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Experimental Aging Research:

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Confirmatory Factor Analysis

of the Quality of Life in
Alzheimer’s Disease Scale
in Patients with Alzheimer’s
Disease
a b
María Gómez-Gallego , Juan Gomez-García &
c
Manuel Ato-García
a
Department of Neuroscience, Catholic University
of Murcia, Campus of Jerónimos, Murcia, Spain
b
Department of Quantitative Methods, University of
Murcia, Campus of Espinardo, Murcia, Spain
c
Department of Psychobiology, University of Murcia,
Campus of Espinardo, Murcia, Spain
Published online: 30 Apr 2014.

To cite this article: María Gómez-Gallego, Juan Gomez-García & Manuel Ato-García
(2014) Confirmatory Factor Analysis of the Quality of Life in Alzheimer’s Disease Scale
in Patients with Alzheimer’s Disease, Experimental Aging Research: An International
Journal Devoted to the Scientific Study of the Aging Process, 40:3, 266-279, DOI:
10.1080/0361073X.2014.896664

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 Experimental Aging Research, 40: 266–279, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0361-073X print/1096-4657 online
DOI: 10.1080/0361073X.2014.896664

CONFIRMATORY FACTOR ANALYSIS OF THE QUALITY OF

LIFE IN ALZHEIMER’S DISEASE SCALE IN PATIENTS
WITH ALZHEIMER’S DISEASE

María Gómez-Gallego
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Department of Neuroscience, Catholic University of Murcia, Campus of

Jerónimos, Murcia, Spain

Juan Gomez-García

Department of Quantitative Methods, University of Murcia, Campus of

Espinardo, Murcia, Spain

Manuel Ato-García

Department of Psychobiology, University of Murcia, Campus of Espinardo,

Murcia, Spain

Background/Study Context: Quality of life (QoL) has become an impor-

tant outcome measure in clinical trials for Alzheimer’s disease (AD). The
Quality of Life in Alzheimer’s Disease (QoL-AD) Scale is widely used for
assessing QoL of patients with AD. This research aims to determine the
factor structure of the QoL-AD Scale in AD patients.
Methods: One hundred thirty-nine patients with mild-to-moderate AD
were administered the QoL-AD Scale. Based on the model proposed for
healthy people, confirmatory factor models were built using modification
indices and residual analysis to improve the model fit.
Results: Confirmatory factor analysis indicated poor fit for both the
initial model and the single-factor model. Two models showed a good fit: a
three-factor model (perceived health, perceived environment and perceived

Received 19 December 2012; accepted 21 May 2013.

Address correspondence to María Gómez-Gallego, Neuroscience, Catholic University of
Murcia, Campus of Jerónimos, 135 Murcia, Spain, 30107. E-mail: mgomezg@um.es
 Factor Structure of the QoL-AD Scale in AD Patients 267

functional ability) and a two-factor model (perceived physical health and

perceived psychological health). Because no differences in fit were found
between both models, the authors proposed the more parsimonious solu-
tion as the best model.
Conclusion: These results provide evidence supporting the construct
validity of the QoL-AD Scale. This instrument seems to measure the
perception of two related constructs (behavioral competence and environ-
ment) and could be used together with instruments measuring psycholog-
ical well-being and the perception of health.

Over the past 20 years, the use of quality of life (QoL) measures in
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dementia has increased in both medical practice and research (Rabins,

