Development of a health risk appraisal for the elderly (HRA-E)

Health Risk Appraisals With Aging Adults: An Integrative Review

Identification of risk factors unique to the aging experience is vital to support health promotion efforts and prevent loss of independence for the increasing aging population. Health risk appraisals are tools capable of identifying a broad range of factors that affect health; however, these tools were designed for use with predominantly healthy working-age adults. The purpose of this integrative review was to describe uses and adaptations of health risk appraisals with aging adults. A total of 43 articles met inclusion criteria, identifying multiple adaptations necessary to effectively identify the risks faced by aging adults, including those related to activities of daily living, pain, depression, social support/network, vision, hearing, and cognitive status. Uses included support for health promotion efforts and to determine risk for depression, falls, and loss of independence. Further research needs to be done to evaluate impact when used as a health promotion and prevention tool for aging adults.

Effects of health risk assessment and counselling on physical activity in older people: A pragmatic randomised trial

BACKGROUND

Interventions to increase physical activity (PA) among older community-dwelling adults may be enhanced by using multidimensional health risk assessment (HRA) as a basis for PA counselling.

METHODS

The study was conducted among nondisabled but mostly frail persons 65 years of age and older at an ambulatory geriatric clinic in Bucharest, Romania. From May to July 2014, 200 participants were randomly allocated to intervention and control groups. Intervention group participants completed an initial HRA questionnaire and then had monthly counselling sessions with a geriatrician over a period of six months that were aimed at increasing low or maintaining higher PA. Counselling also addressed the older persons' concomitant health risks and problems. The primary outcome was PA at six months (November 2014 to February 2015) evaluated with the International Physical Activity Questionnaire.

RESULTS

At baseline, PA levels were similar in intervention and control groups (median 1089.0, and 1053.0 MET [metabolic equivalent of task] minutes per week, interquartile ranges 606.0-1401.7, and 544.5-1512.7 MET minutes per week, respectively). Persons in the intervention group had an average of 11.2 concomitant health problems and risks (e.g., pain, depressive mood, hypertension). At six months, PA increased in the intervention group by a median of 180.0 MET minutes per week (95% confidence interval (CI) 43.4-316.6, p = 0.01) to 1248.8 MET minutes per week. In the control group, PA decreased by a median of 346.5 MET minutes per week (95% CI 178.4-514.6, p<0.001) to 693.0 MET minutes per week due to a seasonal effect, resulting in a difference of 420.0 MET minutes per week (95% CI 212.7-627.3, p< 0.001) between groups.

CONCLUSION

The use of HRA to inform individualized PA counselling is a promising method for achieving improvements in PA, and ultimately health and longevity among large groups of community-dwelling older persons.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number: ISRCTN11166046.

Effect of health risk assessment and counselling on health behaviour and survival in older people: a pragmatic randomised trial

BACKGROUND

Potentially avoidable risk factors continue to cause unnecessary disability and premature death in older people. Health risk assessment (HRA), a method successfully used in working-age populations, is a promising method for cost-effective health promotion and preventive care in older individuals, but the long-term effects of this approach are unknown. The objective of this study was to evaluate the effects of an innovative approach to HRA and counselling in older individuals for health behaviours, preventive care, and long-term survival.

METHODS AND FINDINGS

This study was a pragmatic, single-centre randomised controlled clinical trial in community-dwelling individuals aged 65 y or older registered with one of 19 primary care physician (PCP) practices in a mixed rural and urban area in Switzerland. From November 2000 to January 2002, 874 participants were randomly allocated to the intervention and 1,410 to usual care. The intervention consisted of HRA based on self-administered questionnaires and individualised computer-generated feedback reports, combined with nurse and PCP counselling over a 2-y period. Primary outcomes were health behaviours and preventive care use at 2 y and all-cause mortality at 8 y. At baseline, participants in the intervention group had a mean ± standard deviation of 6.9 ± 3.7 risk factors (including unfavourable health behaviours, health and functional impairments, and social risk factors) and 4.3 ± 1.8 deficits in recommended preventive care. At 2 y, favourable health behaviours and use of preventive care were more frequent in the intervention than in the control group (based on z-statistics from generalised estimating equation models). For example, 70% compared to 62% were physically active (odds ratio 1.43, 95% CI 1.16-1.77, p = 0.001), and 66% compared to 59% had influenza vaccinations in the past year (odds ratio 1.35, 95% CI 1.09-1.66, p = 0.005). At 8 y, based on an intention-to-treat analysis, the estimated proportion alive was 77.9% in the intervention and 72.8% in the control group, for an absolute mortality difference of 4.9% (95% CI 1.3%-8.5%, p = 0.009; based on z-test for risk difference). The hazard ratio of death comparing intervention with control was 0.79 (95% CI 0.66-0.94, p = 0.009; based on Wald test from Cox regression model), and the number needed to receive the intervention to prevent one death was 21 (95% CI 12-79). The main limitations of the study include the single-site study design, the use of a brief self-administered questionnaire for 2-y outcome data collection, the unavailability of other long-term outcome data (e.g., functional status, nursing home admissions), and the availability of long-term follow-up data on mortality for analysis only in 2014.

