Unco ec ed Au ho P oo
Jou nal o Alzheime ’s Disease xx (20xx) x–xx
DOI 10.3233/JAD-200806
IOS P ess
1
Heal h-Rela ed Quali y o Li e in
Communi y-Dwelling Olde People
wi h Cogni i e Impai men : EQ-5D-3L
Measu emen P ope ies
1
2
3
4
Pila P´
e ez-Rosa,b,c,∗, Ra ael Vila-Candela,d,e, Sal ado Ma in-U illaa,b,
and F ancisco M. Ma ´
ınez-A nauc,g
5
6
aDepa men o Nu sing, Uni e sidad Ca ´olica de Valencia San Vicen e M´
a i , Valencia, Spain7
bGRICPAL Resea ch G oup, Uni e sidad Ca ´olica de Valencia San Vicen e M´
a i , Valencia, Spain8
cF ail y and Cogni i e Impai men Resea ch G oup (FROG), Uni e si a de Val`encia, Valencia, Spain9
dDepa men o Obs e ics and Gynecology, Hospi al Uni e si a io de la Ribe a, FISABIO, Valencia, Spain10
eDepa men o Nu sing, Facul y o Nu sing and Podia y, Uni e si a de Val`encia, Valencia, Spain11
Pallia i e Ca e Uni , Valencia Ins i u e o Oncology, Valencia, Spain12
gDepa men o Physio he apy, Uni e si a de Val`encia, Valencia, Spain13
Accep ed 17 July 2020
Abs ac .
14
Backg ound: Assessing quali y o li e (QoL) in olde people wi h cogni i e impai men is a challenge. The e is no consensus
on he bes ool, bu a sho , use - iendly scale is ad ised.
15
16
Objec i e: This s udy aimed o assess he psychome ic p ope ies o he sel - epo ed and gene ic EQ-5D (including he
EQ index and EQ isual analog scale [VAS]) in communi y-dwelling olde adul s wi h cogni i e impai men .
17
18
Me hods: C oss-sec ional s udy analyzing he easibili y, accep abili y, eliabili y, and alidi y o he EQ-5D based on
188 sel -adminis e ed ques ionnai es in a sample o communi y-dwelling olde adul s wi h Mini-Men al S a e Examina ion
(MMSE) sco es o 10 o 24 poin s.
19
20
21
Resul s: The EQ index was 0.69 (±0.27) and he EQ VAS was 63.8 (±28.54). Adequa e measu emen p ope ies we e ound
in accep abili y and easibili y. C onbach’s alpha was 0.69. Good alidi y was obse ed in he co ela ion o each dimension
o he EQ-5D wi h ge ia ic assessmen scales. Highe alidi y was obse ed o he EQ index compa ed o he EQ VAS.
22
23
24
Conclusion: The EQ-5D scale could be a good ool o assessing heal h- ela ed QoL in communi y-dwelling olde adul s
wi h cogni i e impai men , hough i is necessa y o assess he dimensions and he EQ index.
25
26
Keywo ds: Cogni i e impai men , communi y-dwelling, measu emen , olde people, quali y o li e27
INTRODUCTION
28
The inc easing in e es in measu ing quali y o 29
li e (QoL) in olde people esides in he need o30
∗Co espondence o: Pila P´
e ez-Ros, Espa e o 7, 46010
Valencia, Spain. Tel.: +34 963637412 4262; E-mail: pila .
pe ez@uc .es.
unde s and he e ec i eness o in e en ions in p e- 31
en ion and heal h p omo ion p og ams. Resou ce 32
managemen is subjec o cons an inno a ions, so 33
he implemen a ion o p e en i e s a egies a di e - 34
en le els should be e alua ed. In e en ions a ge ed 35
a olde people should be assessed o hei cos - 36
e ec i eness in o de o iden i y hose wi h he 37
s onges capaci y o imp o e QoL and p o ide alue 38
ISSN 1387-2877/20/$35.00 © 2020 – IOS P ess and he au ho s. All igh s ese ed
Unco ec ed Au ho P oo
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e ez-Ros e al. / Quali y o Li e in Olde People wi h Cogni i e Impai men
o money. Indeed, assessing QoL as an economic39
measu e o in e en ions is a widely used ac ic in
40
adul s, hough less so in olde people [1].41
Assessing he e ec o heal h in e en ions on QoL42
could p o ide mo e consis en esul s han analyzing43
disease ou comes due o he high como bidi y p e-
44
sen ed by his popula ion [2]. Quali y o li e is de ined45
as “an indi idual’s pe cep ions o hei posi ion in46
li e, in he con ex o he cul u e and alue sys ems in47
which hey li e, and in ela ion o hei goals, expec-
48
a ions, s anda ds and conce ns” [3]. Heal h- ela ed49
quali y o li e (HRQoL) can be de ined as “how well a50
pe son unc ions in hei li e and his o he pe cei ed
51
wellbeing in physical, men al, and social domains o 52
heal h.”
