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Meaningful treatment outcomes in Alzheimer’s disease
  1. A Burns
  1. Department of Old Age Psychiatry, University of Manchester, Education & Research Centre, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK
  1. Correspondence to:
 Professor A S Burns;
 a_burns{at}man.ac.uk

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Goal Attainment Scaling allows for problems identified by patients and carers to be the focus of treatment

The explosion of interest in clinical trials for the treatment of the symptoms of Alzheimer’s disease has resulted in an industry developing instruments, which assess the disorder and the changes that can occur as a result of interventions.1 The ability to quantify phenomena is an essential prerequisite to measure the effects of any treatments.

The questioning of the relevance of a purely cognitive approach to monitoring change in Alzheimer’s disease—that is, the understandable doubt as to the clinical relevance of, say, remembering eight as opposed to four of a list of 12 words—led to the development of global assessment scales, which reflect the myriad expressions of the disease. Originally they were uncomplicated, their comparative simplicity was their strength, rating patients as improved, the same, or worse, on a seven point scale.2,3 The rationale was that if a clinician noticed an improvement, then that in itself was significant. Their ability to capture changes in cognitive function, improvements in behavioural and psychological symptoms, and maintenance of daily functioning in conjunction with caregiver reports, attest to their strength.

In the paper by Rockwood et al (this issue, pp 500–7),4 the beneficial effects of treatment are further explored using a technique called Goal Attainment Scaling (GAS). GAS is similar to global assessments, but measures individual problems identified by patients and carers, elicited by an open ended introductory question.5 Zero is taken as the baseline on a five point scale and follow up captures symptoms which are a lot better (+2), a little better (+1), no change (0), a little worse (−1), and a lot worse (−2). Thus, attention is concentrated on specific problems identified by patients and their carers which become the goals of treatment. In a study of 108 patients with mild to moderate Alzheimer’s disease, patients and carers identified a mean of nine goals per subject compared to three identified by their doctors. Patients and carers were particularly likely to value leisure activities and social interaction and they also show a consistent improvement across all goals. For physician ratings, some goals improved and others deteriorated. There was a modest, correlation between GAS scores, a global assessment, and cognitive function.

GAS represents a novel way of measuring meaningful outcomes for patients and carers in Alzheimer’s disease, but there is no reason to think it would be any different for other types of dementia. Patients’ expectations of treatment and their aspirations for improvement can now be documented. The technique helps us to challenge how we should measure the effects of interventions in dementia, puts the patient and their carer at the forefront of determining benefits, and also helps to challenge our assumption that every aspect of a patient’s illness needs to improve for that treatment to be regarded as successful.

Goal Attainment Scaling allows for problems identified by patients and carers to be the focus of treatment

REFERENCES

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Footnotes

  • Competing interests: AB receives honoria from parmaceutical companies involved in the development of drugs for people with Alzheimer’s disease

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