Testing the measurement properties of the Short Form-36 Health Survey in a frail elderly population

What patient-reported outcome measures may be suitable for research involving older adults with frailty? A scoping review

INTRODUCTION

The need to develop and evaluate frailty-related interventions is increasingly important, and inclusion of patient-reported outcomes is vital. Patient-reported outcomes can be defined as measures of health, quality of life or functional status reported directly by patients with no clinician interpretation. Numerous validated questionnaires can thus be considered patient-reported outcome measures (PROMs). This review aimed to identify existing PROMs currently used in quantitative research that may be suitable for older people with frailty.

METHOD

PubMed and Cochrane were searched up to 24/11/22. Inclusion criteria were quantitative studies, use of a PROM, and either measurement of frailty or inclusion of older adult participants. Criteria were created to distinguish PROMs from questionnaire-based clinical assessments. 197 papers were screened. PROMs were categorized according to the domain assessed, as derived from a published consensus 'Standard Set of Health Outcome Measures for Older People'.

RESULTS

88 studies were included. 112 unique PROMs were used 289 times, most frequently the SF-36 (n = 21), EQ-5D (n = 21) and Barthel Index (n = 14). The most frequently assessed outcome domains included Mood and Emotional Health and Activities of Daily Living, with fewer assessments of Participation in Decision-Making and Carer Burden.

CONCLUSIONS

PROM usage in frailty research is highly heterogeneous. Frequently used PROMs omit important outcomes identified by older adults. Further research should evaluate the importance of specific outcomes and identify PROMs relevant to people at different stages of frailty. Consistent and appropriate PROM use in frailty research would facilitate more effective comparisons and meaningful evaluation of frailty interventions.

Cardiovascular Disease and Medication Adherence Among Patients with Type 2 Diabetes Mellitus in an Underserved Community

Optimal management of Type 2 diabetes mellitus (Type 2 DM) is impeded by widespread nonadherence to efficacious medication regimens. Cardiovascular disease (CVD) is the most common cause of morbidity and mortality among persons with Type 2 DM. In this work we evaluated the relationship between CVD and medication adherence to antihypertensives, oral hypoglycemic agents, and antidepressants among patients with Type 2 DM. We also sought to understand how patients perceived barriers to and facilitators of adherence to medications. Adherence to medications was measured in 72 primary care patients from the West Philadelphia area using electronic monitoring (Medication Event Monitoring System caps) over 12 weeks. Standard questions assessed the presence of CVD. Participants answered open-ended questions about barriers to and facilitators of medication adherence. Participants who had CVD were significantly less likely to achieve ≥80% adherence to an antidepressant, oral hypoglycemic agent, and antihypertensive medications at 12 weeks. Participants identified four themes related to medication adherence: Interference from Psychosocial Demands, Need for Technological Innovation, Awareness of Disease Severity, and Integrating Community Linkages. Interventions to improve medication adherence among persons with Type 2 DM in underserved communities may aim to address social determinants of health, create community linkages, emphasize disease severity and utilize apps which are integrated with existing primary care services.

Sedentary Time in Older Adults With Acute Cardiovascular Disease

Background

Older adults may be subject to prolonged bedrest during hospitalization for acute cardiovascular disease, which can contribute to poor functional outcomes posthospitalization. Our objective was to describe mobility status in hospitalized older adults with acute cardiovascular disease.

Methods

Patients aged ≥ 60 years old in the cardiac intensive care unit and cardiovascular ward at a tertiary care academic centre in Montréal, Québec were prospectively enrolled from April 2019 to March 2020. Activity levels were measured with the ActiGraph GT9X Link 3-axis accelerometer (ActiGraph, Pensacola, FL). Sedentary was defined as lying in bed or in a sitting position. Health-related quality of life (HRQOL) was measured with the Short-Form 36 (SF-36) questionnaire by telephone at 1 month posthospitalization. The primary outcome was percentage of sedentary time during hospitalization.

Results

There were 35 patients included in the analysis (75.7 ± 6.9 years old; 45.7% female; 22.9% ischemic heart disease; 20.0% heart failure). Patients spent 91.2% ± 5.5 in a sedentary position during their hospital stay. Mean steps per minute were 1.0 ± 1.2, and mean kcals consumed per day were 116.6 ± 124.5. In the multivariable analysis, a higher percentage of sedentary time and lower steps per minute were each associated with lower total SF-36 scores at 1-month posthospitalization (both P < 0.05).

Conclusions

Older adults with acute cardiovascular disease may be sedentary for a large part of their hospital stay. Increased sedentary time is associated with worse self-reported posthospital HRQOL. Future studies are needed to determine whether interventions to increase activity during hospitalization improve posthospital HRQOL and functional outcomes.

Health-Related Quality of Life in Older Adults With Acute Cardiovascular Disease Undergoing Early Mobilization

Background

Early mobilization (EM) is safe and feasible in older adults with acute cardiovascular disease (CVD) and may improve posthospitalization patient-centred outcomes. Our objective was to assess posthospitalization health-related quality of life (HRQOL) in older adults with acute CVD undergoing EM.

Methods

Patients aged ≥ 60 years with acute CVD undergoing EM at an academic tertiary centre in Montreal, Quebec were prospectively enrolled from January 2018 to January 2020. Functional status was measured using the validated Level of Function Mobility Scale. HRQOL was measured using the Short-Form 36 questionnaire at 1 and 12 months posthospitalization. The primary outcome was the questionnaire's physical component summary (PCS) score at 1 month posthospitalization.

Results

There were 147 patients included in the analysis (aged 75.0 ± 8.7 years; 44.6% female; 48.6% with ischemic heart disease). The mean 1-month PCS score was 34.7 ± 9.7, which was 11.5 points and 8.4 points lower compared to age-matched Canadian normative data for people ages 65-74 years and ≥ 75 years, respectively. The mean PCS score at 12 months (36.5 ± 9.2) and the mean mental component summary scores at 1 and 12 months (36.9 ± 11.1; 40.5 ± 11.5) were lower than those of the age-matched population (all P < 0.0001). In the multivariable analysis, increased age and worse prehospitalization function were associated with lower PCS score at 1 month.

Conclusions

Older adults with acute CVD had lower HRQOL at 1 and 12 months posthospitalization than age-matched Canadian norms. Prehospitalization functional status was predictive of poor posthospitalization HRQOL. The EM program was safe and feasible in this patient population. Further studies are needed to determine whether EM can improve posthospitalization patient-centred outcomes in older adults, particularly those with poor prehospitalization functional status.