2007). Different approaches have been used to assess patients’ QoL: self-
reports, proxy reports, and observational measures (Logsdon, Gibbons,
McCurry, & Teri, 2002; Vogel, Bhattacharya, Waldorff, & Waldemar,
2012). Several studies have shown that in the early stages, dementia
patients can give reliable and valid reports about their QoL (Buckley et al.,
2012; Gómez-Gallego, Gómez-Amor, & Gómez-García, 2012; Logsdon
et al., 2002). Because QoL has an important subjective component, self-
report measures are preferred except for advanced stages (Brod, Steward,
Sands, & Walton, 1999).
The Quality of Life in Alzheimer’s Disease (QoL-AD) Scale has been
widely used with dementia patients due to its ease and rapidity of adminis-
tration. This scale is also recommended because of its good psychometric
properties when administered to both patients and proxies in different
cultural settings (Gomez-Gallego et al., 2012; Lin et al., 2008; Logsdon
et al., 2002; Mougias, Politis, Lyketsos, & Mavreas, 2011). The QoL-
AD Scale has 13 items referring to domains included in the Lawton QoL
model, which are scored on a 4-point Likert scale: poor, fair, good, and
excellent. The overall score is computed by summing item scores, so
it could be interpreted as a global measure of the domain “perceived
QoL” (Lawton, 1991). As the original scale was intended for ambulatory
patients, modified versions were constructed for patients living in residen-
tial care facilities (Gómez-Gallego et al., 2012; Sloane et al., 2005). The
studies of validation of the QoL-AD Scale have included consistency and
stability tests to assess reliability, and also correlation analyses to assess
convergent validity (Gómez-Gallego et al., 2012; Logsdon et al., 2002;
Thorgrimsen et al., 2003). However, few studies have analyzed the con-
struct validity of this scale. Construct validity is an essential psychometric
property that refers to the extent to which test scores represent the hypo-
thetical construct of interest (Cronbach & Meehl, 1955). In an exploratory
factor analysis of the original version, four principal components with
 268 M. Gómez-Gallego et al.

eigenvalue exceeding 1 were found (Thorgrimsen et al., 2003). However,

the researchers assumed the existence of a single factor due to the pat-
tern of loading of the items and the percentage of the variance explained
by the first component. Applying the maximum likelihood method and
oblimin rotation to a 15-item version, Edelman, Fulton, Kuhn, and Chang
(2005) provided evidence of the existence of two important factors that
moderately correlated to each other. A recent study (Gomez-Gallego et al.,
2012) suggested a three-factor solution, as only three items cross-loaded
on more than one factor. Only a single study has used the confirmatory
factorial analysis (CFA) technique to explore the latent structure of the
QoL-AD Scale (Revell, Caskie, Willis, & Schaie, 2009). CFA is consid-
ered the best method for evaluating construct validity because it allows
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explicit hypothesis testing. In a sample of 653 nondemented older adults,

the best fit was obtained for a three-factor solution (physical, social, and
psychological well-being domains), with weak invariance across age group
and gender (Revell et al., 2009). The suggested model supports the validity
of the QoL-AD Scale, since it is in agreement with the multidimensional
model of QoL (Lawton, 1991). However, notable differences are likely
to exist between cognitively impaired and cognitively intact people when
assessing their QoL. Considering that the QoL-AD Scale was designed to
measure the QoL of AD patients, the knowledge of its internal structure
in these subjects is especially necessary. The objective of this study is to
establish the factorial structure of the QoL-AD Scale in patients with AD.
The results are compared with those previously reported for the original
version in healthy people (Revell et al., 2009).

METHODS

Subjects

The sample was recruited from psychogeriatric clinics, day hospitals, and
day care centers. Patients had received diagnosis of probable AD according
to the criteria of the National Institute of Neurological and Communicative
Disease and Stroke and the Alzheimer’s Disease and Related Disorders
Association (McKhann et al., 1984). Dementia severity was rated with
the Global Deterioration Scale (GDS) (Reisberg, Politis, Lyketsos, &
Mavreas, 1982) and Mini-Mental State Examination (MMSE) (Folstein,
Folstein, & McHugh, 1975). Only patients with GDS score of 3–5 and
MMSE score higher than 11 were recruited because the psychometric suit-
ability of the QoL-AD Scale for more severely impaired patients has not
been established. MMSE scores of 10 or below indicate severe dementia,
whereas scores of 11–20 indicate moderate dementia. This procedure also
 Factor Structure of the QoL-AD Scale in AD Patients 269

allows working with a heterogeneous sample, as it is recommendable for

factor analysis (Gorsuch, 1997). Both patients and their respective prox-
ies were informed about the details of the study and gave consent to
participate. This study was approved by the Bioethics Committee of the
University of Murcia.
The final sample consisted of 139 patients whose average age was 72.7,
with a standard deviation (SD) of 6.61 (range = 65–87). Of these 78 were
women, the mean QoL-AD score was 36.75 (SD = 5.2, range = 27–45).
GDS was 3 in 23 cases, 4 in 81 cases, and 5 in 35 cases. The mean of
MMSE score was 18.5 (SD = 4.3, range = 13–27), indicative of moderate
dementia. All the patients were administered the Spanish version of the
QoL-AD Scale (Gómez-Gallego et al., 2012).
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Measures