53
Ye , measu ing QoL can be di icul because he54
concep i sel is complex. Assessmen is cha ac e -55
ized by i s mul idimensionali y, wi h bo h objec i e
56
and subjec i e measu es, and mul i a ia e e alua ion57
designs a e based on he pe son and hei en i onmen 58
as well as conside a ion o he sys ems pe spec i e,59
which encompasses he mul iple en i onmen s ha 60
impac on he pe son and he inc easing pa icipa ion61
o people wi h cogni i e disabili y [4].62
Di e en s udies ha e obse ed ha communi y-
63
dwelling olde adul s ha e shown highe HRQoL han
64
hose in ins i u ions, mainly due o lowe como bid-65
i y and dependency along wi h g ea e socializa ion
66
[5–7]. The mos impo an ac o s men ioned in he67
li e a u e o imp o e HRQoL in communi y-dwelling68
olde adul s a e: cohabi a ion a home, socializa ion
69
and social suppo , independence, and physical ac i -70
i y, while he ac o s ha ha e a nega i e in luence
71
a e mainly como bidi ies ha impai unc ion, pain,
72
dep ession, alls, ail y, sa copenia, and demen ia73
[8–12].74
Assessing sel -pe cei ed HRQoL in olde people75
wi h demen ia is gene ally conside ed challenging.76
In ad anced s ages, his synd ome can a ec he eli-77
abili y o he da a collec ed [13]. Al hough he e a e
78
s udies showing di e ences be ween sel - epo ed79
assessmen by he pa ien wi h demen ia and ha by
80
he amily ca egi e [14], a ac ha has led o dis-81
c epan pe spec i es on he desi abili y o using a82
p oxy, like he p ima y ca egi e o clinicians, e -83
sus di ec ly ob aining in o ma ion om he pe son84
being assessed—which is always p e e able when85
condi ions allow [15]. Al hough some au ho s de end86
he use o p oxies, poin ing o he good psychome-
87
ic p ope ies achie ed, ac o s like emo ional s a e
88
o ca egi e a igue can nega i ely a ec a HRQoL
89
assessmen [16]. The e is a dea h o li e a u e ha
90
analyzes HRQoL acco ding o he se e i y o he 91
demen ia o o he ac o s ha nega i ely in luence 92
HRQoL, independen ly o he se e i y o he condi- 93
ion, o example a pe son’s knowledge ha hey ha e 94
cogni i e impai men [13]. 95
The e a e di e en ools o assessing HRQoL in 96
olde people, bo h gene ic and speci ic o di e en 97
pa hologies, including demen ia. Howe e , he e is a 98
need o u he esea ch in o de o know he alidi y 99
o demen ia-speci ic ins umen s in di e en g oups 100
and a eas [17, 18]. Mo eo e , he di e si y o he ools 101
makes i di icul o s anda dize an ins umen [19] 102
and compa e he esul s o di e en s udies in he li - 103
e a u e [1]. Using gene ic scales in popula ions wi h a 104
speci ic pa hology would enable compa ison o in e - 105
en ions in di e en popula ions and se ings, bu i is 106
necessa y o know hei p ope ies in he popula ions 107
unde s udy. 108
In ha ega d, he EQ5D has been shown o be a 109
good ins umen o assessing HRQoL in communi y- 110
dwelling olde adul s [20] and in ins i u ionalized 111
people wi h cogni i e impai men [21]. This scale 112
is a sho and easy- o-use, and i is widely applied 113
in communi y-dwelling olde adul s [20, 22]. Diaz- 114
Redondo e al. [23] analyzed he psychome ic 115
p ope ies o he p oxy- a ed EQ-5D, showing i o be 116
a alid al e na i e o assessing quali y o li e in ins i- 117
u ionalized olde people wi h demen ia. Ank i e al. 118
[16] also poin o he possibili y o using he EQ-5D 119
o people wi h demen ia, al hough di e en au ho s 120
indica e he need o mo e s udies ha analyze bo h 121
i s p ope ies o assessing HRQoL acco ding o he 122
se e i y o he demen ia and i s alidi y in he absence 123
o a gold s anda d [16, 24]. 124
The aim o ou s udy was o assess he psychome- 125
ic p ope ies o he EQ-5D in communi y-dwelling 126
olde adul s wi h cogni i e impai men . 127
MATERIALS AND METHODS 128
S udy design and pa icipan s 129
A c oss-sec ional s udy was ca ied ou om 1 130
Janua y 2020 o 13 Ma ch 2020. The inclusion 131
c i e ia we e: pa icipan s aged 70 yea s o olde ; 132
cogni i e impai men assessed by amily physician 133
a e cogni i e e alua ion wi h he Mini-Men al S a e 134
Examina ion (MMSE), wi h C onbach’s alpha 0.90 135
and a sco e be ween 10 o 24, indica ing cogni- 136
i e impai men [25, 26]; li ing independen ly in he 137