Adherence to Antidepressants in Underserved Communities: A Comparison of Electronic Monitoring and Self-report Measures

Nonadherence to antidepressants is widespread and poses a significant barrier to optimal management and treatment of depression in community settings. The objective of this study was to compare self-reported and electronic monitoring of adherence to antidepressants and to examine the relationship of these measures with depressive symptoms in a medically underserved community. Adherence to antidepressants was measured in 38 primary care patients from the West Philadelphia area using self-report and electronic monitoring (Medication Event Monitoring System caps). Self-report and electronic monitoring of antidepressant adherence showed fair agreement at baseline, slight agreement at 6 weeks, and slight agreement at 12 weeks. Adherence to antidepressants as assessed by electronic monitors was significantly associated with depression remission at 12 weeks [adjusted odds ratio 18.6, 95% confidence interval (1.05, 330.56)]. Compared with electronic monitoring, self-reported adherence tended to overestimate medication adherence to antidepressants. Adherence assessed by electronic monitoring was associated with depression remission.

Self-reported Physical Function Decline and Mortality in Older Adults Receiving Hemodialysis

Rationale & Objective

Timely recognition of functional decline in older adults receiving dialysis will allow clinicians to pursue interventions to prevent further disability and/or lead patient-centered goals of care discussions. Annual change in the 12-Item Short Form Health Survey (SF-12) physical component score (PCS) could identify patients with functional decline. Our objectives were to assess SF-12 PCS change over a year, risk factors associated with SF-12 PCS change, and the association of SF-12 PCS change with mortality in a survivor cohort of older adults receiving dialysis.

Study Design

Retrospective study.

Setting & Participants

1,371 adults 65 years or older receiving hemodialysis for 6 or more months who completed SF-12 PCSs 300 or more days apart from 2012 to 2013.

Exposures

Serum albumin level; hemodialysis access type; SF-12 PCS change (for mortality analyses).

Outcomes

SF-12 PCS change and mortality.

Analytical Approach

Multivariable-adjusted linear regression model; Cox proportional hazards model.

Results

We excluded 24% (n = 801) of our cohort for death before the second SF-12 PCS. Among the 1,371 with sufficient SF-12 PCS data, mean age was 79.9 ± 4.5 years. Average SF-12 PCS change in 1 year was minimal (−0.9 ± 9.6), but 39.3% (n = 539) and 32.2% (n = 442) had clinically relevant SF-12 PCS decline and improvement, respectively. Albumin level and access type were not statistically associated with SF-12 PCS change. SF-12 PCS change was not associated with mortality (adjusted HR, 0.98; 95% CI, 0.96-1.00).

Limitations

2 time points to assess SF-12 PCS change; covariate assessment only at baseline; survivor bias.

Conclusions

In this cohort of older adults receiving hemodialysis, nearly one-fourth died, while among survivors, it was more common for SF-12 PCS to decline than improve in a year. Annual SF-12 PCS change was not associated with traditional risk factors for functional impairment or mortality risk. Additional research is needed to identify appropriate measures and frequency of assessment for functional decline.

Quality of life evaluation of frail elderly in Campinas, São Paulo

OBJECTIVE

describe the quality of life of frail elderly assisted by the Centro de Referência à Saúde do Idoso (CRI), Campinas, São Paulo, Brazil.

METHODS

the convenience sample included 122 frail elderly being treated from January 2010 to July 2011, out of a total of 668 frail elderly who were referred to the CRI after application of the brief evaluation form of the elderly, recommended by Ministry of Health, which identifies the elderly with some degree of frailty. Descriptive observational study collected data through sociodemographic questionnaire and quality of life questionnaires: WHOQOL-BREF, WHOQOLOLD and SF-36.

RESULTS

the study included 122 frail elderly. Of these, 74.6% (91) were female, mean age 73 years, 46.7% (57) were married, 51.6% (63) had less than 3 years of schooling and 87.7% (107) reported income of one to four minimum wages. The mean total score of the WHOQOL-BREF was 56.6, the WHOQOL-OLD 57.6 and SF-36 Physical Component Summary 34.5 and Mental Component Summary 43.6.

CONCLUSION

knowledge of the impairment profile of quality of life among frail elderly is, therefore, essential for planning health care to this population.

A quantitative dynamic systems model of health-related quality of life among older adults

Health-related quality of life (HRQOL) is a person-centered concept. The analysis of HRQOL is highly relevant in the aged population, which is generally suffering from health decline. Starting from a conceptual dynamic systems model that describes the development of HRQOL in individuals over time, this study aims to develop and test a quantitative dynamic systems model, in order to reveal the possible dynamic trends of HRQOL among older adults. The model is tested in different ways: first, with a calibration procedure to test whether the model produces theoretically plausible results, and second, with a preliminary validation procedure using empirical data of 194 older adults. This first validation tested the prediction that given a particular starting point (first empirical data point), the model will generate dynamic trajectories that lead to the observed endpoint (second empirical data point). The analyses reveal that the quantitative model produces theoretically plausible trajectories, thus providing support for the calibration procedure. Furthermore, the analyses of validation show a good fit between empirical and simulated data. In fact, no differences were found in the comparison between empirical and simulated final data for the same subgroup of participants, whereas the comparison between different subgroups of people resulted in significant differences. These data provide an initial basis of evidence for the dynamic nature of HRQOL during the aging process. Therefore, these data may give new theoretical and applied insights into the study of HRQOL and its development with time in the aging population.

Classification of quality of life subscales within the ICF framework in burn research: identifying overlaps and gaps

OBJECTIVE

Quality of life (QOL) is one of the leading outcomes in burn care research. This study classifies subscales of common QOL measures within the International Classification of Functioning disability and health (ICF) framework to determine to which extent the measures are complementary or overlapping and to investigate whether the instruments are able to describe the full spectrum of patients' functioning.

METHODS

A literature search was performed to determine the most frequently used questionnaires in burn research. The subscales of the three mostly used questionnaires were classified within the ICF framework.

RESULTS

Two generic measures, the Short Form-36 items (SF-36) and the European Quality of Life 5 Dimensions (EQ-5D), and a disease specific measure, the Burn Specific Health Scale-Brief (BSHS-B), were analyzed. The BSHS-B covered most domains and was the only scale that included personal factors. The SF-36 included only one domain in the activity limitations and similar to the EQ-5D no contextual factors were included. Environmental factors were not addressed in the questionnaires, even though these may have an impact on the quality of life in patients with burns.

CONCLUSION

To capture the full spectrum of dysfunctioning a combination of the BSHS-B with a generic questionnaire seems obligatory. However still some domains of functioning remain uncovered.

Feasibility and acceptability of a Tai Chi Chih randomized controlled trial in senior female cancer survivors

OBJECTIVE

The purpose of this randomized controlled trial (RCT) was to examine the feasibility and acceptability of a Tai Chi Chih (TCC) intervention in senior female cancer survivors with physical functioning limitations, and its effects on health-related quality of life (QOL).

DESIGN

This was a two-armed, parallel group, RCT with 12-weeks of Tai Chi Chih or Health Education Control.

METHODS

Sixty-three senior (M age = 67 years, SD = 7.15) female cancer survivors (83% breast cancer, stages I-III) with physical functioning limitations (SF-12 Health Survey role-physical & physical functioning subscales) were randomized to 12-weeks of TCC or Health Education control (HEC). Primary outcomes were feasibility and acceptability. Secondary outcomes included health-related QOL (SF-36 Health Survey), and participants' qualitative feedback on the intervention.

