptoms.
3.2.3. Health-related quality of life of caregiver
a. Caregiver health-related quality of life and personal characteristic
Table 3.15: Main caregiver physical health and mental health score (SF-12)
according to personal characteristics (n=120).
Physical health
Metal health
Characteristic

X
X
SD
SD
All caregivers(n = 120)
45.50
10.05
38.84
10.10
Gender of caregiver
Male
45.15
10.01
39.40
9.80
Female
44.67
10.03
38.56
10.30
p
0.165
0.628
Age of caregiver
< 45 years (n = 50)
52.02
5.63
41.35
8.39
45 - 54 years(n = 24)

44.45
9.21
37.68
10.32
55 - 64 years(n = 16)
45.38
8.72
37.31
12.76


12

Characteristic

Physical health
X
SD
35.53
8.78
0.001

≥ 65 years(n = 30)
p
Labor status of caregiver
Still working (n = 75)
50.12
No working (n = 45)
37.80
p

0.001
Relationship of caregiver with patient
Spouses (n = 43)
36.68
Offspring/daughters-in-law (n =
50.49
71)
Siblings/grandchildren (n=6)
49.63
p
0.001
X

Metal health
X
SD
36.41
10.59
0.104

7.00
9.68

40.21
36.56

9.50
10.75
0.051

9.25

36.11

11.49

6.62
5.30

40.42
9.09
39.75
7.96
0.066

: mean; SD: standard deviation

Comment: The physical health scoreof the caregiver was 45.50 ± 10:05;
mental health was 38.84 ± 10:10. Caregivers aged 65 years and older had the
physical health scores significantly lower than younger people and still
working (p = 0.001). Caregivers being spouses of patients had lowerhealthrelated quality of life score than children or relatives of patients (p = 0.001).
b. Caregiver health-related quality of life (SF-12)and patient’s cognitive
status
Table 3.16: Main caregiver physical health and mental health score (SF-12)
according to patient stage (n=120).
Mental health
Physical health
Patient’s status
X
X

SD
SD
Severe (n = 26)
43.33
11.73
33.17
9.50
Moderate(n=57)
47.45
8.72
40.27
9.78
Mild (n = 37)
44.01
10.41
40.62
9.82
0.192
0.005
p
X

: mean; SD: standard deviation

Comment: Caregiver mental health-related quality of life of patients with
severe cognitive impairment was significantly lower than caregivers of mild
and moderate patients (p = 0.005).
c. Caregiver health-related quality of life (SF-12) and patient’s
neuropsychiatric symptoms
Table 3.17: Caregiver health-related quality of life (SF-12) and patient’s

neuropsychiatric symptoms (n=120).
Correlation coefficientwith SF-12
Symptoms
Physical health
Mental health
Delusions
-0.11
-0.12
Hallucinations
-0.10
-0.19*
Agitation or aggressive
-0.07
-0.20*


13

Correlation coefficientwith SF-12
Physical health
Mental health
Depression
-0.07
-0.28*
Anxiety
-0.06
-0.10
Elation
-0.01
-0.10

Insensitivity or indifference
- 0.00
-0.16
Disinhibition
-0.14
-0.03
Irritability/emotional instability
-0.16
- 0.10
Aberrant Motor Behavior
-0.09
-0.14
Night-time Behavior
-0.33*
-0.24*
Appetite/Eating Changes
-0.13
-0.00
Severity of NPI
-0.17
-0.31*
Discruption of NPI
-0.20*
-0.32*
Comment: Caregiver mental health-related quality of life had a negative
correlation with agitation or aggression, depression or mood disorders of
patient, but night-time behavior disorder of patientwas at a lower level
(correlation coefficient was -0.20, -0.24 and -0.28; p <0.05). Caregiverphysical
health-related quality of life had negative correlation with patients’ night-time
behavior disorder (rho: - 0.33, p <0.05).

