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Alzheimer's Disease Cooperative Study Prevention Instrument Project Assessing Resource Use and Volunteer and Paid Work in Healthy Elders: A Longitudinal Study

2014; Wiley; Volume: 62; Issue: 5 Linguagem: Inglês

10.1111/jgs.12816

1532-5415

Carolyn W. Zhu, Mary Sano, Steven H. Ferris, Peter J. Whitehouse, Marian B. Patterson, Douglas Galasko, Lon S. Schneider, Paul Aisen,

Health disparities and outcomes

Therapy for dementia is rapidly shifting to prevention as recognition grows that interventions at the time of symptoms may be “too late.”1 A major challenge in designing prevention trials is the measurement of subtle changes at presymptomatic stages of the disease. Currently available instruments are designed for individuals with dementia and may not be sufficiently sensitive to measure changes in asymptomatic individuals. To fill this gap, the Alzheimer's Disease Cooperative Study (ADCS) conducted a 4-year simulated prevention trial, the Prevention Instrument (PI) Study, to develop instruments capable of capturing changes that occur as elderly adults transition from normal aging to the earliest stages of cognitive and functional impairment.2 Among these instruments is the Resource Use Inventory (RUI), designed to assess health-related resource use (e.g., hospitalizations, doctor visits, informal care). A unique aspect of the RUI is the addition of items that assess subjects' participation in productive activities. Specifically, the RUI asks about subjects' participation in volunteer and paid work and, for those who participated, hours of participation. An earlier study demonstrated that the RUI was sensitive to demographic and clinical characteristics in an elderly population without dementia. Feasibility, reliability, and efficiency of administering the RUI at home have also been reported.3 Active and socially integrated lifestyles have been shown to be associated with better cognitive status,4-6 but whether subtle differences in cognition affect participation in productive activities, such as volunteerism and participation in the workforce, is yet to be documented. As retirement age is delayed and demand for volunteerism and continued participation in the workforce grows, preventing cognitive impairment and maintaining paid or volunteer work efforts may become an increasingly important component of the economics of cognitive impairment. The current study used data from the PI Study to examine participation in volunteer and paid work over 4 years. Subjects were recruited from 39 ADCS sites in the United States. At study entry, subjects were aged 75 and older, living in the community, without dementia, in good physical and mental health, with no exclusionary medical conditions, and not taking any excluded medications. Cognitively normal subjects (Clinical Dementia Rating (CDR) = 0) and subjects with mild cognitive impairment (MCI, CDR = 0.5) were included and followed for 4 years, with annual in-person follow-up assessment; 61.2% of the subjects completed the 4-year study. The longitudinal cohort included 642 subjects and their study partners, providing a total of 2,592 observations. Mean age at baseline was 80, 42% were male, 56% were married, and subjects had an average of 15 years of education. Because of the requirement that each site achieve at least 20% minority enrollment, 23% of the subjects were nonwhite. Average CDR Sum of Boxes (SOB) score was 0.3 ± 0.5; 62% had a CDR-SOB of 0. Mean modified Mini-Mental State Examination (mMMS) score was 95 ± 3.6, and mean ADCS activity of daily living inventory (ADL) was 49 ± 4.1. Subjects showed minimal symptoms of depression (mean Geriatric Depression Scale score 1.5 ± 2.0). Random-effects logistic regression analyses were used to examine the relationships between rates of participation in volunteering and paid work and baseline cognition (CDR = 0.5 vs 0). Control variables included clinical characteristics (baseline ADCS-ADL, current mMMS, number of comorbidities), demographic characteristics (subject and study partner age, sex, race and ethnicity, marital status, education), and subject and study partner relationship and living arrangement.7 During the study period, participation in volunteer and paid work decreased progressively, from 52% to 45% and 14% to 10%, respectively (Figure 1). Over time, difference in the rate of volunteering according to baseline cognition was sustained, with higher participation rate at every assessment in subjects with a CDR of 0 than in those with a CDR of 0.5. These results suggest that, in addition to examining health-related resource use, there may be important changes in volunteering and paid work in the transition from normal cognition to impairment. As retirement age increases and demand on volunteer and paid work time grows, this work effort may become an increasingly important