p o ince o Valencia (Spain) and wi h he abili y 138
o ead and w i e. Exclusion c i e ia we e: e usal 139
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o pa icipa e in he s udy, se ious psychia ic p ob-140
lems (se e e dep ession subjec ed o ea men o
141
acu e psychosis), o se e e cogni i e impai men 142
(diagnosed p e iously by a physician), he exis-143
ence o associa ed disease condi ions esul ing in144
a li e expec ancy o unde 6 mon hs, blindness,
145
o dea ness.146
Sample size desc ip ion147
A o al o 361,575 communi y-dwelling olde 148
adul s p o ince-wide we e included in he popula ion149
census o 2019. The sample size was calcula ed based150
on his census o es ima e a 18.5% incidence o olde
151
adul s wi h mild-se e e cogni i e impai men [27],152
wi h an alpha e o o 5%, p ecision o 3%, and a153
s a is ical powe o 95%. The inal minimum sample
154
o pa icipan s equi ed was 165.155
In o de o use an adequa e sampling ame, we
156
decided o ec ui pa icipan s o e a pe iod o wo157
mon hs. The assessmen was ca ied ou in p ima y
158
ca e cen e s o Valencia. All people who showed hei 159
willingness o pa icipa e and who me he inclusion160
c i e ia we e included. To encou age pa icipa ion,
161
pos e s we e hung and lye s dis ibu ed; open in o -162
ma ion sessions we e also held o olde indi iduals163
in e es ed in pa icipa ing in he s udy. In addi ion,164
olun ee s signed up on a lis in each cen e , and165
hei da a we e eco ded using alphanume ic codes
166
iden i ying he cen e and he indi idual.167
Da a collec ion and quali y o li e assessmen 168
Pe sonalized in e iews we e unde aken wi h169
each pa icipan o pe o m he ge ia ic assessmen 170
and collec da a on age and sex as well as cogni i e,
171
unc ional, and emo ional a iables. Fou nu ses wi h
172
a leas i e yea s’ expe ience in p ima y heal h ca e173
cen e s and nu sing homes we e in cha ge o his ask,
174
which was pa o hei ou ine clinical p ac ice; hey
175
we e no o he wise in ol ed in he s udy. All assess-
176
men s we e pe o med in he mo ning, a e b eak as 177
and be o e lunch, be ween 9 am and 12 pm.178
Heal h- ela ed quali y o li e was assessed using179
he EQ-5D isual analog scale (VAS) and, he EQ-
180
5D index acco ding o he pa ame e s o he Spanish181
popula ion. In o de o p o ide in o ma ion on he182
h ee aspec s o HRQoL, he EQ-5D-3L (Le els)
183
was used. Fi s , i s desc ip i e sys em assesses he184
le el o impai men in each o he i e dimensions185
included in he scale: mobili y, sel -ca e, usual ac i -186
i ies, pain/discom o , and anxie y/dep ession. Each187
dimension has h ee le els o impai men : no p ob- 188
lems (le el 1), some p oblems (le el 2), and ex eme 189
p oblems (le el 3). Second, he desc ip i e esponse 190
om he EQ-5D can be adap ed in o an index sco e. 191
The sco e anges om less han 0 o 1 (whe e 0 is a 192
heal h s a e equi alen o dea h and nega i e alues 193
a e wo se han dea h) and 1 is he mos posi i e sco e 194
( he maximum le el o pe cei ed HRQoL acco ding 195
o he i e dimensions included on he scale). Finally, 196
he EQ VAS sco e was ob ained by asking he pa ien s 197
o a e hei heal h on a 20 cm e ical scale. The scale 198
anges om 0–100, whe e 0 is he ‘wo s imaginable 199
heal h’ and 100 is he ‘bes imaginable heal h’ [22]. 200
The unc ional and emo ional assessmen ools 201
we e he Ba hel Index Basic Ac i i y o Daily Li - 202
ing, he Tine i Balance and Gai Scale, he Yesa age 203
Ge ia icDep essionScale(GDS), heLaw onIns u- 204
men al Ac i i y o Daily Li ing Scale (IADL), and 205
he VAS pain. In he p esen s udy hey we e used o 206
ob ain he in o ma ion and comple e an indi idual- 207
ized ge ia ic assessmen o each pa icipan . 208
The Ba hel Index (BI) is a sco ing echnique ha 209
measu es he pa ien ’s pe o mance in 10 ac i i ies o 210
daily li e. The i ems can be di ided in o a g oup ha 211
is ela ed o sel -ca e ( eeding, g ooming, ba hing, 212
d essing, bowel and bladde ca e, and oile use) and 213
a g oup ela ed o mobili y (ambula ion, ans e s, and 214
s ai climbing). The o al sco e anges om 0 ( o ally 215
dependen ) o 100 ( o ally independen ); sco es a e 216
awa ded in mul iples o 5 [28]. The BI akes may 217