3.3. The effectiveness of non-pharmacological interventions (Objective 2)
Intervention program was carried out on 30 days of Alzheimer's patients
- caregiver with the combination of non-pharmacological measures within 24
weeks. The control group included 56 pairs of patients and caregivers.
3.3.1. The effectiveness of non-pharmacological interventions for
Alzheimer’s disease patients
3.3.1.1. Comparison of intervention and control groups before
intervention
a. Comparison of the general characteristics of the intervention and
control patient groups before intervention
No differences in demographic characteristics between the intervention and
control groups (p> 0.05, χ2 test).
b. Comparison of the clinical characteristics of the intervention and
control groups before intervention
The clinical characteristics (MMSE score, Activities of Daily Living ADL,
Activities of Daily Living using Instruments, means IADL, Severity, Impact of
neuropsychiatric and behavioral symptoms, Quality of life by patient and
caregiver assessments) of intervention group previous intervention did not
differ to control group (p> 0.05).
c. The behavioral symptoms. mental intervention group and control group
before the intervention
Symptoms


14

No differences in neuropsychiatric symptoms (NPI) between the
intervention and control groups before intervention (p> 0.05).
d. Comparison of the psychological test of the intervention and control
patient groups before intervention

No differences in psychological testsymptoms (NPI) between the
intervention and control groups before intervention (p> 0.05).
3.3.1.2. Clinical changes of the control group after 24 weeks
Table 3.23: Changes in clinical characteristics of the control group after 24
weeks (n=56).
After 24
week
X
X
SD
SD
18.30 3.89 16.57 4.54
4.94 1.32 4.41 1.63

0.001
0.001

Index
before–
after(%)
- 9.5
-10.7

4.71

2.18

3.94

2.33

0.001

-8.3

5.11
4.27
27.52
25.16

4.31 5.54
4.77 5.54
3.80 25.03
3.76 23.02

4.28
5.01
3.41
3.63

0.001
0.001
0.001
0.001

8.4
29.7
-9.0
-8.5

Before

Characteristic
Cognitive status (MMSE)
Activities of daily living ADL
Activities of daily living using
instrument, means (IADL)
Severity NPI
Discruption NPI
QOL patient self-report
QOL proxy report

p

: mean; SD: standard deviation
Comment: cognitive status, daily activities (ADL, IADL), the quality of life
of patients declined more than at admission (p = 0.001).
3.3.1.3. The effectiveness of interventions
a. The level of exercise participation of the intervention patient
19 patients (63%) in the intervention group regularlyparticipated in
rehabilitation (≥ 80% of sessions). 11 patients (37%) irregularly participated in
practice. The reason of irregular: the distance, family members (children) had
to work and had not enough time to take patient to the practice regularly.
During the training course, not occur any adverse events to patients.
a. Clinical change of intervention group after intervention period
Table 3.25: Clinical change of intervention group after intervention (n=30)
X

p

Effective
index/
(%)

17.67
4.37

SD
3.90
1.61

After 24
week
X
SD
18.77 3.77
4.931 1.3

0.001
0.001

6.2
12.8

4.57

1.96

4.93

1.93

0.030

7.9

6.37
4.83

5.22
5.90

5.10
3.10

3.88
3.57

0.030
0.002

-19.9
-35.8

Before
Characteristic
X

Cognitive status (MMSE)
Activities of daily living ADL

Activities of daily living using
instrument, means (IADL)
Severity NPI
DistressNPI


15

Before
Characteristic
X

QOL patient self-report
QOL proxy report

28.03
24.67

SD
4.89
5.12

After 24
week
X
SD
30.10 4.78
27.37 4.11

p

Effective
index/
(%)

0.001
0.001

7.4
10.9

Comment: Cognitive status (MMSE score), activities of daily living (ADL)
and activities of daily living using instruments, means (IADL) were increased.
Patient quality of life were of improvedthough according to the patient or
caregiver assessment. These improvements were statistically significant with p
<0.05.
- Satisfaction of patient intervention groups according the participation
level
Most intervention patients satisfied with the rehabilitation but patients in
regularlyparticipated group had higher satisfaction
3.3.1.4. The difference of the intervention group and control group after
intervention
Table 3.28: The difference of the intervention group (n=30) and control group
(n=56) after intervention.
Intervention Control group
Characteristic
p
group
X
X

SD
SD
Cognitive status (MMSE)
18.77
3.77
16.60
3.95 0.034
Activities of daily living ADL
4.93
1.31
4.32
1.67 0.136
Activities of daily living using
instrument, means (IADL)
Severity NPI
Discruption NPI
QOL patient self-report
QOL proxy report

4.93

1.93

3.94

2.38

0.044

5.10

3.10
30.10
27.37

3.88
3.57
4.78
4.11

5.54
5.54
25.03
23.02

4.28
5.01
12.00
11.0

0.699
0.022
0.001
0.001

X : mean; SD: standard deviation

Comment: Cognitive status, activities of daily living using instruments,
means and quality of life of intervention patients group were higher than the
control group (p <0.05).
3.3.1.5. The effectiveness of non-pharmacological interventions