In this study, the Spanish version of the QoL-AD Scale was used
(Appendix). This scale consists of 13 items ordered like the original instru-
ment (Logsdon et al., 2002). As Edelman et al. did, Items 7 “marriage”
and 12 “money” were replaced by items “people who live with” and “abil-
ity to decide,” respectively. Contrary to what these authors did, we did
not add any other item. Like the original version, items are scored on
a 4-point multiple-choice options and range of the total score is 13–52.
The scale was translated into Spanish by two professional translators,
who finally synthesized the two versions. Then, this version was trans-
lated into English to ensure that the wording of the Spanish items reflected
the meaning of the original version items. An expert committee (neurolo-
gist, geriatrician, and psychologist) reviewed the final version to check for
content validity.
The Spanish version of the QoL-AD Scale has good internal consis-
tency (Cronbach’s alpha coefficient = .85,) and good test-retest reliability
(intraclass correlation = .87), similarly to those reported by Logsdon et al
(2002). Likewise, our version showed strong convergent validity, since it
was highly correlated to measures of QoL, depression, functional state,
and neuropsychiatric symptoms (Gomez-Gallego et al., 2012).

Statistical Analyses

Starting from a model similar to that previously obtained in healthy people

(Revell et al., 2009) and using modification indices procedures and analy-
sis of residuals, we collected a set of different relevant models to find the
best structure of the QoL-AD Scale. In the original Revell et al.’s study,
four items were hypothesized to load on Factor 1 (V1, V2, V10, and V11),
 270 M. Gómez-Gallego et al.

five items were hypothesized to load on Factor 2 (V4, V6, V7, V8, and
V12), and five items were hypothesized to load on Factor 3 (V3, V5, V9,
V11, and V13).
Although Likert-scaled items are ordinal variables, they are currently
treated as continuous variables in many studies. This procedure is not
statistically risky with items having five or more categories (Zumbo &
Zimmerman, 1993). QoL-AD items have four levels that could not be
equidistant, since only one item can receive a below-average rating and
results could be biased in favor of a positive outcome. Thus, in this study,
QoL-AD items have been treated as ordinal variables. Statistical analysis
of ordinal categorical variables assumes that they are categorized versions
of hypothetical latent variables that are truly continuous and multivariate
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normally distributed (Bentler, 2005; Byrne, 2006). Hence, the correlation

between categorical ordinal variables can be estimated by polychoric cor-
relation coefficients. The modeling of categorical data was done using EQS
6.1. This software computes a matrix of polychoric correlations with a
weight matrix to be used in the second step of estimation. With small sam-
ple sizes (N = 100–150), the recommended procedure is a robust method
of maximum likelihood (Bentler, 2005; Byrne, 2006; Flora & Curran,
2004) that can be used unless normality of the underlying scales is severely
violated (Mardia’s multivariate kurtosis >50; Mardia, 1970), which is not
the case in our sample (Mardia’s multivariate kurtosis = 3.93, p < .01).
A corrected measure of χ 2 and F test is proposed with this procedure:
Yuan-Bentler (Y-B) χ 2 . Although, residual-based statistics are generally
sensitive to sample size, Y-B χ 2 could be used with modest sample (Yuan
& Bentler, 1998).

Description of Model Fit

The model fit was evaluated using the χ 2 statistic, the comparative fit
index (CFI), the Tucker-Lewis index (TLI), the incremental fit index (IFI),
the root mean square of approximation (RMSA), and the standardized
root mean square residual (SRMS). The χ 2 statistic evaluates “the mag-
nitude of discrepancy between the sample and fitted covariances matrices”
(Hu & Bentler, 1999). A nonsignificant χ 2 suggests an adequate fit of
the hypothesized model. Relative indices (IFI and TLI) compare a chi-
square for the model tested to one from an independence model (or null
model). Like IFI and TLI, CFI assumes that all latent variables are uncor-
related (independence model) and compares the sample covariance matrix
with this null model (Bentler, 1990). However, CFI considers sample size
and performs well even in small samples. CFI, TLI, and IFI values above
.95 are indicative of good fit (Hu & Bentler, 1999; Schumacker & Lomax,
2004). RMSEA is an index useful for correcting for parsimony, based on
 Factor Structure of the QoL-AD Scale in AD Patients 271