RESULTS

Retention (TCC = 91%; HEC = 81%) and class attendance (TCC = 79%; HEC = 83%) rates, and satisfaction levels for both study arms were high, but did not significantly differ from one another. At one-week post-intervention, none of the SF-36 scores differed between the TCC and HEC groups. Within-group analyses revealed significant improvements in the mental component summary score in TCC (p = 0.01), but not in HEC. Qualitative analyses indicated that the TCC group felt they received mental and physical benefits, whereas HEC group reported on social support benefits and information received.

CONCLUSION

The TCC intervention was found to be a feasible and acceptable modality for senior female cancer survivors. Future, larger definitive trials are needed to clarify TCC dosage effects on QOL in this vulnerable population.

Measurement bias of the SF-36 Health Survey in older adults with chronic conditions

PURPOSE

The objectives of this study were to investigate the psychometric properties of the SF-36 in a sample of older adults with chronic conditions and to test whether measurement bias exists based on the levels of comorbidity.

METHODS

Participants included were 979 cognitively intact older adults with comorbidities who were interviewed at their homes. We examined the psychometric properties of the SF-36 and conducted confirmatory factor analysis (CFA) to investigate the assumption of measurement invariance by the levels of comorbidity.

RESULTS

Overall data quality was high and scaling assumptions were generally met with few exceptions. Floor and ceiling effects were present for the role-physical and role-emotional subscales. Using CFA, we found that a three-factor measurement model fits the data well. We identified two violations of measurement invariance. Results showed that participants with high comorbidity level place more emphasis on social functioning (SF) and bodily pain (BP) in relation to physical health-related quality of life (HRQoL) than those with low comorbidity level.

CONCLUSIONS

Measurement bias was present for the SF and BP components of the SF-36 physical HRQoL measure. Researchers should be cautious when considering the use of SF-36 in clinical studies among older adults with comorbidities.

Quality of life in older people: a structured review of self-assessed health instruments

A range of terms (including quality of life, health-related quality of life and health status) describe a broad set of aspects of self-reported health that can be captured by questionnaires and related instruments. Health in older people particularly requires attention to broader aspects of the impact of health on physical, social and psychological function. A structured review was performed to assess how well such issues are measured by available instruments. A total of 45 instruments were identified that have received some degree of evaluation to establish their use in assessing the health of older individuals. Two types of instruments were included in the review: generic and older-people-specific instruments. The SF-36 has by far the largest evidence base to support its use in older people. The OMFAQ has the best evidence base amongst older-people-specific instruments. Many instruments have only minimal evidence of measurement properties. Concepts such as quality of life are still defined and used in a variety of ways, and major questions must be addressed before uniform practice emerges in this important area of health policy.

A cross-sectional study of somatic symptoms and the identification of depression among elderly primary care patients

OBJECTIVE

To examine the relationship between somatization and depression as rated by primary care physicians.

METHOD

This study was a cross-sectional survey of 355 older adults with and without significant depressive symptoms. Physicians' ratings of somatization and depression were obtained for 341 of the 355 patients. Patients were sorted into 4 groups on the basis of physician ratings (no depression/no somatization, somatization only, depression only, and both somatization and depression). Data were collected from 2001-2003.

RESULTS

Patients who were rated as somatizing were 4.03 (95% CI, 2.52-6.45) times as likely to be rated as depressed as well as somatizing. A comparison of the 4 groups defined by physicians' ratings found that functional status, ethnicity, number of medical conditions, depressive symptoms, and anxiety were statistically significantly different (P < .05). Primary care physicians were 3.95 (95% CI, 1.53-10.16) times more likely to identify older black patients as somatizing only versus depressed and somatizing compared to older white patients among patients above a threshold on a standard depression instrument.

CONCLUSIONS

Our study fills a gap in the literature by focusing on the primary care physician ratings of depression and somatization, and also specifically on older primary care patients. Blacks are less likely to be rated as depressed, but this may reflect the tendency of doctors to rate them as somatizing.

Construct validity of the SF-12 in three different samples

RATIONALE, AIMS AND OBJECTIVES

Studies have challenged the validity and underlying measurement model of the physical and mental component summary scores of the 36-item Short-Form Health Survey in, for example the elderly and people with neurological disorders. However, it is unclear to what extent these observations translate to physical and mental component summary scores derived from the 12-item short form (SF-12) of the 36-item Short-Form Health Survey. This study evaluated the construct validity of the SF-12 in elderly people and people with Parkinson's disease (PD) and stroke.

METHODS

SF-12 data from a general elderly (aged 75+) population (n = 4278), people with PD (n = 159) and stroke survivors (n = 89) were analysed regarding data quality, reliability (coefficient alpha) and internal construct validity. The latter was assessed through item-total correlations, exploratory and confirmatory factor analyses.

RESULTS

Completeness of data was high (93-98.8%) and reliability was acceptable (0.78-0.85). Item-total correlations argued against the suggested items-to-summary scores structure in all three samples. Exploratory factor analyses failed to support a two-dimensional item structure among elderly and stroke survivors, and cross-loadings of items were seen in all three samples. Confirmatory factor analyses showed lack of fit between empirical data and the proposed items-to-summary measures structure in all samples.

CONCLUSIONS

These observations challenge the validity and interpretability of SF-12 scores among the elderly, people with PD and stroke survivors. The standard orthogonally weighted SF-12 scoring algorithm is cautioned against. Instead, when the assumed two-dimensional structure is supported in the data, oblique scoring algorithms appear preferable. Failure to consider basic scoring assumptions may yield misleading results.

Walk on the sunny side of life--epidemiology of hypovitaminosis D and mental health in elderly nursing home residents

OBJECTIVES

Old age is a well-known risk factor for both depression and hypovitaminosis D, and an association between both conditions has been postulated. We document the prevalence of vitamin D deficiency in nursing home residents, and we examine the link with self-reported depressive symptoms and pharmacotherapy for depression.

DESIGN

Cross- sectional.

SETTING

nursing homes in Antwerp, Belgium.

PARTICIPANTS

Healthy elderly (n=589), with a mean age of 84 years.

MEASUREMENTS

We detected depressive symptoms by means of SF-36, a validated quality of life assessment; we registered the use of antidepressants and anxiolytics, and we measured serum 25(OH)D concentrations in all participants.

RESULTS

Almost our entire study population appeared to be vit D deficient. Comparison of the most severely and least deficient subgroups showed a consistent tendency towards more depressive symptoms and more use of antidepressants in the group with the lowest vit D level.

CONCLUSION

Nursing home residents are particularly vulnerable to preventable vit D deficiency. The relevance of the association with depressive symptoms and the possibilities for treatment are critically reviewed in the discussion.

