Objectives: To evaluate application of the Barthel Index (BI) in assessing basic activities of daily living (ADL) of patients with dementia using Rasch analysis. Design: A multi-country cross-sectional study. Setting and Participants: Nineteen long-term care facilities located in China, Japan, South Korea, and Thailand. A total of 644 patients with dementia were included. Methods: Unidimensionality, global and item fit, local dependence, person-item targeting, threshold disordering, and differential item functioning (DIF) were examined. Negative correlations between scores for DIF items and Neuropsychiatric Inventory Nursing Home version (NPI-NH) were evaluated. Results: Item reliability (1.0) and person reliability (.88) were acceptable. The Rasch dimension explained 72.9% of the variance (Eigenvalue = 27), while the first contrast explained 6.6% (Eigenvalue = 2.4). The "mobility" was misfitting to the Rasch model (infit mean square = 1.86). The overall difficulty of the BI exceeded patients' ability (person location = −2.27 logits). The "stairs climbing" and "mobility" showed narrow category thresholds (< 1.4 logits). The location of "controlling bladder" and "toilet use" overlapped. Removing "stairs climbing", collapsing categories with narrow threshold widths in "mobility", and combining "controlling bowel" and "controlling bladder" into one item, improved unidimensionality, and item fit of the scale. Only three items ("grooming", "dressing", and "toilet use") were free from DIF across countries. The scores for "feeding" were negatively related to scores for "disinhibition" (r = −0.46, P < 0.01), and scores for "controlling bowel" were negatively related to scores for "disinhibition" (r = −0.44, P < 0.01), "agitation" (r = −0.32, P < 0.05), and "aggression" (r = −0.27, P < 0.01) in Japanese samples. Conclusions and Implications: The performance of the BI for assessing patients with dementia might be compromised by misfit items, person-item mistargeting, measurement gaps, redundant items, narrow threshold width, and item bias. Mobility ability might not be helpful for determining capability of basic ADL in the patients. Comparisons of BI scores between countries should be undertaken with caution due to

Background Chinese government launched a pilot study on public long-term care insurance (LTCI) recently. Guangzhou is one of the fifteen pilot cities, officially started providing LTCI in August 2017. An in-depth analysis of experimental data from the pilot city may provide suggestions for developing a fair and effective LTCI system. This study aimed to evaluate the LTCI pilot by exploring the characteristics and care needs of claimants, and performance of the assessment tool. Methods A retrospective cross-sectional study in which claims data between July 2018 and March 2019 in the Guangzhou pilot was analyzed. LTCI claimants during the study period were included. The care needs were determined based on claimants’ physical function assessed by the Barthel Index and their medical conditions. Rasch analysis was used to explore the performance of the Barthel Index. Results Among 4810 claimants included, 4582 (95.3%) obtained LTCI benefits. Of these beneficiaries, 4357 (95.1%) were ≧ 60 years old, and 791 (17.3%) had dementia. Among 228 (4.7%) unsuccessful claimants, 22 (0.5%) had dementia. The prevalence of stroke was high in beneficiaries with (38.1%) or without dementia (56.6%), as well as in unsuccessful claimants with (40.9%) or without dementia (52.4%). Beneficiaries without dementia needed more support for basic activities of daily living and nursing care than those with dementia, while beneficiaries with dementia were more likely to be institutionalized. Five (22.7%) unsuccessful claimants with dementia and 48 (23.3%) unsuccessful claimants without dementia were disabled in at least two basic self-care activities. Regarding Barthel Index, Rasch analysis showed threshold disordering in “mobility” and “climbing stairs”, and the narrow interval was observed between all the adjacent categories of the ten items (< 1.4 logits). Conclusions Stroke and dementia were two common reasons for needing long-term care in LTCI claimants. The Barthel Index is not suitable for assessing and dividing LTCI claimants, because of inappropriate items and narrow category responses. A comprehensive assessment and grading system is required, together with needs-led care services. The eligibility should be expanded gradually based on balance finance solutions.

ObjectivesTo investigate differences in behavioral and psychological symptoms of dementia (BPSD) and caregiver distress caused between older adults with dementia living in the community and in nursing homes.DesignA comparative cross-sectional study.Setting and ParticipantsParticipants were recruited from outpatient clinics of a tertiary psychiatric hospital and dementia units of a nursing home in Guangzhou, China.MethodsNeuropsychiatric Inventory was used to assess symptoms and caregiver distress. Dementia severity was determined using the Clinical Dementia Rating.ResultsThis study included 157 community and 112 nursing home residents with dementia. Clinically significant symptoms (item score ≥ 4) were found in 88.5% of the former and 75% of the latter. Caregivers of 79.6% of the former and 26.8% of the latter reported that at least one of these caused them moderate-to-severe distress (distress score ≥ 3). Among the community patients, anxiety was the most frequent “very severe” symptom, while sleep disorders and agitation caused the most frequent “very severe” caregiver distress. After controlling for dementia severity and medication use, family caregiving remained an independent risk predictor for clinically significant symptoms and moderate-to-severe caregiver distress. The prediction of caregiver distress based on symptom scores varied across caregiver types and individual symptoms (R2 0.36–0.82). Group differences in clinically significant symptoms and moderate-to-severe caregiver distress showed at the stage of moderate-to-severe dementia.Conclusions and ImplicationsTailored management strategies to relieve family caregivers’ BPSD-induced distress are needed, especially at the stage of moderate-to-severe dementia. An effective service system should be established for supporting family caregivers to cope with BPSD.