noncentral χ 2 distribution (Steiger & Lind, 1980). An RMSEA ≤.06 rep-

resents good fit, and an RMSEA ≤.10 yields acceptable fit (Hu & Bentler,
1999; MacCallum, Browne, & Cai, 2006). SRMR can be interpreted as the
average discrepancy between the correlations observed in the input data
and the correlations predicted by the model (Brown, 2006). An SRMR
≤.08 is generally considered a good fit, and an SRMR <.10 represents an
acceptable fit (Hu & Bentler, 1999). The Akaike’s information criterion
(AIC) (Akaike, 1987) and the consistent AIC (CAIC) (Bozdogan, 1987)
were used for comparisons across several plausible models where their
lowest values indicate the best fitting model. The AIC is defined as AIC =
−2 log L + 2p; being L the likelihood and p the number of degrees of free-
dom (Akaike, 1987). The CAIC (Bozdogan, 1987) is a derivative of the
AIC that adjusts the AIC for sample size effects and is defined as CAIC =
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−2 log L + p(log(n) +1).

Finally, analyses on a factor level were conducted for the models that fit
the data well. For each factor, mean and SD were calculated as well as floor
(proportion of patients with lowest factor scores) and ceiling (proportion
of patients with highest factor scores) effects. The internal consistency of
each factor was calculated using Cronbach’s alpha coefficient.

RESULTS

Model I

Revell et al.’s three-factor model was essentially replicated in our mod-

erately demented patient sample data using the Spanish version of the
QoL-AD Scale. However, we obtained an alternative two-factor model,
which provides a better fit. Robust residual-based statistic Y-B χ 2 was non-
significant, Y-B F(61.41) was significant, and both RMSEA and SRMR
indices were out of recommendable limits (see Table 2). In a thorough
inspection of results, we observed that V11 presented aberrant loadings on
Factors 1 (F1) and 3 (F3). Besides, V12 (ability to decide), an item differ-
ing from the original version, reached a nonsignificant loading on Factor
2 (F2). Moreover, F1 and F3 were strongly correlated (r = .968). The
distribution of correlation residuals was symmetric, with residual values
clustered around the zero point. Nevertheless, there was some indication
of misfit, with more than 30% of residual values greater than .10.

Model II

Some modifications of the Model I structure were necessary to fit the data
adequately. Initially, we systematically removed nonsignificant paths and
 272 M. Gómez-Gallego et al.

items. Removing the path from F1 to V11 caused only a small improve-
ment in fit indices (Y-B χ 2 (65) = 84.677, p = .029; F(65, 37) = 3.528, p =
.000; CFI = .957; TLI = .946; IFI = .958; RMSEA = .081 [.052–.107]).
Moreover, 25% of residual values were higher than .10. The deletion of
the path from F3 to V11 led to worse fit to the data than the former.
Then, we used the modification indices to improve the model fit. Firstly,
we introduced the path from F3 to V12 and deleted the path from F2 to
V12 because it was not found significant. Fit indices indicated that the
Model II (Table 2) provided a better fit to the data, with nonsignificant
robust measures (Y-B χ 2 (62) = 68.01, p = .280; Y-B F(62, 40) = 1.36,
p = .152) and all criteria and indices inside the limits. However, more than
20% of correlation residuals were higher than .10. The correlation between
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F1 and F3 were still very high too (Table 1).

Model III

Following the modification indices, we introduced the path from F1 to V3

(Table 2), which resulted in a substantial improvement in fit (Y-B χ 2 (62) =
69.284, p = .245; CFI = .981; TLI = .976; RMSEA = .054; 20% of resid-
uals >.10). Correlation between F1 and F3 decreased but it was still high.
This suggested the need to test the hypothesis of a two-factor model, com-
bining F1 with F3 (Model IV, Table 1). The mean and SD of the items
of Factors 1, 2, and 3 were 2.258 (SD = 0.848), 3.029 (SD = 0.744),
and 2.173 (SD = 0.858), respectively. Some floor effect was found for F1
(10%) but ceiling effect was not apparent for this factor (1.4%). We did not
find floor or ceiling effects for F2 (1.4% and 3.6%, respectively) and F3
(2.1% and 1.4%, respectively). Internal consistency (Cronbach’s α coeffi-
cient) was .788 for F1, .518 for F2, and .709 for F3. The value of the model
AIC was −50.445 and model CAIC was −275.193.