Impacto da doença crônica na qualidade de vida de idosos da comunidade em São Paulo (SP, Brasil)

O objetivo deste artigo é avaliar o impacto da doença crônica na qualidade de vida de idosos da comunidade no município de São Paulo (SP). Trata-se de um estudo transversal de indivíduos acima de 60 anos, com aplicação de um questionário clínico-demográfico padronizado e do questionário genérico de qualidade de vida Short-Form 36 items (SF-36). Foram feitas análise estatística descritiva dos dados clínicos e demográficos e análise de variância (ANOVA) para correlação das médias dos domínios do SF-36 com a idade e o número de morbidades. Avaliaram-se 353 indivíduos. A média de idade foi de 71,6 anos, com 48,7% de homens e 51,3% de mulheres. O sexo feminino apresentou os piores níveis de qualidade de vida em todos os domínios avaliados. A análise de variância revelou uma variação significativa da qualidade de vida, em vários domínios, conforme o aumento do número de morbidades. O domínio mais comprometido foi limitação por aspectos físicos (p<0,05). A mesma análise, aplicada às médias dos domínios por faixa etária, mostrou uma relação inversa do domínio capacidade funcional (p<0,05) com a idade. O aumento do número de morbidades e o aumento da idade influenciam de modo significativo vários domínios da qualidade de vida dos idosos. O SF-36 apresenta-se como um instrumento válido para a avaliação de qualidade de vida da população idosa brasileira.

Which generic health related Quality of Life questionnaire should be used in older inpatients: comparison of the Duke Health Profile and the MOS Short-Form SF-36?

OBJECTIVES

The objective of our study was to compare advantages and limitations of two generic Quality of Life questionnaires administered in older inpatients.

DESIGN

Two validated generic health-related Quality of Life instruments : the MOS Short-Form 36 (9 dimensions, 36 items) and the Duke Health Profile (6 dimensions, 4 dysfunctions, 17 items) were administered to inpatients over 65 years.

SETTING AND PARTICIPANTS

The sample was drawn from the CliniQualVie program that assessed systematically Quality of Life among hospitalized inpatients (18-79 years) in 10 medical and surgical wards at Nancy University Hospital.

RESULTS

The two self-administered questionnaires were completed by 701 patients over 65 years at admission (mean age 71 +/- 4, 63% men). The proportion of patients who completed all items were 72.5% for the Duke and 66.9% for the SF-36 (p < .001). The Duke's internal consistency was low as compared with the SF-36, but other psychometric properties were comparable. Good correlations (Spearman) were observed between the two questionnaires for physical health (0.59, p < .0001), mental health (0.68, p < .0001) and health perception (0.56, p < .0001) scores. Low correlations were observed for the social score.

CONCLUSIONS

This is the first study to our knowledge to assess the interest of using the Duke Health Profile in a general elderly inpatients population as compared with the SF-36 questionnaire. Although these two questionnaires have four comparable dimensions, they differ in their content and psychometric properties. The Duke questionnaire, due to its better completion rate and despite some psychometric limitations may be useful in this population, particularly in the more frail patients.

Integrating type 2 diabetes mellitus and depression treatment among African Americans: a randomized controlled pilot trial

PURPOSE

The purpose of this study was to examine whether integrating depression treatment into care for type 2 diabetes mellitus among older African Americans improved medication adherence, glycemic control, and depression outcomes.

METHODS

Older African Americans prescribed pharmacotherapy for type 2 diabetes mellitus and depression from physicians at a large primary care practice in west Philadelphia were randomly assigned to an integrated care intervention or usual care. Adherence was assessed at baseline, 2, 4, and 6 weeks using the Medication Event Monitoring System to assess adherence. Outcomes assessed at baseline and 12 weeks included standard laboratory tests to measure glycemic control and the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression.

RESULTS

In all, 58 participants aged 50 to 80 years participated. The proportion of participants who had 80% or greater adherence to an oral hypoglycemic (intervention 62.1% vs usual care 24.1%) and an antidepressant (intervention 62.1% vs usual care 10.3%) was greater in the intervention group in comparison with the usual care group at 6 weeks. Participants in the integrated care intervention had lower levels of glycosylated hemoglobin (intervention 6.7% vs usual care 7.9%) and fewer depressive symptoms (CES-D mean scores: intervention 9.6 vs usual care 16.6) compared with participants in the usual care group at 12 weeks.

CONCLUSION

A pilot randomized controlled trial integrating type 2 diabetes mellitus treatment and depression was successful in improving outcomes among older African Americans. Integrated interventions may be more feasible and effective in real-world practices with competing demands for limited resources.

"You don't want to burden them": older adults' views on family involvement in care

Burden emerged as an important concept among older adults in a study of how older adults interact with their families around care. The authors conducted 50 semistructured interviews with adults older than the age of 65 years and a spouse or adult child. The sample was stratified by ethnicity thus giving the opportunity to explore both ethnic similarities and differences. Older adults who expressed the concept of burden were more likely to be White compared with older adults who did not express burden. Older respondents discussed burden in relation to not wanting to complicate the busy lives of adult children, guilt about health problems, and concern that children were overly worried about the care of their older family member. The expression and meaning of burden differed according to ethnicity. This study has implications for practice and policies to meet the needs of families and promote the independence of older persons.

Depression, cognition, apolipoprotein e genotype: latent class approach to identifying subtype

OBJECTIVES

Possessing the epsilon4 allele of apolipoprotein E (APOE-epsilon4) genotype is associated with cognitive impairment in nondemented older adults. The authors hypothesized that they might find a subtype of depression related to impaired cognitive performance associated with the APOE-epsilon4 allele.

DESIGN

A survey conducted between 2001 and 2003 with APOE genotyping.

SETTING

Primary care offices in the Baltimore area.

PARTICIPANTS

The study sample consisted of 305 adults aged 65 or older with complete information on APOE genotyping and covariates.

MEASUREMENTS

The authors used the latent class model to classify respondents according to symptom criteria of American Psychiatric Association's Diagnostic and Statistical Manual as assessed in the Composite International Diagnostic Interview and the following four measures of cognitive function: the Mini-Mental State Exam, Hopkins Verbal Learning Test, Controlled Oral Word Association Test, and the Brief Test of Attention. The authors examined the relationship between class membership and APOE genotype.

RESULTS

The latent class model yielded three classes: a nondepressed class, a class with depressive symptoms and average cognitive functioning, and a class with depressive symptoms (particularly thoughts of death and suicide) and impaired cognitive functioning. Possessing at least one APOE-epsilon4 allele was not predictive of class membership.

CONCLUSION

A subgroup of elderly patients with depressive symptoms, cognitive impairment, and a high likelihood of experiencing thoughts of death or suicide may exist that may not be related to APOE-epsilon4. Subgroups of older patients with depressive symptoms may be important to identify because of the association with thoughts of death or suicide and cognitive impairment.

Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study

BACKGROUND

Preferences for life-sustaining treatment elicited in one state of health may not reflect preferences in another state of health.

METHODS

We estimated the stability of preferences for end-of-life treatment across 3 years and whether declines in physical functioning and mental health were associated with changes in preferences for end-of-life treatment. In this longitudinal cohort study of medical students in the graduating classes of 1948 to 1964 at Johns Hopkins University, 818 physicians completed the life-sustaining treatment questionnaire in 1999 and 2002 (mean age at baseline, 69 years).

RESULTS

Although the prevalence of the 3 clusters of life-sustaining treatment preferences remained stable across the 3-year follow-up, certain physicians changed their preferences with time. The probability that physicians were in the same cluster at follow-up as at baseline was 0.41 for "most aggressive," 0.50 for "intermediate care," and 0.80 for "least aggressive." Physicians without advance directives were more likely to transition to the most aggressive cluster than to the least aggressive cluster during the 3-year follow-up (odds ratio, 1.96; 95% confidence interval, 1.11-3.45). Age at baseline and decline in physical and mental health were not associated with transitions between 1999 and 2002.

CONCLUSION

Periodic reassessment of preferences is most critical for patients who desire aggressive end-of-life care or who do not have advance directives.

Integration of depression and hypertension treatment: a pilot, randomized controlled trial

PURPOSE

We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications, depression outcomes, and blood pressure control among older primary care patients.

METHODS

Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Outcomes were assessed at baseline, 2, 4, and 6 weeks using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression, an electronic monitor to measure blood pressure, and the Medication Event Monitoring System to assess adherence.

RESULTS

In all, 64 participants aged 50 to 80 years participated. Participants in the integrated care intervention had fewer depressive symptoms (CES-D mean scores, intervention 9.9 vs usual care 19.3; P <.01), lower systolic blood pressure (intervention 127.3 mm Hg vs usual care 141.3 mm Hg; P <.01), and lower diastolic blood pressure (intervention 75.8 mm Hg vs usual care 85.0 mm Hg; P <.01) compared with participants in the usual care group at 6 weeks. Compared with the usual care group, the proportion of participants in the intervention group who had 80% or greater adherence to an antidepressant medication (intervention 71.9% vs usual care 31.3%; P <.01) and to an antihypertensive medication (intervention 78.1% vs usual care 31.3%; P <.001) was greater at 6 weeks.

CONCLUSION

A pilot, randomized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes. Integrated interventions may be more feasible and effective in real-world practices, where there are competing demands for limited resources.

Primary care physicians' assessments of older patients' health and psychological status and recommendation of mammography

BACKGROUND

Recommendation of mammography may be particularly important for older women; nevertheless, physicians are less likely to recommend mammography to older women. Our objective was to examine the characteristics of older patients for whom primary care physicians recommend mammography.

METHODS

Two hundred sixteen women aged 65 to 80 years were screened for depressive symptoms in primary care offices and invited to participate. They then completed a baseline in-home assessment between 2001 and 2003. At the time of the baseline in-home assessment, mammogram use and psychological status were assessed with commonly used and validated standard questionnaires. At the time of the index visit, physicians were asked to provide assessments of the patients.

RESULTS

Patient-reported physician recommendation of mammography was more likely among patients the physicians rated as anxious than among patients the physicians rated as not being anxious (unadjusted odds ratio, 2.08; 95% confidence interval, 1.10-3.94). In multivariate models that controlled for physician ratings of knowledge of the patient, the association between physician rating of anxiety with patient-reported physician recommendation of mammography remained significant. Patient-reported physician recommendation of mammography was not significantly more likely among patients the physicians rated as depressed than among patients the physicians rated as not being depressed (unadjusted odds ratio, 1.57; 95% confidence interval, 0.86-2.85).

CONCLUSIONS

Identification of anxiety may influence the recommendation of mammography among primary care physicians. An understanding of factors that influence the recommendation of mammography by primary care physicians may have important implications for interventions to improve rates of mammography use among older women.

Qualidade de vida e estratégias de enfrentamento em idosos com incontinência fecal: uma revisão da literatura

RESUMO O objetivo desta revisão foi apreciar criticamente a literatura sobre a avaliação da qualidade de vida (QV) e das estratégias de enfrentamento em idosos com incontinência fecal (IF), tendo como referencial o envelhecimento populacional brasileiro e o aumento da incidência de doenças crônicas que comprometem o bem-estar dos idosos. Foi realizada pesquisa nas principais bases de dados e a qualidade metodológica das publicações foi avaliada. A perda involuntária de fezes gera conseqüências físicas, sociais, emocionais e econômicas, sendo mais prevalente em idosos e mulheres. Recentemente, a avaliação de medidas centradas no paciente, incluindo a QV e as estratégias de enfrentamento foram apontadas como fundamentais. A qualidade de vida de idosos com IF pode ser avaliada através de instrumentos genéricos, como o WHOQOL e de instrumentos específicos, como o FIQL e o GIQLI. Alguns estudos têm indicado variáveis que podem se associar a um maior ou menor comprometimento da QV, mas ainda há escassez de trabalhos com idosos incontinentes. Embora já existam instrumentos de avaliação genérica das estratégias de enfrentamento disponíveis para uso no Brasil, nesta revisão, não foram encontradas pesquisas sobre a forma de enfrentamento da IF na população em geral ou entre os idosos. Esta revisão confirma a necessidade de mais estudos sobre como a IF afeta os idosos e como os mesmos lidam com essa disfunção.

The link between depressive symptoms, negative cognitive bias and memory complaints in older adults

OBJECTIVES

We sought to examine the relationship between depressive symptoms and subjective memory problems. We hypothesized that the relationship between depressive symptoms and poor subjective memory functioning is mediated by negative cognitive bias that is associated with hopelessness, a wish to die and low self-esteem.

METHODS

Complete data were available for 299 older adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate, completed a baseline in-home assessment. Subjective memory functioning and psychological status was assessed with commonly used, validated standard questionnaires.

RESULTS

In regression models that included terms for age, gender and cognitive measures, depressive symptoms were significantly inversely associated with the global self-assessment of memory (beta=-0.019; p=0.006). When components of negative cognitive bias were included in the model (hopelessness, low self-esteem, a wish to die), the relationship of depressive symptoms with subjective memory problems was attenuated, consistent with mediation.

CONCLUSIONS

Our results suggest that assessment and successful interventions for memory complaints in non-demented older adults need to account for negative cognitive bias as well as depressive symptoms. Longitudinal research is needed to confirm our findings before a mediator relationship can be presumed.

Devenir et qualité de vie d'une population âgée de plus de 80 ans trois mois après un séjour en réanimation

OBJECTIVES

The aging of the population has seen an increase in the number of elderly patients admitted to reanimation units. We sought to know the outcomes and evolution of the quality of life of a population of elderly patients after their experience with this type of service.