a y depending on pa icipan s’ ole ance and abili- 218
ies o sel - epo o 2 o 5 min and o submi o di ec 219
obse a ion o 20 min. 220
The Tine i scale has a gai sco e and a balance 221
sco e. I uses a 3-poin o dinal scale o 0, 1 and 2. 222
Gai is sco ed o e 12 and balance is sco ed o e 16 223
o a o al o 28 possible poin s. A o al sco e o less 224
han 19 poin s indica es a i e old inc eased isk o 225
alls, so he lowe he o al sco e, he highe he isk 226
o alling [29]. The ime o comple e is 10 o 15 min. 227
A Sho Fo m GDS consis ed o 15 ques ions. Ten 228
o he 15 i ems indica e he p esence o dep ession 229
when answe ed posi i ely, while he o he 5 (ques ion 230
numbe s 1, 5, 7, 11, 13) a e indica i e o dep es- 231
sion when answe ed nega i ely. Sco es o 0 o 4 a e 232
conside ed no mal, depending on age, educa ion, and 233
complain s; 5 o 8 indica e mild dep ession; 9 o 11 234
indica e mode a e dep ession; and 12 o 15 indica e 235
se e e dep ession [30]. This o m can be comple ed in 236
app oxima ely 5 o 7 min, making i ideal o people 237
who a e easily a igued o a e limi ed in hei abili y 238
o concen a e o longe pe iods o ime. The ime 239
Unco ec ed Au ho P oo
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o comple e can be up o 20 min, depending on he240
pe son’s emo ional s a e.241
The Law on IADL scale measu es people’s abil-
242
i y o pe o m eigh ac i i ies (using he elephone,243
shopping o g oce ies, ood p epa a ion, housekeep-244
ing, launde ing, sel -medica ing, anspo a ion, and
245
managing inances). The o al sco e anges om 0
246
( o ally dependen ) o 8 ( o ally independen ) [31].
247
The Law on IADL scale akes 10 o 15 min o admin-
248
is e and con ains eigh i ems, wi h a summa y sco e249
om 0 (low unc ion) o 8 (high unc ion). The ime250
o comple e is 2 o 5 min i sel - epo ed.251
The VAS pain scale [11] is a con inuous scale com-
252
p ised o a ho izon al o e ical line, usually 10 cm253
in leng h. Fo pain in ensi y, he scale goes om 0
254
(indica ing no pain) o 10 (wo s imaginable pain)
255
[32]. The ime o comple e is 2 min.
256
E hics257
All pa icipan s ga e hei in o med consen o 258
inclusion be o e hey en olled in he s udy. The s udy
259
was conduc ed in acco dance wi h he Decla a ion260
o Helsinki, and he p o ocol was app o ed by he261
Clinical Resea ch E hics Commi ee o he Uni e si y262
o Valencia (Valencia, Spain; P ojec iden i ica ion
263
code 1060896).
264
Measu emen p ope ies265
We analyzed he main measu emen p ope ies o 266
he QoL ins umen s, including easibili y, accep -
267
abili y, eliabili y, and cons uc alidi y, acco ding
268
o he c i e ia se ou in Table 1. As he e is no gold-269
s anda d measu e o QoL, c i e ion alidi y was no
270
app aised [33].
271
In o de o de e mine he easibili y o he ins u- 272
men unde no mal condi ions, we analyzed he 273
pe cen age o missing da a [34]. The adequa e dis- 274
ibu ion o sco es among he sample indica es he 275
accep abili y [35], including measu es o cen al en- 276
dency and loo and ceiling e ec [36, 37]. 277
To analyze eliabili y, we assessed C onbach’s 278
alpha o in e nal consis ency and he s abili y o he 279
measu e [31]; and he in aclass co ela ion coe i- 280
cien (ICC) o e alua e he s abili y be ween he EQ 281
index and he EQ VAS [38]. 282
Validi y con e gence de e mines he ela ionship 283
o he scale wi h o he measu es assessing he same 284
cons uc . We used he co ela ion coe icien (Pea - 285
son’s o Spea man’s), conside ing high co ela ion, 286
R≥0.50; mode a e, R o 0.35 o 0.49; and weak, 287
R≤34, which was assessed acco ding o Feeny e 288
al.’s c i e ia [39]. Mo eo e , he co ela ion be ween 289
dimensions o EQ and assessmen scales was ana- 290
lyzed. 291
The esul s o each EQ-5D domain we e a ed om 292
1 (no p oblems) o 3 (ex eme p oblems) and com- 293
pa ed o he scales assessing he same domains. The 294
Tine i scale (gai and balance) unc ional sco e e e s 295
o domain 1 (mobili y) in he EQ-5D; he Ba hel 296
scale sco e (ADL) e e s o domain 2 (sel -ca e); 297
he Law on scale (IADL), o domain 3 (usual ac i - 298
i ies); he GDS (dep ession symp oms), o domain 299
4 (anxie y-dep ession); and he VAS pain scale, o 300
domain 5 (pain). 301