Table 3.29: The intervention effectiveness forAlzheimer’s patient
Characteristic
Cognitive status (MMSE)
Activities of daily living ADL
Activities of daily living using
instrument, means (IADL)
Severity NPI

Intervention Pre-post
Index(%)
Index (%)

Effectivenes
s Index (%)

6.2
12.8

- 9.5
- 10.7

15.7
22.5

7.9

- 8.3

16.2

- 19.9

8.4

- 28.3


16

- 35.8
29.7
- 65.5
7.4
- 9.0
16.4
10.9
- 8.5
19.4
Comment: After intervention: general cognitive status of patients
increased 15.7%; activities of daily living 22.5%; activities of daily living
using instruments, means increased16.2%, the severity of psychiatric
behavioral symptoms declined 28.3%, caregiver distress of symptoms
decreased by 65.5%, patients’ self-report quality of life up 16.4%; quality of
life of patients proxy – report increased 19.4%.
3.3.2. The effectiveness of interventions for caregivers
3.3.2.1. The differences of caregiver intervention group and control group
before the intervention
Care burden (ZBI), health-related quality of life (mental and physical
health (SF-12) of the intervention caregivers group did not differ to control
group at pre-intervention (p> 0:05).

3.3.2.2. The results of the caregiver intervention group
Table3.32: The results of the caregiver intervention group (n=30).
PrePostEffectiveness
intervention intervention
Characteristic
p
Index (%)
X
X
SD
SD
Caregiverburden
30.20 15.01 22.56 13.36 0.001
-25.3
Physical health score 44.62 9.91 46.67 8.92 0.049
4.6
Mental health score
39.17 10.00 44.31 7.33 0.001
13.1
X : mean; SD: standard deviation
Comment: After intervention, caregiver burden of intervention group
dropped nearly 8 points. Physical health-related quality of life increased 2
points; mental health increased more than 5 points. The improvement were
statistically significant (p = 0.001 and 0.049, Wilcoxon test).
3.3.2.3. Change of caregiver control group after intervention
Table 3.33: Change of caregiver control group after intervention (n=56).
Discruption NPI
QOL patient self-report
QOL proxy report

Characteristic
Caregiver burden
Physical health score
Mental health score

Preintervention
X
SD
23.96
11.37
47.01
9.39
41.73
8.93

Postintervention
X
SD
28.13 11.46
46.61
9.20
37.59
8.31

p

Effectivenes
s Index (%)

0.001

0.545
0.001

17.4
-0.8
-9.9

: mean; SD: standard deviation
Comment: Caregiver burden of control group increased from 23.96±11.37
to 28.13±11.46 (p = 0.001). Mental health score significantly reduced (- 4.17
points, p = 0.001). No differences in physical health status (p= 0545, Wilcoxon
test).
X


17

3.3.2.4. The differences of intervention and control caregiver group after
intervention
Table3.34: The differences of intervention (n = 30) and control (n = 56)
caregiver group after intervention
Intervention
Control group
group
Characteristic
p
X
X
SD
SD

Caregiver burden
22.56
13.36
28.13
11.46
0.013
Physical health score
46.67
8.92
46.61
9.20
0.863
Mental health score
44.31
7.33
37.59
8.31
0.001
X : mean; SD: standard deviation
Comment: In the intervention group, caregiver burden was lower than
the control group (p = 0.013), mental health status better than the control group
(p = 0.001). Physical health of the intervention group and the control group
after intervention did not differ (p> 0:05).
3.3.2.5. Intervention effectiveness for caregivers
Table 3.35: Intervention effectiveness for caregivers
Intervention
Pre-post
Effectiveness
Characteristic
Index (%)

Index (%)
Index (%)
- 25.3
17.4
Caregiver burden
- 42.7
4.6
- 0.8
Physical health score
5.4
13.1
- 9.9
Mental health score
23.0
Comment: When implementing a number of associated nonpharmacological measures to coordinate, caregiver burden decreased 42.7%;
physical health of caregivers increased 5.4% and mental health increased 23%.
CHAPTER 4.
DISCUSSION
4.1. Quality of life status of Alzheimer’s disease patients and their
caregivers
4.1.1. Quality of life status of Alzheimer’s disease patients and related
factors
4.1.1.1. Socio-demographiccharacteristics of Alzheimer’s disease patients
Age and gender of Alzheimer’s disease patients
In our study.Patients of 60 years old and over were 92.5%. The mean age
of AD patients was 72.03±8.7.The same with the other study at National
Geriatric Hospital (70.44 ± 9.37 71.95 ± 7.99). It shown that this is a disease of
elderly. However, the mean age in foreign studies was higher from 75.1±6.6 to
81.0 years old. In developed countries.Life expectancy is higher so mean age
of AD patients was higher too.