CONCLUSIONS

This is the first trial to our knowledge demonstrating that a collaborative care model of HRA in community-dwelling older people not only results in better health behaviours and increased use of recommended preventive care interventions, but also improves survival. The intervention tested in our study may serve as a model of how to implement a relatively low-cost but effective programme of disease prevention and health promotion in older individuals.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number: ISRCTN 28458424.

Risk factors for depressed mood amongst a community dwelling older age population in England: cross-sectional survey data from the PRO-AGE study

BACKGROUND

The Quality and Outcomes Framework in the United Kingdom (UK) National Health Service previously highlighted case finding of depression amongst patients with diabetes or coronary heart disease. However, depression in older people remains under-recognized. Comprehensive data for analyses of the association of depression in older age with other health and functional measures, and demographic factors from community populations within England, are lacking.

METHODS

Secondary analyses of cross-sectional baseline survey data from the England arm of a randomised controlled trial of health risk appraisal for older people in Europe; PRO-AGE study. Data from 1085 community-dwelling non-disabled people aged 65 years or more from three group practices in suburban London contributed to this study. Depressed mood was ascertained from the 5-item Mental Health Inventory Screening test. Exploratory multivariable logistic regression was used to identify the strongest associations of depressed mood with a previous diagnosis of a specified physical/mental health condition, health and functional measures, and demographic factors.

RESULTS

Depressed mood occurred in 14% (155/1085) of participants. A previous diagnoses of depression (OR 3.39; P < 0.001) and poor vision as determined from a Visual Function Questionnaire (OR 2.37; P = 0.001) were amongst the strongest factors associated with depressed mood that were independent of functional impairment, other co-morbidities, and demographic factors. A subgroup analyses on those without a previous diagnosis of depression also indicated that within this group, poor vision (OR 2.51; P = 0.002) was amongst the strongest independent factors associated with depressed mood.

CONCLUSIONS

Previous case-finding strategies in primary care focussed on heart disease and diabetes but health-related conditions other than coronary heart disease and diabetes are also associated with an increased risk for depression. Complex issues of multi-morbidity occur within aging populations. 'Risk' factors that appeared stronger than those, such as, diabetes and coronary heart disease that until recently prompted for screening in the UK due to the QOF, were identified, and independent of other morbidities associated with depressed mood. From the health and functional factors investigated, amongst the strongest factors associated with depressed mood was poor vision. Consideration to case finding for depressed mood among older people with visual impairment might be justified.

Why is tractable vision loss in older people being missed? Qualitative study

BACKGROUND

There is compelling evidence that there is substantial undetected vision loss amongst older people. Early recognition of undetected vision loss and timely referral for treatment might be possible within general practice, but methods of identifying those with unrecognised vision loss and persuading them to take up services that will potentially improve their eyesight and quality of life are not well understood. Population screening does not lead to improved vision in the older population. The aim of this study is to understand why older people with vision loss respond (or not) to their deteriorating eyesight.

METHODS

Focus groups and interviews were carried out with 76 people aged 65 and over from one general practice in London who had taken part in an earlier study of health risk appraisal. An analytic induction approach was used to analyse the data.

RESULTS

Three polarised themes emerged from the groups and interviews. 1) The capacity of individuals to take decisions and act on them effectively versus a collection of factors which acted as obstacles to older people taking care of their eyesight. 2) The belief that prevention is better than cure versus the view that deteriorating vision is an inevitable part of old age. 3) The incongruence between the professionalism and personalised approach of opticians and the commercialisation of their services.

CONCLUSIONS

The reasons why older people may not seek help for deteriorating vision can be explained in a model in which psychological attributes, costs to the individual and judgments about normal ageing interact. Understanding this model may help clinical decision making and health promotion efforts.