In o de o ela e he quan i a i e scales (Tine i, 302
Ba hel, Law on, GDS, and VAS pain) wi h he EQ- 303
5D domains, we classi ied he alida ed sco es o each 304
scale in o h ee ca ego ies, co esponding o he EQ- 305
5D le els 1 o 3. Thus, o sel -ca e, he dis ibu ion on 306
he Ba hel Index was: le el 1, 65 o 100 poin s; le el 307
Table 1
Measu emen p ope ies o QoL ins umen
P ope y C i e ia
Feasibili y Pe cen age o missing da a (should be <10%)
Pe cen age o compu able da a (should be >95%)
Mean, median, and s anda d de ia ion simila ac oss i ems (15% maximum di e gence)
Accep abili y Asymme y and ku osis should oscilla e be ween –1 and 1
Floo and ceiling e ec (pe cen age o sco es in he lowe and uppe ex emes should be <15%)
In e nal consis ency: C onbach´s alpha (accep able alues ≥0.7)
Reliabili y S abili y o he measu e: ICC (EQ index and EQ VAS, one-way, andom-e ec s model; accep able alues we e
≥0.7)
Con e gence: a) co ela ion be ween EQ index and VAS, and b) co ela ion be ween dimensions o EQ and
assessmen scales
Validi y Di e gence: co ela ion be ween EQ VAS and assessmen scales (should be low; R ≤0.30)
In e nal: R2o wo linea eg essions be ween EQ index and assessmen scales and EQ VAS and assessmen
scales
ICC, in aclass co ela ion coe icien ; EQ index, Eu oQol 5 Dimensions 3 Le els Index; EQ VAS, Eu oQol Visual Analog Scale.
Unco ec ed Au ho P oo
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2, 35 o 60 poin s; and le el 3, 0 o 30 poin s o mobil-308
i y. The Tine i sco es we e ca ego ized as ollows:
309
le el 1 (no p oblems), 20 o 28 poin s; le el 2 (some310
p oblems), 10 o 19 poin s; and le el 3 (ex eme p ob-311
lems), 0 o 9 poin s. Fo anxie y/dep ession, he GDS312
sco es we e ans o med as: le el 1, 0 o 4 poin s;
313
le el 2, 5 o 10 poin s; and le el 3, 11 o 15 poin s.314
Fo usual ac i i ies, Law on sco es we e o de ed as:315
le el 1, 6 o 8 poin s; le el 2, 3 o 5 poin s; and le el 3,316
0 o 2 poin s. Fo pain/discom o , VAS sco es we e
317
dis ibu ed in o: le el 1, 0 o 3 poin s; le el 2, 4 o 7318
poin s; and le el 3, 8 o 10 poin s.319
Di e gen alidi y e e s o he associa ion be ween
320
he scale and o he measu es ha assess di e en 321
cons uc s [40]; only he EQ VAS was analyzed
322
since he EQ index is ob ained om he compu a-323
ion o he dimensions compa able o he assessmen 324
scales. To assess in e nal alidi y, we pe o med
325
wo linea eg essions wi h he EQ index and he326
EQ VAS. In o de o unde s and he ela ionship327
be ween he a iables included and he alue o R2,328
he ca ego ized scales we e included in o he h ee329
le els equi alen o he dimensions o he EQ-5D-3L330
(Table 1).331
S a is ical analysis
332
The a iables a e epo ed as p opo ions333
and/o means and s anda d de ia ion (SD). The334
Kolmogo o -Smi no es was used o assess no -
335
mali y, and he Le ene es was applied o explo e
336
homogenei y o a iances o con inuous a iables
337
(age, MMSE, EQ-5D VAS and EQ-5D index,
338
Ba hel Index, Tine i Index, GDS, Law on Index,339
and VAS pain). The e we e no signi ican ou lie s.340
The da a me he main assump ions o no mali y,341
so he - es o independen samples was used o
342
compa e means. The chi-squa ed es was used o343
compa e ca ego ical a iables (gende ).344
RESULTS345
O he 361 people ini ially e alua ed o eligibil-346
i y, 47.9% (n= 173) we e excluded: 6.9% (n= 12)347
declined o pa icipa e, 81.5% (n= 141) did no mee 348
he selec ion c i e ia, and 11.5% (n= 20) we e no 349
capable o esponding o he i ems on he ques ion-
350
nai e. The inal s udy sample hus comp ised 188351
pa icipan s (52.1%) wi h a p edominance o women352
(64.9%; n= 122). The pa icipan s p esen ed high353
unc ionali y in bo h IADL and gai and balance, as354
Table 2
Baseline pa icipan cha ac e is ics (n= 188)
Va iables Mean (SD) Min Max
Age, y 79.19 (5.18) 70 95
MMSE, poin s (0–30) 21.18 (3.17) 10 24
Ba hel Index, poin s (0–100) 88.48 (17.27) 0 100
Law on Index, poin s (0–8) 6.24 (2.06) 0 8
Tine i Index, poin s (0–28) 21.26 (6.84) 0 28
GDS, poin s (0–15) 3.97 (3.56) 2 15
VAS pain, poin s (0–10) 3.07 (2.86) 0 10
GDS, Ge ia ic Dep ession Scale; MMSE, Mini-Men al S a e
Examina ion; SD, s anda d de ia ion; VAS, isual analog scale.