METHOD

We included all patients older than 80 years who had been in two intensive care units in the Loire region of France between October 2005 and May 2006. We studied their state of mind 3 months after they exited the service. Then, for the survivors, we used the Activities of Daily Living (ADL) scale and the generic questionnaire of health, the SF-36, to evaluate the evolution of their degree of autonomy and quality of life related to health compared to that one month prior to entry in the reanimation unit.

RESULTS

We included 70 patients (mean age 85.2+/-4.5 years). At 3 months after exiting reanimation, the survival rate was 57%, and 28 survivors underwent rating scale testing. The physical score of the SF-36 and the ADL score were significantly decreased as compared with that one-month before admission, with no significant difference in mental score of the SF-36. Physical deterioration did not have a significant effect on the evolution of perceived health (dimension GH of the SF-36), life and relations with others (dimension SF) or mental health (dimension MH). The decreased ADL score was correlated with that of the two physical dimensions of the SF-36, with no correlation with the four psychic dimensions. A total of 92% of patients were satisfied with their care in reanimation and three of four would agree to go back if their state required it. For the others, it is a question of respecting the will of the elderly patients confronted with reanimation care.

CONCLUSION

Three months after intensive care with reanimation, elderly patients do not have significantly modified perceived health and psychic state as compared with objective deteriorated physical capacity. The absence of consensus on the threshold of old age and the quality-of-life instrument to use prevents a comparison of our results with those in the literature. However, others have shown and we agree that elderly people could benefit from reanimation therapy.

Psychometric properties of the Minnesota Living with Heart Failure—Brazilian version—in the elderly

BACKGROUND

Heart failure (HF) has implications for the quality of life for any age range, more so for the elderly who simultaneously present other limitations imposed by multiple co-morbidities. Although there are several instruments to measure Health Related Quality of Life (HRQL), none is specific to the elderly with HF. Among disease-specific instruments, Minnesota Living with Heart Failure(LHFQ) has not been studied extensively among the elderly with respect to its psychometric properties.

OBJECTIVE

The purpose of this study was to evaluate the convergent, divergent and discriminative validity of the Brazilian version of LHFQ applied to elderly HF patients.

METHOD

One hundred and seventy (170) elderly were interviewed. LHFQ capacity to discriminate subjects among New York Heart Association (NYHA) Classes I, II and III/IV was analyzed. Convergent and divergent validity was evaluated through the correlation between the domains of LHFQ and the generic instrument, Medical Outcomes Study (MOS) 36-item Short-Form Health Survey (SF-36).

RESULTS

The LHFQ total score and physical dimension sub-scale discriminated between the three sub-groups of NYHA Classes I, II and III/IV (P < .0001). The emotional dimension discriminated NYHA Classes I and III/IV (P = .0034). The physical and emotional dimensions of the LHFQ and SF-36 were significantly correlated (coefficients from .46 to .70 for physical dimension and from .31 to .65 for emotional dimension). However, contrary to expectations, the divergent validity was not totally confirmed as there was no difference in the magnitude of the correlations between the LHFQ emotional and physical dimensions and the SF-36 role physical, social functioning and role emotional. Thus, the results suggest that LHFQ seems to be a valid tool to measure HRQL in the elderly, but new studies remain necessary to gain a better understanding of its discriminative validity for more advanced NYHA functional classes and for its divergent validity.

Tai chi and perceived health status in older adults who are transitionally frail: a randomized controlled trial

BACKGROUND AND PURPOSE

Tai chi, a Chinese exercise derived from martial arts, while gaining popularity as an intervention for reducing falls in older adults, also may improve health status. The purpose of this study was to determine whether intense tai chi (TC) exercise could improve perceived health status and self-rated health (SRH) more than wellness education (WE) for older adults who are transitionally frail.

SUBJECTS

Study subjects were 269 women who were >or=70 years of age and who were recruited from 20 congregate independent senior living facilities.

METHODS

Participants took part in a 48-week, single-blind, randomized controlled trial. They were randomly assigned to receive either TC or WE interventions. Participants were interviewed before randomization and at 1 year regarding their perceived health status and SRH. Perceived health status was measured with the Sickness Impact Profile (SIP).

RESULTS

Compared with WE participants, TC participants reported significant improvements in the physical dimension and ambulation categories and borderline significant improvements in the body care and movement category of the SIP. Self-rated health did not change for either group.

DISCUSSION AND CONCLUSION

These findings suggest that older women who are transitionally frail and participate in intensive TC exercise demonstrate perceived health status benefits, most notably in ambulation.

Walker use, but not falls, is associated with lower physical functioning and health of residents in an assisted-living environment

The relationship between perceived health and walker use has seldom been addressed. Concerns over falls and falls risk are precursors to walker use. We compared the SF-36 scores of 26 women and 14 men, mean age 86.8 +/- 6.0 years based on walker use and faller status. An analysis of covariance (ANCOVA) with age as the covariate, compared groups for the SF-36 constructs and totals score. Significant differences were noted between walker users and nonusers in physical functioning, role limitations due to physical problems, general health, and the total SF-36 score. Pairwise comparisons favored nonusers, while no differences were seen due to faller status. Walker use is associated with lower self-perceptions of physical functioning, role limitations due to physical problems, and general health in assisted-living residents. Faller status is not associated with self-perceived health status. Although walker use aids mobility and lowers the probability of falls, further research is needed to determine if the prescription of assistive devices has a more negative impact on self-perceived health than does falling. This possibility could be explained, in part, by the greater activity levels of those individuals who do not depend on walkers.

Longitudinal metric properties of disability rating scales for Parkinson's disease

OBJECTIVES

This study analyzes the longitudinal metric attributes of three Parkinson's disease (PD) disability scales, taking Hoehn and Yahr (HY) staging as the reference measure of PD progression.

METHODS

A sample of 87 PD patients was assessed during regular medical visits, using the HY, the Unified Parkinson's Disease Rating Scale--Activities of Daily Living Section (UPDRS-ADL), the Schwab and England Scale (SES), and the Intermediate Scale for Assessment of PD (ISAPD), across a follow-up period of 2.6 +/- 1.0 years.

RESULTS

The following cross-sectional attributes were analyzed, at baseline and again on conclusion of the study: floor and ceiling effects, convergent validity, reliability, and standard error of measurement, all of which were found to be adequate. Longitudinal reproducibility values (intraclass correlation coefficient) were 0.81 (ISAPD) to 0.84 (UPDRS-ADL). Insofar as longitudinal validity was concerned, the change scores of the three disability scales correlated significantly with the HY change score, absolute value r = 0.33 to 0.45, P < 0.003. Slightly lower values were found when taking the annual rate of change, absolute value r = 0.20 to 0.36. The three scales were acceptable, even though there were small differences among them. The "minimal clinically important difference" proposed for these scales is: SES, -6; UPDRS-ADL, +2; ISAPD, +1.5 points.