Model IV

This model reached also an acceptable fit, with fit indices similar to those
of Model III (Table 2). The mean score was 2.222 (SD = 0.867) for F1 and
3.029 (SD = 0.744) for F2. Neither floor nor ceiling effect was found for
F1 (2.1% and 1.4%, respectively) and for F2 (1.4% and 4.3%, respec-
tively). Cronbach’s α coefficient was .856 for F1 and .518 for F2. The
model values of AIC and CAIC were −36.845 and −268.843, respec-
tively. The comparison between Models III and IV showed that there were
no significant differences between them (χ 2 (2) = 3.28, p = .194).
 Downloaded by [193.147.25.67] at 03:32 28 October 2014

Table 1. Confirmatory factor analysis solution for all models of the QoL-AD Scale
Model I Model II Model III Model IV Model V

Items F1 F2 F3 F1 F2 F3 F1 F2 F3 F1 F2 F1

1 Physical health .71 .69 .70 .67 .65

2 Energy .71 .69 .71 .67 .66
3 Mood .80 .79 .82 .80 .79
4 Living situation .40 .41 .43 .43 .23∗
5 Memory .35 .36 .35 .36 .36
6 Family .68 .72 .73 .73 .39
7 People who live with .54 .55 .56 .56 .24∗
8 Friends .73 .73 .71 .71 .52
9 Self as a whole .77 .76 .77 .76 .76
10 Ability to do chores .76 .78 .76 .78 .77
11 Ability to do things for fun −.48 1.17 .72 .72 .73 .73
12 Ability to make decisions .38∗ .55 .54 .55 .55
Factor Structure of the QoL-AD Scale in AD Patients

13 Life as a whole .70 .69 .70 .68 .70

Correlations
F1
F2 .49 .42 .38 .53
F3 .97 .64 .99 .59 .86 .59

Note. Factor loadings are standardized regression coefficients. All loadings except marked with ∗ were significant at p < .01. F1 =
Factor 1; F2 = Factor 2; F3 = Factor 3.
273
 274 M. Gómez-Gallego et al.

Table 2. Goodness of fit of the models

RMSEA
Models Y-B χ 2 Y-B F (df ) CFI TLI IFI SRMR (90% CI)

I 79.86 2.63 (61, 41) .955 .966 .956 .103 .083

p> p < .001 (.055–.112)
.050
II 68.01 1.36 (62, 40) .973 .966 .974 .077 .064
p= p = .152 (.027–.093)
.280
III 67.85 1.35 (62, 40) .988 .985 .988 .060 .048
p= p = .158 (.000–.077)
.285
IV 71.13 1.45 (64, 38) .971 .976 .972 .065 .063
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p= p = .110 (.030–.092)
.252
V 75.88 1.77 (65, 37) .926 .911 .927 .081 .106
p= p = .031 (.079–.129)
.168

Note. Y-B = Yuan-Bentler; df = degrees of freedom; CI = confidence interval.

Model V

Finally, a unifactorial solution (Model V, Table 1) was also tested. All the
fit indices indicated a poor model fit (Table 2).

DISCUSSION

In this study, we have established the factorial structure of the QoL-AD

Scale in AD patients, which are the target population for this scale. In addi-
tion, we were interested in knowing whether the hypothesized model for
the healthy people (Revell et al., 2009) would be replicable in cognitive
impaired patients.
According to our results, the solution found in healthy people might
not properly represent the factorial structure of the QoL-AD Scale in
patients (Revell et al., 2009). After some modifications, model fit improved
notably. Taking into consideration the multifactorial character of the con-
struct of QoL, Model III could be proposed as the best solution. Its three
factors reflect the domains of perceived QoL: functional ability, health,
and environment. In contrast to solution found by Revell et al. (2009),
we did not find a psychological well-being domain. In our data, Item 3
(mood) clearly saturates Factor 1 together with other items referred to
health. We think that Factor 3 is more related to functional status than
 Factor Structure of the QoL-AD Scale in AD Patients 275