Fig. 1. Dis ibu ion o esponses on he Eu oQol dimensions.
Table 3
Feasibili y and accep abili y p ope ies o he EQ index and EQ
VAS (n= 188)
EQ index EQ VAS
Mean 0.69 63.8
S anda d de ia ion 0.27∗28.54∗
Median 0.74 70
Asymme y –0.49 –0.76
Ku osis –0.75 –0.23
Ceiling 29.7†14.6†
Floo 5.5 4.8
∗Di e gence >15%; deg e ec >10%.
well as a low le el o dep essi e symp oms and pain 355
(Table 2). 356
The sample showed good HRQoL, as assessed 357
by he EQ-5D, wi h o e 60% o he pa icipan s 358
showing no p oblems in he dimensions o mobil- 359
i y, sel -ca e, usual ac i i ies, o pain. The anxie y 360
sco es showed a la ge p opo ion o pa icipan s wi h 361
some o ex eme p oblems (Fig. 1). Pa icipan s p e- 362
sen ed good QoL sco es on bo h he EQ index and he 363
EQ VAS, wi h mean index and VAS sco es ho e ing 364
a ound 60% o 70% o he maximum possible QoL 365
(Table 3). 366
Unco ec ed Au ho P oo
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e ez-Ros e al. / Quali y o Li e in Olde People wi h Cogni i e Impai men
Psychome ic p ope ies: easibili y and367
accep abili y
368
The e we e ew missing da a, and jus 9.6%
369
(n= 20) o he 208 olde adul s who we e willing o370
pa icipa e we e unable o espond o he ques ion-371
nai e i ems, so easibili y was adequa e. All da a we e
372
compu able.373
A e analyzing he i ems o accep abili y, simi-374
la alues we e obse ed in he mean and median,375
while asymme y and ku osis we e wi hin he ec-
376
ommended bounds. On he con a y, a ceiling e ec 377
was obse ed in bo h EQ index and EQ VAS, and he378
SD di e ged mo e han 15% (Table 3).
379
Psychome ic p ope ies: eliabili y and alidi y380
We ob ained a alue o C onbach’s alpha o 0.69,
381
e y close o he minimum 0.7 accep able alue o 382
analyzing in e nal consis ency as a measu e o elia-
383
bili y. Mo eo e , o assess he s abili y o he measu e,384
he ICC o he EQ index and he EQ VAS was cal-385
cula ed, ob aining a alue o 0.01 (95% con idence
386
in e al [CI] –0.32 o 0.26 p= 0.461), indica ing a387
poo co ela ion.
388
The co ela ion be ween EQ index and EQ VAS389
was R = 0.371, p< 0.001). The co ela ion be ween390
he i e dimensions o he EQ and he co espond-
391
ing assessmen scales (Tine i, Ba hel, Law on, GDS,392
and VAS pain), ca ego ized in o h ee le els as indi-
393
ca ed in he Me hods, was analyzed o de e mine394
he con e gen alidi y. Signi ican co ela ions we e395
ound in all dimensions: he s onges was o anxie y
396
(>0.7), ollowed by usual ac i i ies (>0.6) and pain397
(>0.5) (Table 4).398
To assess he di e gen alidi y, we analyzed he399
co ela ions be ween con inuous alues o he EQ400
VAS and he ge ia ic assessmen scales. As shown401
in Fig. 2, he e we e low, s a is ically signi ican co -
402
ela ions be ween he EQ VAS, bu he Tine i and403
Ba hel Indexes we e mo e han 0.3.
404
Table 4
Con e gen alidi y. Co ela ion be ween Eu oQol 5 Dimensions
and assessmen scales (n= 188)
Eu oQol 5 Comp ehensi e ge ia ic
dimensions assessmen scales
1. Mobili y Tine i Index 0.371∗
2. Sel -ca e Ba hel Index 0.340∗
3. Usual ac i i ies Law on Index 0.628∗
4. Pain VAS pain 0.504∗
5. Anxie y Ge ia ic Dep ession Scale 0.703∗
VAS, isual analog scale; ∗p< 0.001.