In this study, 56.7% patients were woman.Similar to mental study of National
Geriatric Hospital in the years 2008-2010 (female was 62.5%). This is


18

consistent with the general trend of the world.When the studies mentioned risk
factors of Alzheimer's gender factorwith a higher proportion of women from
50.5% to 68 %. At high ages, the percentage of women with Alzheimer's
disease is also higher.
Patients’Occupation and education
Patients with levels of education from junior high school or less
(equivalent to 9 year) accounted for 40.9%.Education is one of the most
important risk factor in Alzheimer's disease. The percentage of patients with a
previous occupation as farmers and workers was 45%.Theless skilled and
trained labor jobs were, the less cognitive stimulation they were and that could
increase the risk of Alzheimer's disease and dementia.
4.1.1.2. Clinical characteristics of patients with Alzheimer disease
- On the cognitive status
In our study, the mean point of cognitive state (MMSE) was 14.71 ±
7.13. Patients in the early stage were 30.8%, 47.5% of average and severe
cognitive impairment was 21.7%. Alzheimer's patients in Vietnam usually
were diagnosed late. This was a study done at the hospital so mild and
moderate patients were taken to hospital to medical care more thansevere
patientswho typically were taken careof at home. These results are similar to
studies of Thang Pham and colleagues atNational Geriatric Hospital (MMSE
16.71 ± 6.45).
- On the neuropsychological tests. activities of daily living
Most Alzheimer's patients in our study did not reach the normal range on
tests of Memory, Language, Digit Span Forward, Digit Span Backward,

Executive Dysfunction, Clock Drawing Test, Visuomotor Speed, Activities of
Daily Living (over 70%). Research of PhamThang et al also gave similar
results. Alzheimer's disease patients were dependent on activities of daily
living (ADL) higher than the other diseases, such as broken pelvis,
Cerebrovascular disease, cardiovascular disease and cancer.
- On neuropsychiatric and behavioral symptoms
90.8% of Alzheimer's patients had at least one neuropsychiatric and
behavioral symptomwhich were commonly hallucination,irritability,
disinhibition,agitation,
anxiety,
apathy,
indifference
with
surroundings,aberrantmotor behavior, sleep and nighttime behavior disorders.
This situation was similar to the clinical literature review in Alzheimer's
disease and in other countries.
4.1.1.3. Quality of life of people with Alzheimer's disease
Assessing the quality of life in Alzheimer's disease (QOL-AD)
Our research shows that people with moderate and mild Alzheimer's
disease could reliably evaluate and value their quality of life. 95 Alzheimer’s
patients (79.2%) had the ability to complete the evaluation of their quality of
life with MMSE score ≥ 9 points.


19

Internal reliability of the questionnaire high with Cronbach alpha = 0.82
index. The study of foreign authors were also found QOL-AD questionnaire
has intrinsic reliability from 0.78 to 0.86 and high value. In Vietnam, there
were not any study deeply into the field of quality of life as well as the tools

developed to assess the quality of life of Alzheimer's patients. Therefore, this
toolkit can be used to assess the quality of life for Alzheimer's patients in
particular and dementia in general in Vietnam.
The Alzheimer's patients quality of life Score
In our study, the quality of life in care recipients (CR) (27.5 ± 4.1) was
higher than caregivers’ (CG) rate (24.7 ± 4.3) (p <0.05). Although there was a
small difference but the quality of life scores of care recipients and caregivers’
rate were closely correlated (Spearman rho correlation coefficient = 0.67,
p=0.001). Other authors also found that patients rated their quality of life
higher than caregivers assessed and there was aunificationbetween these two
assessments.
Quality of life of patients is generally low, achieving only 47.5% (as
assessed by the caregiver) to 52.8% (as assessed by the patient) compared to
the quality of life at best, significantly lower than the quality of life of other
healthy elderly people. A study in Brazil found the quality of life of elderly
people without Alzheimer's disease was 40.18 points (corresponding to 77.3%
compared to the quality of life at best) higher than the quality of life of patients
Alzheimer's was 29.32 points (56.4% compared to the quality of life at best
with p <0.001). This suggests that Alzheimer's disease has a negative impact
on their quality of live.
Quality of life of patients with Alzheimer's and related factors
- Quality of life according to cognitive status (MMSE score)
In our study, the quality of life assessed by care recipients (self-reports)
was not different between severe, moderate and mild patient groups as defined
by a MMSE score. But as caregiver report, quality of life scores of patients
with severe cognitive impairmentwho could not answer questions was (18.2 ±
2.9) significantly lower compared to quality of life of patients with moderate
stage (24.04 ± 3.66) and mild stage (26.03 ± 4.79) and only reached to 35 %
compared to the quality of life at best. Ready et al also found that the quality of
life of patients is inversely proportional to the severity of disease (Spearman