A randomized trial of effects of health risk appraisal combined with group sessions or home visits on preventive behaviors in older adults

BACKGROUND

To explore effects of a health risk appraisal for older people (HRA-O) program with reinforcement, we conducted a randomized controlled trial in 21 general practices in Hamburg, Germany.

METHODS

Overall, 2,580 older patients of 14 general practitioners trained in reinforcing recommendations related to HRA-O-identified risk factors were randomized into intervention (n = 878) and control (n = 1,702) groups. Patients (n = 746) of seven additional matched general practitioners who did not receive this training served as a comparison group. Patients allocated to the intervention group, and their general practitioners, received computer-tailored written recommendations, and patients were offered the choice between interdisciplinary group sessions (geriatrician, physiotherapist, social worker, and nutritionist) and home visits (nurse).

RESULTS

Among the intervention group, 580 (66%) persons made use of personal reinforcement (group sessions: 503 [87%], home visits: 77 [13%]). At 1-year follow-up, persons in the intervention group had higher use of preventive services (eg, influenza vaccinations, adjusted odds ratio 1.7; 95% confidence interval 1.4-2.1) and more favorable health behavior (eg, high fruit/fiber intake, odds ratio 2.0; 95% confidence interval 1.6-2.6), as compared with controls. Comparisons between intervention and comparison group data revealed similar effects, suggesting that physician training alone had no effect. Subgroup analyses indicated favorable effects for HRA-O with personal reinforcement, but not for HRA-O without reinforcement.

CONCLUSIONS

HRA-O combined with physician training and personal reinforcement had favorable effects on preventive care use and health behavior.

The self-administered 24-item geriatric pain measure (GPM-24-SA): psychometric properties in three European populations of community-dwelling older adults

OBJECTIVE

To explore the feasibility and psychometric properties of a self-administered version of the 24-item Geriatric Pain Measure (GPM-24-SA).

DESIGN

Secondary analysis of baseline data from the Prevention in Older People-Assessment in Generalists' practices trial, an international multi-center study of a health-risk appraisal system.

PARTICIPANTS

One thousand seventy-two community dwelling nondisabled older adults self-reporting pain from London, UK; Hamburg, Germany; and Solothurn, Switzerland.

OUTCOME MEASURES

GPM-24-SA as part of a multidimensional Health Risk Appraisal Questionnaire including self-reported demographic and health-related information.

RESULTS

Among the 1,072 subjects, 655 had complete GPM-24-SA data, 404 had <or=30% missing GPM-24-SA data, and 13 had >30% missing GPM-24-SA data. In psychometric analyses across the three European populations with complete GPM-24-SA data, the measure exhibited stable internal consistency, good convergent, divergent and discriminant validity, and produced stable pain measurements. However, factor analysis indicated differences in the GPM-24-SA across sites with discrepancies mainly related to items of a single subscale that failed to load appropriately. Analyses including imputation for subjects with <or=30% missing data demonstrated psychometric properties comparable to complete data analyses suggesting that imputation in cases with <or=30% missing GPM-24-SA data provides sufficient information to generate a valid score.

CONCLUSION

The GPM-24-SA is a promising tool for self-administered assessment of pain in community dwelling older adults. However, because of incomplete response and uncertainty in factor structure, further refinement and psychometric evaluation of the GPM-24-SA is needed before it could be recommended for widespread use.

Social network assessment in community-dwelling older persons: results from a study of three European populations

BACKGROUND AND AIMS

In clinical practice, the status of living alone is often used as the only measure describing an older person's social network. We evaluated whether additional use of a brief social network measure provides relevant additional information in relation to social support and engagement.

METHODS

Cross-sectional survey of 6982 community- dwelling adults 65 years or older living in London, UK; Hamburg, Germany; and Solothurn, Switzerland. Data were collected using the self-administered multidimensional Health Risk Appraisal Questionnaire. Multivariate models were used to analyse adjusted correlations between the two measures of social network (living alone status, risk for social isolation with marginal family and friend network subscales) and potential consequences of inadequate social network (marginal emotional or instrumental support, lack of social engagement).

RESULTS

Living alone status was more strongly associated with marginal instrumental support [OR=7.6 (95% CI 6.3, 9.1)] than with marginal emotional support [OR=4.2 (95% CI 3.4, 5.1)], and showed no statistically significant association with lack of social engagement [OR=0.9 (95% CI 0.8, 1.0)]. Risk of social isolation was more strongly related to marginal emotional support [OR=6.6 (95% CI 5.4, 8.0)] than to marginal instrumental support [OR=3.3 (95% CI 2.8, 4.0)], and was moderately related to lack of social engagement [OR=2.9 (95% CI 2.5, 3.4]. Marginal family and friend network subscales showed consistent and unique associations with social support and social engagement.