Finally, using he EQ index and he EQ VAS as ou - 405
come a iables, we pe o med wo linea eg essions. 406
We included he sco es o he scales ca ego ized in 407
h ee le els and adjus ed o age and sex, as explana- 408
o y a iables. Fo bo h he EQ index and he EQ VAS, 409
he model showed a s a is ically signi ican ela ion- 410
ship, wi h g ea e associa ion and R2 o EQ index 411
han o EQ VAS (EQ index: F = 26.57; p< 0.001; 412
R = 0.691; R2= 0.477; EQ VAS: F = 11.44; p< 0.001; 413
R = 0.555; R2= 0.311). The Ba hel Index (ADL) was 414
he a iable ha was mos s ongly (and nega i ely) 415
co ela ed wi h EQ index, whe eas he Tine i Index 416
(gai and balance) was mos s ongly (and nega i ely) 417
co ela ed wi h EQ VAS (Table 5). 418
DISCUSSION 419
In ecen yea s he e has been an inc ease in 420
he measu emen o HRQoL in people wi h cogni- 421
i e impai men . The e a e many speci ic ools, bu 422
despi e he cu en lack o s anda diza ion on he bes 423
measu emen ins umen , ew s udies ha e analyzed 424
he alidi y o he gene ic HRQoL measu emen ools 425
[17, 18] in o de o be able o compa e esul s wi h 426
o he s udies. The p esen s udy aimed o analyze he 427
measu emen p ope ies o he gene ic EQ-5D scale 428
in communi y-dwelling olde adul s wi h cogni i e 429
impai men . The gene ic scale has adequa e easibil- 430
i y, accep abili y and eliabili y. The alidi y o EQ 431
index was s onge han he EQ VAS. 432
The sample p esen ed a good quali y o li e, as 433
e lec ed by he high pe cen age o pa icipan s wi h- 434
ou p oblems in he dimensions and in he ceiling 435
e ec o he EQ index and EQ VAS al hough i 436
is lowe han o he s udies on communi y-dwelling 437
olde people wi h demen ia [41]. Olde people wi h 438
cogni i e impai men ha e highe HRQoL when hey 439
li e in he communi y compa ed o an ins i u ion. 440
Social ac o s, dependence, and como bidi y a ec 441
his popula ion nega i ely [42]. 442
Feasibili y measu emen p ope ies o EQ-5D can 443
be conside ed accep able. Despi e a gumen s om 444
some au ho s indica ing he need o he use o a 445
p oxy o ca egi e in e en ion in QoL analysis [19], 446
we ob ained a good esponse om he olde adul s, 447
wi h ew missing da a and all da a compu able. This 448
may be due o he ease o use o he scale as well 449
as he s age o cogni i e impai men selec ed in he 450
inclusion c i e ia. 451
Accep abili y was good, bu some aspec s did no 452
me c i e ia such as he ceiling e ec and he di e - 453
Unco ec ed Au ho P oo
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e ez-Ros e al. / Quali y o Li e in Olde People wi h Cogni i e Impai men 7
Fig. 2. Sca e plo be ween he EQ VAS and he Ge ia ic Assessmen scales. A) Tine i Index (0–28: lowe sco es = mo e dependence in
mobili y). B) Ba hel Index (0–100: lowe sco es = mo e dependence in ac i i ies o daily li ing). C) Law on Index (0–8: lowe sco es = mo e
dependence in ins umen al ac i i ies o daily li ing). D) The Ge ia ic Dep ession Scale GDS (0–10: highe sco es = mo e dep ession). E)
The isual analog scale VAS (1–10: highe sco es = mo e pain). *p< 0.001.
Unco ec ed Au ho P oo
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e ez-Ros e al. / Quali y o Li e in Olde People wi h Cogni i e Impai men
Table 5
Mul i a ia e linea eg ession analysis wi h EQ-5D Index and VAS as dependen a iables (n= 188)
EQ index (95% CI) PEQ VAS (95% CI) P
Cons an 0.83 (0.78, 0.88) <0.001 82.87 (76.91,88.82) <0.001
Ba hel –0.16 (–0.26, –0.05) 0.005 –4.4 (–17.13, 8.32) 0.495
Law on –0.06 (–0.15, –0.04) 0.002 –5.54 (–6.30,7.55) 0.859
Tine i –0.07 (–0.13, –0.01) 0.024 –13.14 (–20.39, –5.89) <0.001
VAS –0.12 (–0.16, –0.07) <0.001 –10.44 (–15.74, –5.14) <0.001
GDS –0.13 (–0.018, –0.08) <0.001 –11.60 (–17.64, –5.57) <0.001
CI, con idence in e al; GDS, Ge ia ic Dep ession Scale; VAS, isual analog scale.
gence in he SD. This aspec is simila o se e al454
speci ic scales o elde ly people wi h demen ia,455
whe e esul s on hese poin s ha e also been poo 456
[18]. This may be due o he cha ac e is ics o his
457
pa hology, which impede he co ec collec ion o 458
da a in some s ages.459
In e nal consis ency was limi ed in he analyzed460
sample, as e alua ed in he eliabili y analysis by461
means o he C onbach´s alpha, which showed a mod-
462
e a e alue close o 0.7 and a poo ICC be ween he463
EQ index and EQ VAS. This alue is lowe han mos 464
o he speci ic scales ha analyze HRQoL in olde 465
people wi h cogni i e impai men [18], al hough be -
466
e alues han in o he s udies using he same scale467
and p oxies o he assessmen [16, 23]. This ea-
468
u e could be esponsible o a dec ease in he alues469
ob ained in he gene ic scale.