rho = - 0.35). Lyketsos and Vogel said the quality of life of patients declined
over time. However, according to some authors, cognitive status was not
related to quality of life assessment. In the study of Rebecca Logsdon, MMSE
scores did not correlate with the quality of life rated by both patients and
caregivers.
- Quality of life of patients and neuropsychiatric symptoms
Patients with depression, indifference, abnormalnighttime behaviors had
quality of life scores significantly lower than those without symptoms


20

(p<0.05). The behavioral and neuropsychiatric disorders in patients with
Alzheimer’s disease were important predictors of quality of life assessment by
patients and caregivers.
- Patient quality of life and neuropsychological tests and activities of daily
living function
When memory, language ability, focus, executive function, autonomy in
activities of daily living of patients impaired, quality of life of patients were
declined significantly. This result was similar to the study of Hoe and
Andersen.
4.1.2. Regarding the burden of care and quality of life associated with
health care providers and a number of related factors
4.1.2.1. The burden of caregivers of Alzheimer's patients
Toolkit assessment of caregiver burden
In our study, the tool of Caregiver Burden Interview (ZBI) in
Vietnamese version had high reliability (Cronbach alpha = 0.92) and good for
measurement of Alzheimer's disease caregiver burden. This result was
consistent with studies in other countries such as in Japan, China, Italy,
Singapore,Braziland South Korea.

Some characteristics of caregivers
Caregivers in our study were mainly the children of patients; 35.8 %
were spouses of patients. 66.7% of them were women and employed and had
steady income. The mean age of caregivers was 51.8 ± 15.1 years old.
Notably, a quarter of caregivers over 65 yearswho should be taken care of by
other people but still have to take care of AD patients. Patient care time
average of 1.94 ± 1.44 years. Caregivers spend an average of 4.09 ± 3.72 hours
per day to care for patients.
Characteristics of Alzheimer's patient caregivers in Vietnam has many
similarities with other countries. Many surveys show that the majority of
caregivers are spouses, then offspring, daughters-in-law, in which women were
majority. Typical profile of caregiver was daughter in middle-aged and older
or spouses of the patient.
The burden of Alzheimer's disease caregivers
Mean burden of Alzheimer's disease caregivers in our study on
Caregiver Burden Interview (ZBI) was 29.30 ± 13.58, median levels of the
rating scale. However, level of the caregiver burden depends on many factors
belonging to both patients and caregivers. 43.3 % Alzheimer's caregiver
burden in moderate, 32.5 % caregiver burden mild, 24.2 % caregiver burden in
severity and at same level as in the study by Chan and colleagues in China
(ZBI score was 24.6 ), Moraes from Brazil (37.3 ± 13.08), Saeed (42.0 points),
Seng in Singapore (ZBI score was 35.4) or in the study of Yoon in Korea (ZBI
score was 31.0). These results suggested that Alzheimer's disease had created a
significant burden for their care in though all countries.