component of the economics of cognitive impairment. These results also suggest that volunteer work be included as a potential real-world outcome in future prevention trials, supplementing current measures of cognition, function, and global decline. Results of this study underscore the need to consider multiple domains and endpoints in evaluating interventions aimed at preventing cognitive and functional decline in elderly adults. Data from this study can aid in the design of future trials. The authors thank the following, who participated in the trial: Oregon Health & Science University, PI Jeff Kaye; University of Southern California, PI Lon Schneider; University of California, San Diego, PI Adam Fleisher; University of Michigan, Ann Arbor, Raymond Scott Turner; Mayo Clinic, Rochester, PI Ron Petersen; University of Washington (SIBCR), PI Murray Raskind; Baylor College of Medicine, PI Rachelle Doody; Columbia University, PI Karen Bell; University of Alabama, Birmingham, PI Ed Zamrini; Mount Sinai School of Medicine, PI Mary Sano; Rush University Medical Center, PI David Bennett; Wien Center for Clinical Research, PI Raj Duara; Washington University, St. Louis, PI James Galvin; New York University Medical Center, PI Steve Ferris; Duke University Medical Center, PI Murali Doraiswamy; University of Pennsylvania, PI Chris Clark; University of Kentucky, PI Greg Jicha; University of Pittsburgh, PI Steve DeKosky; University of Rochester Medical Center, PI Pierre Tariot; University of California, Irvine, PI Carl Cotman; University of Texas, Southwestern MC, PI Ramon Diaz-Arrastia; Emory University, PI Allan Levey; University of California, Los Angeles, PI Jeff Cummings; Mayo Clinic, Jacksonville, PI Neil Graff-Radford; Indiana University, PI Martin Farlow; Memorial Hospital Rhode Island, Brown University, PI Brian Ott; Yale University, PI Chris Van Dyck; University of California, Davis, PI Charles DeCarli; SUNY Stony Brook, PI Mark Sedler; Arizona Health Sciences Center, PI Geoffrey Ahern; The Memory Clinic at Southwestern Vermont Medical Center, PI Paul Soloman; Barrow Neurology; PI Jiong Shi; Northwestern University, PI Marek-Marsel Mesulam; Medical University of South Carolina, PI Jocobo Mintzer; Premiere Research Institute, PI Carl Sadowsky; Georgetown University, PI Paul Aisen; Brigham and Women's Hospital, PI Reisa Sperling; Boston University, PI Robert Green; Howard University, PI Thomas Obisesan; Case Western Reserve University, PI Alex Auchus; Neurological Care of CNY, PI Smita Kittur; MD Clinical, PI Kerri Wilks; Stanford, PI Jerome Yesavage; SUNY Downstate, PI Howard Crystal. Conflict of Interest: Dr. Sano serves on a scientific advisory board for Medivation, Inc. and as a consultant for Bayer Schering Pharma, Bristol-Meyers Squibb, Elan Corporation, Genentech, Inc., Medivation, Inc., Medpace Inc., Pfizer Inc, Janssen, Takeda Pharmaceutical Company Limited, and United Biosource Corporation and receives research support from the National Institutes of Health (NIA/National Center for Research Resources). Dr. Ferris serves as a scientific consultant for Accera, Baxter, Bristol-Myers Squibb, Cebria, Eisai, Eli Lilly, Janssen Alzheimer's Immunotherapy, Lupin, MedAvante, Merck, Neuronix, Merz, Targacept, Lundbeck, Pfizer, and United Biosource and receives research support from the NIH (NIA) and from Janssen Alzheimer's Immunotherapy, Bristol Myers Squibb, Merck, GE Healthcare, Neuronix, Roche, and Takeda. Dr. Galasko serves as a Consultant for Elan Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Pfizer, Inc, Balance Pharmaceuticals, Inc, and receives research funding from the NIH (NIA), California Institute for Regenerative Medicine, Alzheimer's Drug Discovery Foundation, and Michael J. Fox Foundation. Dr. Schneider has received grants from the Alzheimer's Association, NIH, State of California, California Institute for Regenerative Medicine, AstraZeneca, Baxter, Johnson & Johnson, Eli Lilly, Lundbeck, Novartis, Pfizer, Roche, and Tau Rx and has served as a consultant to Abbvie, AC Immune, Allon, AstraZeneca, Baxter, Biogen Idec, Chiesi, Elan, Eli Lilly, En Vivo, GlaxoSmithKline, Ipsen, Johnson & Johnson, Lundbeck, MedAvante, Merck, Novartis, Roche, Servier, Takeda, Targacept, Tau Rx, Toyama, and Zinfandel. The work was supported by National Institute on Aging (NIA) Grants P50 AG005138 and U01AG10483. Author Contributions: Zhu, Sano: drafting and revision of manuscript, study concept and design, analysis and interpretation of data. Ferris: revision of manuscript, study concept and design, interpretation of data. Whitehouse: design, review, commenting on manuscript. Patterson, Galasko: revision of manuscript. Schneider: study design and conduct, interpretation of data, revision of manuscript. Aisen: drafting and revision of manuscript, study concept and design, analysis and interpretation of data. Sponsor's Role: None.