470
On he o he hand, good alues we e obse ed o 471
cons uc alidi y. The e was a mode a e co ela ion
472
be ween he EQ index and he EQ VAS. This may473
be due o he ac ha he EQ index is he esul o 474
he e ec o he dimensions ha a e mo e s able om
475
one day o he nex , while he EQ VAS [22] is mo e476
sensi i e o change, since i esponds o how people477
a e eeling a he ime o he e alua ion. While his478
aspec may esul in lowe alidi y alues o he EQ479
VAS in olde people wi h cogni i e impai men [16,480
21], some au ho s a gue ha i is a alid measu e o
481
e alua ing in e en ions [43].482
Cu en ly he e is no ool conside ed o be he
483
gold s anda d o assessing HRQoL, and his makes484
i di icul o es he alidi y o he di e en ins u-485
men s a ailable [23, 24]. Compa ing he dimensions
486
o he EQ-5D and he ge ia ic assessmen scales co -487
esponding o each dimension helps us o unde s and488
he alidi y based on scales widely used in he ge i-489
a ic ield. In addi ion, we obse ed g ea e alidi y490
in communi y-dwelling compa ed o ins i u ionalized
491
olde people [21].492
The di e gen alidi y o he EQ VAS and he493
a ing scales was adequa e, indica ing ha he EQ494
VAS is an easily ob ainable complemen a y measu e.
495
The co ela ion ound wi h espec o independence 496
in mobili y and sel -ca e indica e ha hese dimen- 497
sions a e essen ial in he pe cep ion o quali y o 498
li e in olde adul s [44]. Finally, a high R2is 499
obse ed in bo h eg essions (bu highe in he EQ 500
index), sugges ing ha a ing scales could be a good 501
ool o analyze he alidi y o he EQ-5D in his 502
popula ion. 503
Knowing he measu emen p ope ies o he EQ- 504
5D in he communi y-dwelling olde adul s wi h 505
cogni i e impai men could encou age clinicians 506
and decision-make s o use a gene ic scale ha is 507
al eady used in communi y-dwelling olde adul s, 508
enabling he compa ison o in e en ions in di e - 509
en popula ions [45]. The measu emen p ope ies 510
a e accep able, and al hough hey a e lowe han he 511
speci ic ools in some aspec s [17, 18], p o ession- 512
als should bea in mind ha long and di icul - o-use 513
scales could limi he achie emen o esul s in his 514
popula ion [46]. 515
The e a e many s udies on he use o di e en spe- 516
ci ic ools o assessing HRQoL in ins i u ionalized 517
olde people [18], bu he e is less e idence o hose 518
dwelling in he communi y. I is necessa y o ca y 519
ou mul icen e s udies wi h di e en popula ions in 520
addi ion o in ensi ying he s udy acco ding o s ages 521
o se e i y o demen ia. 522
The p esen s udy has some limi a ions. Fi s o 523
all, esul s may be di e en i g oups a e analyzed 524
acco ding o MMSE anges (mode a e o se e e) and 525
pa icipan s’ le el o educa ion has no been ana- 526
lyzed ei he . Se e al measu emen p ope ies we e 527
no analyzed, such as in e obse e alidi y, as his 528
was a sel -adminis e ed ques ionnai e. Likewise, ou 529
esea ch eam op ed no o do a es - e es in o de no 530
o make olde people e u n o he heal h ca e cen e 531
ano he day, e en hough he EQ VAS assesses he 532
pe cei ed heal h s a e in he momen ha he scale is 533
used, and his could a y i comple ed on di e en 534
days. We also did no analyze di e en o ma s o he 535
o m, o example, a digi al ool. Mo eo e , we did no 536
conside pa icipan s’ como bidi ies, ail y, sa cope- 537
Unco ec ed Au ho P oo
P. P ´
e ez-Ros e al. / Quali y o Li e in Olde People wi h Cogni i e Impai men 9
nia, o cohabi a ion a home, which could in e e e538
wi h he esul s.
539
Conclusions540
We ob ained accep able alues on measu emen 541
p ope ies o he EQ-5D in communi y-dwelling542
olde adul s wi h cogni i e impai men . This gene ic
543
scale could be used o assessing HRQoL in his544
olde popula ion in o de o compa e esul s in a non-545
pa hological popula ion. I is necessa y o analyze546
he dimensions and he EQ index since yield be e 547
measu emen p ope ies wi h espec o he EQ VAS.548
ACKNOWLEDGMENTS549
The au ho s would like o hank all o he pa ici-550
pan s in his esea ch, wi hou whom he s udy would551
no ha e been possible, and he Uni e sidad Ca ´
olica
552
de Valencia “San Vicen e M´
a i ” o i s suppo .553
This esea ch ecei ed no ex e nal unding. T ans-
554
la ion and publica ion cos s we e co e ed by he555
Uni e sidad Ca ´
olica San Vicen e M´
a i 556
Au ho s’ disclosu es a ailable online (h ps://
557
www.j-alz.com/manusc ip -disclosu es/20-0806 1).558
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