21

Unemployed and spouse caregiver groups in our study had a higher
burden (ZBI score was 36.72 ± 14.90) than offspring and daughters-in-law

caregiver group (25.30 ± 11.00) and other caregivergroups (25.50 ± 10.46)
with p = 0.001. It might be a group of elderly, retired and unlabored who were
close to the patient and should spend most of their time to look after patients,
especially the spouses of the patients were more psychologically vulnerable
than other groups and theybare themselves higher burden than other groups.
Caregivers burden of patients with severe cognitive impairment were much
higher than others (p = 0.0001). Caregiver burden related to some behavioral
symptoms such as agitation or aggression, abnormal nigh-time behavior of the
patient.
Characteristics of caregivers in Vietnam
The Vietnamese have tradition, morality "respect for the elderly".
Elderly care is the reward for the class who had reserved long time for raising
up their children, caring for family and contributing to society. This is also
morality expressing "drinking water also remembering its source" of
Vietnamese. Alzheimer's disease patients were carried out by their spouse,
children in the family and there was not the state of being abused or neglected
in our study. Most caregivers did not feel that their relatives asked for more
help than he/she needed (0.4 points on a scale of 4) and not feel that their
relatives affected his/her relationships with other family members or friends in
a negative way (0.53 points). Conversely, caregivers always defined their role
in patient caregiving, mainstay of the patient. They always worried about the
risks that might occur to patients and needed to do more things for patients
(grade point average from 1.65 to 2.9). Sometimes, the patient caregiving was
the pride of the caregiver. Perhaps, this partly explained the caregiver burden
perceived generally at moderate level in our study and lower than other
studies.
4.1.2.2. Quality of life of caregivers of Alzheimer's patients
The level of stress and psychological distress were significantly higher.
satisfaction and physical health were significantly lower in Alzheimer’s
disease caregivers than caregivers in other diseases. In our study, the mean

scores of physical health of caregivers was 45.50 ± 10.05 (no much lower than
the score of physical health in the community was 50.0 ± 10.0), but mental
health score was 38.84 ± 10.10 much lower than the general community (50.0
± 10.0). No difference in quality of life related mental health scores of male
and female caregivers (p > 0.05). Caregivers who were unemployed and aged
of 65 years and over had significantly the quality of life associated with
physical health score lower than caregivers who are working and younger.
Maybe this was the aged groups who retired and spent more time for
caregiving.Physical health impaired due to age should also be more influential
and weaker than young caregivers. The health related quality of life scores of


22

these caregivers (spouses of patients) was significantly lower than caregivers
who were children or relatives of patients (p = 0.00). The mental health related
quality of life of caregivers of severe cognitive impairment patients (33.17 ±
9.50) was significantly lower than caregivers of patients with mild cognitive
impairment (40.62 ± 9.82) and moderate patients (40.27 ± 9.78) ( p = 0.005).
This suggests that the severe Alzheimer's patient caregiving affected the
mental health of the caregiver, especially in severe disease stages. The mental
health related quality of life of caregiver correlated negatively with symptoms
of agitation or aggression, depression or mood disturbances, sleep behavior
disorder of patients but at low-level (correlation coefficient of -0.20 to -0.28. p
< 0.05). Meanwhile, the physical health of caregivers concerned only with
nigh-time behavior disorder patients (correlation coefficient = - 0.33; p<0.05).
Health related quality of life of caregivers inversely correlated with the
dependence degree of Alzheimer's patients and caregiver age. The negative
influence and /or statistical significant factors for the health related quality of
life of caregivers were perceived high level of caregiving burden, long time

care and older ages.
4.2. The effectiveness of non-pharmacological interventions
4.2.1. The effectiveness intervention for patients with Alzheimer's
The pharmaceuticals for Alzheimer's disease treatment currently can
only slow the progression of symptoms but not cure. So, the demand
researching measures treatment in Alzheimer's disease become more urgent
due to the care of patients most unsatisfactory worldwide. The nonpharmacological measures can improve the quality of life of Alzheimer's
patients and caregivers. We have associated a number of non-pharmacological
interventions applied for Alzheimer's outpatients at National Geriatric
Hospital, including the exercise stimulates memory, cognition, exercise the
reality orientation, occupational therapy and physical activity. These measures
were relatively simple, not requiring expensive equipment or complicated
techniques but feasible andcould be applied in program management, patients
caring at the healthcare facilities, day center and in the community. During
practice, there was not any adverse events happeningto patients. Associate the
implementation of non-pharmacological measures had been effective
intervention for patients with Alzheimer's: general cognitive status of patients
increased 15.7%, activities of daily living (ADL) increased 22.5 %, activities
of daily living using instruments or means (IADL) increased 16.2%, the
severity of neuropsychiatric and behavioral symptoms declined 28.3%, the
influence of neuropsychiatric and behavioral symptoms decline 65.5%, the
patient quality of life rated by patients increased 16.4%; quality of life of
patients rated by caregivers increased 19.4%. Results showed that