CONCLUSIONS

The three scales proved adequate for longitudinal assessment of PD disability. UPDRS-ADL was more precise and ISAPD more consistent. Magnitude of change and correlation with change in HY were slightly higher with the ISAPD. Effect size and standardized response mean for the minimal change in HY were higher for the UPDRS-ADL.

Using the Nottingham Health Profile (NHP) among older adult inpatients with varying cognitive function

BACKGROUND

High rates of missing, non-applicable items and insufficient reliability have been frequently reported as limitations of the generic Quality of Life questionnaires for older patients. The Nottingham Health Profile (NHP) might be more suitable as it contains easy to respond (yes/no) items covering moderate-to-severe health deterioration.

OBJECTIVES

To assess feasibility, reliability and validity of the NHP in disabled, older patients.

DESIGN

Cross-sectional study.

SETTING

Acute care hospital.

SUBJECTS

134 inpatients aged >or=65 with severe disability, abnormal cognitive function, or other persistent health problems precluding their discharge.

METHODS

The (interviewer-administered) NHP, Mini-Mental State Examination (MMSE), Barthel Index, and diagnostic information were recorded.

RESULTS

Completion rates varied from 98% of the 49 patients with normal cognition (MMSE >or=21) and 86.3% of the 51 with moderate cognitive impairment (MMSE 10-20), to 5.9% of the 34 with severe cognitive impairment (MMSE<10). Cronbach's alpha of the total NHP score was near 0.9 (0.82 and 0.87 for patients with MMSE >or= 21 and 10-20, respectively; p = 0.291). The correlation between 'Physical Mobility' of the NHP and Barthel Index was also similar in both cognitive groups (0.39 and 0.40).

CONCLUSION

Interviewer-administered NHP is suitable, reliable and valid, even in patients with moderate cognitive function.

Factors affecting completion of the SF-36 in older people

OBJECTIVE

to examine the influence of specific clinical impairments and disabilities on the completion of the SF-36 health status measure among older people.

DESIGN

Prospective observational study.

SETTING/PARTICIPANTS

An SF-36 was administered to 245 subjects aged 65 years and older. Subjects were chosen by sampling from a variety of inpatient, outpatient and community sources to ensure a range of relevant disabilities.

MEASUREMENTS

response rates, overall rates of completion, completion of individual questions and time taken to complete.

RESULTS

severe functional impairment (Barthel index < or = 12) was found in 22.4% (51/228), cognitive impairment in 54.1% (132/244), depressed mood in 77.0% (151/196) and visuospatial dysfunction in 71.3% (134/188). The median number of impairments was three (interquartile range 1-4). Specific physical impairments were visual in 13.2% (31/235), hearing in 30.2% (74/245), impaired manual dexterity in 18.0% (44/245) and dysphasia in 23% (55/239). In multivariate analyses, global functional impairment (P = 0.006), cognitive impairment (P = 0.0001) and impaired manual dexterity (P = 0.005) were significantly associated with more dimensions uncompleted, whilst cognitive impairment (P = 0.001), age (P = 0.006) and visuospatial dysfunction (P = 0.0003) were significantly associated with longer completion times.

CONCLUSION

the most striking finding of the study was that global rather than specific physical and mental dysfunction was associated with the inability to complete the SF-36 questionnaire. The difficulty appears to lie in the performance of a complex task, rather than with specific aspects of the task which could be overcome by adaptation or aids. Our experience is that this relatively complex questionnaire does not adequately measure functional health status in disabled older people because of non-completion and may therefore overestimate the health of populations.

Different factor loadings for SF36: The Strong Heart Study and the National Survey of Functional Health Status

BACKGROUND

To increase our understanding of the psychometric characteristics and factor structure of the SF36 in older American Indian populations.

METHODS

Between 1993 and 1995, SF36 data were collected from 3,488 Phase II participants of the Strong Heart Study (SHS) between the ages of 48 and 81. Comparison data were provided by an age- and gender-matched sample (n = 695) from the National Survey of Functional Health Status (NSFHS) conducted in 1989 and 1990.

RESULTS

Generally, the basic psychometric analyses showed that the SF36 performed adequately in these older American Indians. Exploratory factor analyses indicated that a one-factor model best fit the data for both older groups. On the other hand, confirmatory factor analyses showed that a two-factor model with correlated factors provided a superior fit to the data than a one-factor model. An assumption of equivalent factor loadings for the SHS and NSFHS groups was untenable.

CONCLUSION

These analyses demonstrate that use of summary scores assuming a differentiated physical/mental functioning structure is likely improper in at least some populations. The SF36 provides an important opportunity to understand cultural differences in the conceptualization and measurement of health-related quality of life.

Chronic medical conditions and wishes to die among older primary care patients

OBJECTIVE

To determine the prevalence of wishes to die and the medical correlates of wishes to die among primary care patients aged 65 years and older.

METHOD

Three-hundred and fifty-five adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate completed a baseline in-home assessment. Participants were interviewed using standardized measures of medical conditions, functional status, and psychological status. Thoughts of death and wishes to die were assessed with standard questions from the Composite International Diagnostic Interview (CIDI) Depression Section.

RESULTS

The weighted point prevalence of thoughts of death was 9.7% and 6.1% for the wish to die. Several medical conditions were associated with a wish to die, for example myocardial infarction (MI). In multivariate models that adjusted for potentially influential characteristics, the association between a history of MI and the wish to die remained statistically significant (odds ratio (OR) = 3.32, 95% confidence interval (CI) (1.26, 8.75).

CONCLUSIONS

Thoughts of death and a wish to die are common in older primary care patients and were more likely among persons with chronic medical conditions. Persons with a history of myocardial infarction may be particularly vulnerable to a wish to die.

The role of cardiovascular disease in the identification and management of depression by primary care physicians

OBJECTIVE

The objective of this study was to describe the influence of cardiovascular disease (CVD) on identification and management of depression by primary care physicians.

METHOD

Three hundred fifty-five adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate completed a baseline in-home assessment. CVD was assessed by self-report and psychologic status was assessed with commonly used, validated standard questionnaires. At the index visit, doctors' ratings of depression and reports of active management were obtained on 340 of the 355 patients who completed in-home interviews.

RESULTS

Older adults who reported heart failure were more likely to be identified as depressed than were older adults who did not report heart failure (unadjusted odds ratio [OR]: 2.34; 95% confidence interval [CI]: 1.13-4.85; Wald chi(2) = 5.20, df = 1, p = 0.023). In multivariate models that controlled for potentially influential characteristics such as age, marital status, education, ethnicity, functional status, level of depression, cognitive impairment, attitudes about depression, use of medical care, and number of medications, the findings remained statistically significant. Among older adults identified as depressed, older adults with heart failure were significantly less likely to be actively managed for depression than were older adults without heart failure (unadjusted OR: 0.33; 95% CI: 0.14-0.76; Wald chi(2) = 6.73, df = 1, p = 0.009). After controlling for potentially influential covariates, these findings remained substantially unchanged.