to mood, as it was saturated by ability-related items (9, 10, and 11). Item
5 (memory), as a previous study found, had low standardized loadings on
Factor 3 (Revell et al., 2009). This could be because memory problems are
related to disability in AD, but they are not a major source of it, opposed
to executive dysfunction (Cahn-Weiner et al., 2007).
Some changes in the goodness of fit were expected to occur for mod-
els with lower number of factors. In fact, all the fit indices plus AIC and
CAIC were better for Model III than for Model IV. However, chi-square
statistics showed that there were no significant differences between mod-
els. Model IV shows good fit and is more parsimonious than Model III.
Indeed, Factor 1 combines all items of the factors “Perceived functional
ability” and “Perceived health.” This factor called “Perceived behavioral
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competence” has an explanatory power of 73%. Although the single-factor

solution (Model I) did not adequately fit the data, we cannot exclude
the existence of an underlying general factor, as suggested in a previous
exploratory study (Thorgrimsen et al., 2003). In spite of it, our results sug-
gest that the two-factor solution provides the best representation of the
data. The internal consistency was good for “Behavioral competence” but
only moderate for the factor “Perceived environment.” This allows inter-
pretation of the scores of the two different subscales, but also consideration
of a global score.
The main reason for the discrepancy between the model of Revell et al.
(2009) and the one proposed in this paper is likely to be the clinical
differences in the samples. Our sample was composed of community-
dwelling AD patients having moderate disability for daily living activities.
This explained the higher relevance of behavioral domain in the model.
Cognitive impairment of our sample could have also had an influence on
the number of factors obtained. As Revell et al. (2009) postulated, sim-
ilarly to the decrease in factors found in late adulthood in intelligence
tests (Balinsky, 1941), it could be observed a decrease in factors in other
psychological variables in dementia patients. Psychological well-being
has been considered as the result of perceived QoL by some researchers
(Jonker, Gerritsen, Bosboom, & Van Der Steen, 2004). Thus, we found
that items related to psychological health or emotional well-being (mood
and global items: self as a whole and life as a whole) highly correlate with
items of health and ability.
Methodological issues could also contribute to these somewhat contro-
versial results. The correlation between any two items is affected by both
their substantive and their statistical distributions similarity (Bernstein,
Garbin, & Teng, 1988); therefore, item-level factor analyses using tra-
ditional methods (Person’s matrices) are likely to produce at least some
factors based only on item distribution similarity (Nunnaly & Bermstein,
1994). We do not find large differences in mean scores between factors;
 276 M. Gómez-Gallego et al.

this supports that factors could be attributed to substantive differences and

not simply to statistical causes.
Although we cannot exclude the possibility that using different versions
of the QoL-AD Scale may have influenced the results, we noted that of the
two items (9 and 12) differing between versions, only Item 12 (money
versus ability to make decisions) saturated a different factor in Model III.
In older people, money is related to the ability to enjoy life and being able
to do the things they need (Gabriel & Bowling, 2004). It represents an
instrument to increase both comfort and independence.
The present findings about the two-factor model of QoL-AD could help
clinical decision-making. Patients with different scores in the factors are
supposed to benefit from different treatment. For example, occupational
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therapy, physiotherapy, cognitive stimulation, and drugs would be more

useful for patients with low score in the factor “Behavioral competence.”
On the contrary, patients with low scores in “Perceived environment”
would benefit further from participation in social activities and also from
home modifications to improve safety and comfort. In these latter cases,
caregivers should be referred to support programs in order to help reduce
burden and improve the caregiver-patient relationship.
On the other hand, knowing the scores on each of the factors would
also enable us to understand the effect of particular therapy on the
different aspects of the quality of life (behavioral competence and envi-
ronment). Nevertheless, because differences in cultural background could
have some effect on the results, it seems interesting to perform stud-
ies in different cultures to prove the clinical utility of the subscales and
to examine measurement invariance across groups of different cognitive
abilities.