CONCLUSIONS

CVD, in particular heart failure, may influence the identification and management of depression among older patients by primary care physicians. The findings underlie the importance of developing interventions that integrate the management of depression and CVD in primary care settings.

Patient ethnicity and the identification and active management of depression in late life

BACKGROUND

Black Americans are more likely to obtain mental health care from a primary care physician than from a mental health specialist. We investigated the association of ethnicity with the identification and active management of depression among older patients.

METHODS

Cross-sectional survey of 355 older adults with and without significant depressive symptoms. At the index visit, the physician's ratings of depression and reports of active management were obtained on 341 of the 355 patients who completed in-home interviews.

RESULTS

Older black patients were less likely than older white patients to be identified as depressed (unadjusted odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63) and their depression was less likely to be actively managed in the 6 months before the interview (unadjusted OR, 0.63; 95% CI, 0.19-2.16). In multivariate models that controlled for potentially influential characteristics such as patient age, sex, marital status, level of education, functional status, physical health, severity of depressive symptoms, severity of anxiety symptoms, attitudes about depression, number of office visits in the last 6 months, and the physician's rating of how well they knew the patient, the associations of identification (OR, 0.25; 95% CI, 0.17-0.39) and management (OR, 0.57; 95% CI, 0.19-1.77) with patient ethnicity remained substantially unchanged.

CONCLUSION

Our study calls attention to the role ethnicity may play in the identification and active management of depression among older primary care patients.

Functional Measures Across Neurologic Disease States: Analysis of Factors in Common

OBJECTIVE

To describe the underlying dimensions for a range of functional measures across 3 neurologic diseases at different time points.

DESIGN

Multiple cohort study.

SETTING

Combination of public hospital wards and community.

PARTICIPANTS

Patients (N=308) from 3 cohorts: paralytic poliomyelitis (n=38), mean of 25 years previously, assessed once; acute stroke admitted to hospital and followed up for 12 months postdischarge (n=181); and traumatic brain injury (TBI), admitted to hospital and followed up for 12 months postdischarge (n=89).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Barthel Index, FIM instrument, Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical component score (PCS) and mental component score (MCS), Community Integration Questionnaire (CIQ), and the London Handicap Score (LHS). Measures were compared at 2 time points: pre-event status for stroke, TBI and the polio cohort, and 12-month postdischarge status for stroke and TBI.

RESULTS

The different measures generally correlated highly within disease states at each time point. Principal components analysis revealed 2 underlying dimensions, a physical dimension onto which loaded the Barthel Index, FIM, PCS, and LHS and a cognitive/emotional dimension onto which loaded the MCS and, for subjects with polio, the CIQ. These 2 dimensions accounted for 69% of the variance in measures at the pre-event time point and 85% of the variance at the 12-month time point.

CONCLUSIONS

These data suggest 2 basic underlying dimensions across a wide range of measures in 3 different neurologic conditions even at different time points. Most of the variation in the measures can be captured using the 2 component summary scores (PCS, MCS) of the SF-36.

Quality of life in older people: a structured review of generic self-assessed health instruments

OBJECTIVE

To review evidence relating to the measurement properties of multi-item generic patient or self-assessed measures of health in older people.

METHODS

Systematic literature searches to identify instruments. Pre-defined criteria relating to reliability, validity and responsiveness.

RESULTS

122 articles relating to 15 instruments met the inclusion criteria. The most extensive evidence was found for the SF-36, COOP Charts, EQ-5D, Nottingham Health Profile (NHP) and SIP. Four instruments have evidence of both internal consistency and test-retest reliability--NHP, SF-12, SF-20, SF-36. Four instruments lack evidence of reliability--HSQ-12, IHQL, QWB, SQL. Most instruments were assessed for validity through comparisons with other instruments, global judgements of health, or clinical and socio-demographic variables. Five instruments lack evidence of responsiveness--GQL, HSQ-12, IHQL, QLI and QWB.

CONCLUSION

There is good evidence for reliability, validity and responsiveness for the SF-36, EQ-5D and NHP. There is more limited evidence for the COOP, SF-12 and SIP. The SF-36 is recommended where a detailed and broad ranging assessment of health is required, particularly in community dwelling older people with limited morbidity. The EQ-5D is recommended where a more succinct assessment is required, particularly where a substantial change in health is expected. Instrument content should be assessed for relevance before application. The concurrent evaluation of generic instruments in older people is recommended.

Magnitude and patterns of decline in health and function in 1 year affect subsequent 5-year survival

BACKGROUND

Indicators of physical function and health status can predict important outcomes in older persons, but little is known about the meaning of change in these measures. This study assessed the magnitude and patterns of change occurring in 1 year in six measures of health and function and estimated the effects on survival for 5 years.

METHODS

This prospective cohort study was based in two health care systems. Data were collected during home visits at baseline and every 3 months for 1 year. Subsequent deaths occurring within 5 years were ascertained using the National Death Index.

RESULTS

Of 439 older adults, 88 (20%) died within the subsequent 5 years. The optimal magnitude of decline to predict 5-year mortality was 0.1 meters/second for gait speed, 1 point for the Short Physical Performance Battery, and 0.05 points for Euroqol. Independent contributions were found for decline in gait speed (p =.001 to.002), Short Physical Performance Battery (p =.014 to.026), global health (p <.001), and activities of daily living (p =.005 to.019). More than one half of the episodes of decline were transient. Persistent decline in 1 year consistently predicted death, and transient decline in gait speed and global health increased mortality risk compared with no change.

CONCLUSIONS

A decline in gait speed of 0.1 m/s or 1 point in the Short Physical Performance Battery within 1 year increased the subsequent 5-year mortality rate. Transient declines in gait speed and self-reported health are as common as persistent declines and affect mortality risk.

Are factor analytical techniques used appropriately in the validation of health status questionnaires? A systematic review on the quality of factor analysis of the SF-36

Factor analysis is widely used to evaluate whether questionnaire items can be grouped into clusters representing different dimensions of the construct under study. This review focuses on the appropriate use of factor analysis. The Medical Outcomes Study Short Form-36 (SF-36) is used as an example. Articles were systematically searched and assessed according to a number of criteria for appropriate use and reporting. Twenty-eight studies were identified: exploratory factor analysis was performed in 22 studies, confirmatory factor analysis was performed in five studies and in one study both were performed. Substantial shortcomings were found in the reporting and justification of the methods applied. In 15 of the 23 studies in which exploratory factor analysis was performed, confirmatory factor analysis would have been more appropriate. Cross-validation was rarely performed. Presentation of the results and conclusions was often incomplete. Some of our results are specific for the SF-36, but the finding that both the application and the reporting of factor analysis leaves much room for improvement probably applies to other health status questionnaires as well. Optimal reporting and justification of methods is crucial for correct interpretation of the results and verification of the conclusions. Our list of criteria may be useful for journal editors, reviewers and researchers who have to assess publications in which factor analysis is applied.