REFERENCES

Akaike, H. (1987). Factor analysis and AIC. Psychometrika, 52, 317–332.

Balinsky, B. (1941). An analysis of the mental factors of various age groups from
nine to sixty. Genetic Psychology Monographs, 23, 191–234.
Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychological
Bulletin, 107, 238–246.
Bentler, P. M. (2001). EQS 6 structural equations program manual. Encino, CA:
Multivariate Software.
Bentler, P. M. (2005). EQS 6 structural equations program manual. Encino, CA:
Multivariate Software.
Bernstein, I. H., Garbin, C., & Teng, G. (1988). Applied multivariate analysis.
New York: Springer-Verlag.
Bozdogan, H. (1987). Model selection and Akaike’s information criterion (AIC):
The general theory and its analytical extensions. Psychometrika, 52, 345–370.
 Factor Structure of the QoL-AD Scale in AD Patients 277

Brod, M., Steward, A. L., Sands, L., & Walton, P. (1999). Conceptualization
and measurement of quality of life in dementia: The Dementia Quality of Life
instrument (DQoL). The Gerontologist, 39, 25–35.
Brown, T. A. (2006). Confirmatory factor analysis for applied research. New York:
The Guilford Press.
Buckley, T., Fauth E. B., Morrison, A., Tschanz, J., Rabins P. V., Piercy, K. W.,
. . . Lyketsos, C. G. (2012). Predictors of quality of life ratings for persons with
dementia simultaneously reported by patients and their caregivers: The Cache
County (Utah) Study. International Psychogeriatrics, 24, 1094–1102.
Byrne, B. M. (2006). Structural equation modeling with EQS. Mahwah, NJ:
Lawrence Erlbaum.
Cahn-Weiner, D. A., Farias, S. T., Julian, L., Harvey, D. J., Kramer, J. H., Reed,
B. R., . . . Chui, H. (2007). Cognitive and neuroimaging predictors of instru-
Downloaded by [193.147.25.67] at 03:32 28 October 2014

mental activities of daily living. Journal of International Neuropsychological

Societies, 13, 747–757.
Cronbach, L. J., & Meehl, P. E. (1955). Construct validity in psychological tests.
Psychological Bulletin, 52, 281–302.
Edelman, P., Fulton, B. R., Kuhn, D., & Chang, C. H. (2005). A comparison of
three methods of measuring dementia-specific quality of life: Perspectives of
residents, staff, and observers. The Gerontologist, 45, 27–36.
Flora, D. B., & Curran, P. J. (2004). An empirical evaluation of alternative
methods of estimation for confirmatory factor analysis with ordinal data.
An empirical evaluation of alternative methods of estimation for confirmatory
factor analysis with ordinal data. Psychological Methods, 9, 466–449.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state.
A practical method for grading the cognitive state of patients for the clinician.
Journal of Psychiatric Research, 12, 189–98.
Gabriel, Z., & Bowling, A. (2004). Quality of life from the perspectives of older
people. Quality of life from the perspectives of older people. Ageing and
Society, 24, 675–691.
Gómez-Gallego, M., Gómez-Amor, J., & Gómez-García, J. (2012). Validation of
the Spanish version of the QoL-AD scale in Alzheimer disease patients, their
carers, and health professionals. Neurología, 27, 4–10.
Gorsuch, R. L. (1997). Exploratory factor analysis: Its role in item analysis.
Journal of Personality Assessment, 68, 532–560.
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance
structure analysis: Conventional criteria versus new alternatives. Structural
Equation Modeling, 6, 1–55.
Jonker, C., Gerritsen, D. L., Bosboom, P. R., & Van Der Steen, J. T. (2004). A
model for quality of life measures in patients with dementia: Lawton’s next
step. Dementia and Geriatric Cognitive Disorders, 18, 159–64.
Lawton, MP. (1991). A multidimensional view of quality of life in frail elders. In
J. E. Birren, J. E. Lubben, J. C. Rowe, & D. E. Deutchman (Eds.), The concept
and measurement of quality of life in the frail elderly (pp. 3–27). New York:
Academic Press.
Lin Kiat Yap, P. Yen Ni Goh, J., Henderson, L. M., Min Han, P., Shin Ong,
K., Si Ling Kwek, S., . . . Pui Kwan Loh, D. (2008). How do Chinese patients
 278 M. Gómez-Gallego et al.

with dementia rate their own quality of life? International Psychogeriatrics,

20, 482–493.
Logsdon, R. G., Gibbons, L. E., McCurry, S. M., & Teri, L. (2002). Assessing qual-
ity of life in older adults with cognitive impairment. Psychosomatic Medicine,
64, 510–519.
MacCallum, R. C., Browne, M. W., & Cai, L. (2006). Testing differences between
nested covariance structure models: Power analysis and null hypotheses.
Psychological Methods, 11, 19–35.
Mardia, K. V. (1970). Measures of multivariate skewness and kurtosis with
applications. Biometrika, 57, 519–530.
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D., & Stadlan,
E. M. (1984). Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-
ADRDA Work Group under the auspices of Department of Health and Human
Downloaded by [193.147.25.67] at 03:32 28 October 2014

Services Task Force on Alzheimer’s disease. Neurology, 34, 939–944.

Mougias, A. A., Politis, A., Lyketsos, C. G., & Mavreas, V. G. (2011). Quality of
life in dementia patients in Athens, Greece: Predictive factors and the role of
caregiver-related factors. International Psychogeriatrics, 23, 395–403.
Nunnaly, J., & Bernstein, I. (1994). Psychometric theory. New York: McGraw-
Hill.
Rabins, P. V. 2007. Measuring quality of life in dementia: Purposes, goals,
challenges and progress. International Psychogeriatrics, 19, 401–407.
Reisberg, B., Ferris, S., de Leon, M., & Crook, T. (1982). The Global Deterioration
Scale for assessment of primary degenerative dementia. American Journal of
Psychiatry, 139, 1136–1139.
Revell, A. J., Caskie, G. I., Willis, S. L., & Schaie, K. W. (2009). Factor structure
and invariance of the Quality of Life in Alzheimer’s Disease (QoL-AD) Scale.
Experimental Aging Research, 35, 250–267.
Schumacker, R. E., & Lomax, R. G. (2004). A beginner’s guide to structural
equation modeling. Mahwah, NJ: Lawrence Erlbaum Associates.
Sloane, P. D., Zimmerman, S., Williams, C. S., Reed, P. S., Gill, K. S., & Preisser,
J. S. (2005). Evaluating the quality of life of long-term care residents with
dementia. The Gerontologist, 1, 37–49.
Steiger, J. H., & Lind, J. C. (1980). Statistically-based tests for the number
of common factors. Paper presented at the annual Spring Meeting of the
Psychometric Society in Iowa City, May 30, 1980.
Thorgrimsen, L., et al. (2003). Whose quality of life is it anyway? The validity and
reliability of the Quality of Life–Alzheimer Disease (QoL-AD) Scale. Alzheimer
Disease and Associated Disorders, 17, 201–208.
Vogel, A., Bhattacharya, S., Waldorff, F. B., & Waldemar, G. (2012). Proxy-
rated quality of life in Alzheimer’s disease: A three-year longitudinal study.
International Psychogeriatrics, 24, 82–89.
Yuan, K. H., and Bentler, E. M. (1998). Structural equation modeling with robust
covariances. Sociological Methodology, 28, 363–396.
Zumbo, B. D., and Zimmerman, D. W. (1993). Is the selection of statisti-
cal methods governed by level of measurement? Canadian Psychology, 34,
390–400.
 Factor Structure of the QoL-AD Scale in AD Patients 279

APPENDIX

QOL-AD Scale (Spanish version)

1. Physical health Poor Fair Good Excellent
2. Energy Poor Fair Good Excellent
3. Mood Poor Fair Good Excellent
4. Living situation Poor Fair Good Excellent
5. Memory Poor Fair Good Excellent
6. Family Poor Fair Good Excellent
7. People who live with Poor Fair Good Excellent
8. Friends Poor Fair Good Excellent
9. Self as a whole Poor Fair Good Excellent
10. Ability to do chores around the house Poor Fair Good Excellent
11. Ability to do things for fun Poor Fair Good Excellent
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12. Ability to decide Poor Fair Good Excellent

13. Life as a whole Poor Fair Good Excellent