CONCLUSION

Findings suggest that living alone status and a brief measure of social network identifies distinctive at-risk groups and potential pathways for intervention. Geriatric assessment programs including both social network measures may provide useful information about potentially modifiable social network risks in older persons.

Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice

BACKGROUND

there is inadequate evidence to support currently formulated NHS strategies to achieve health promotion and preventative care in older people through broad-based screening and assessment in primary care. The most extensively evaluated delivery instrument for this purpose is Health Risk Appraisal (HRA). This article describes a trial using HRA to evaluate the effect on health behaviour and preventative-care uptake in older people in NHS primary care.

METHODS

a randomised controlled trial was undertaken in three London primary care group practices. Functionally independent community-dwelling patients older than 65 years (n = 2,503) received a self-administered Health Risk Appraisal for Older Persons (HRA-O) questionnaire leading to computer-generated individualised written feedback to participants and general practitioners (GPs), integrated into practice information-technology (IT) systems. All primary care staff received training in preventative health in older people. The main outcome measures were self-reported health behaviour and preventative care uptake at 1-year follow-up.

RESULTS

of 2,503 individuals randomised, 2,006 respondents (80.1%) (intervention, n = 940, control n = 1,066) were available for analysis. Intervention group respondents reported slightly higher pneumococcal vaccination uptake and equivocal improvement in physical activity levels compared with controls. No significant differences were observed for any other categories of health behaviour or preventative care measures at 1-year follow-up.

CONCLUSIONS

HRA-O implemented in this way resulted in minimal improvement of health behaviour or uptake of preventative care measures in older people. Supplementary reinforcement involving contact by health professionals with patients over and above routine clinical encounters may be a prerequisite to the effectiveness of IT-based delivery systems for health promotion in older people.

Preclinical disability as a risk factor for falls in community-dwelling older adults

BACKGROUND

Falls are common and serious problems in older adults. The goal of this study was to examine whether preclinical disability predicts incident falls in a European population of community-dwelling older adults.

METHODS

Secondary data analysis was performed on a population-based longitudinal study of 1644 community-dwelling older adults living in London, U.K.; Hamburg, Germany; Solothurn, Switzerland. Data were collected at baseline and 1-year follow-up using a self-administered multidimensional health risk appraisal questionnaire, including validated questions on falls, mobility disability status (high function, preclinical disability, task difficulty), and demographic and health-related characteristics. Associations were evaluated using bivariate and multivariate logistic regression analyses.

RESULTS

Overall incidence of falls was 24%, and increased by worsening mobility disability status: high function (17%), preclinical disability (32%), task difficulty (40%), test-of-trend p <.003. In multivariate analysis adjusting for other fall risk factors, preclinical disability (odds ratio [OR] = 1.7, 95% confidence interval [CI], 1.1-2.5), task difficulty (OR = 1.7, 95% CI, 1.1-2.6) and history of falls (OR = 4.7, 95% CI, 3.5-6.3) were the strongest significant predictors of falls. In stratified multivariate analyses, preclinical disability equally predicted falls in participants with (OR = 1.7, 95% CI, 1.0-3.0) and without history of falls (OR = 1.8, 95% CI, 1.1-3.0).

CONCLUSIONS

This study provides longitudinal evidence that self-reported preclinical disability predicts incident falls at 1-year follow-up independent of other self-reported fall risk factors. Multidimensional geriatric assessment that includes preclinical disability may provide a unique early warning system as well as potential targets for intervention.

Development, feasibility and performance of a health risk appraisal questionnaire for older persons

BACKGROUND

Health risk appraisal is a promising method for health promotion and prevention in older persons. The Health Risk Appraisal for the Elderly (HRA-E) developed in the U.S. has unique features but has not been tested outside the United States.

METHODS

Based on the original HRA-E, we developed a scientifically updated and regionally adapted multilingual Health Risk Appraisal for Older Persons (HRA-O) instrument consisting of a self-administered questionnaire and software-generated feed-back reports. We evaluated the practicability and performance of the questionnaire in non-disabled community-dwelling older persons in London (U.K.) (N = 1090), Hamburg (Germany) (N = 804), and Solothurn (Switzerland) (N = 748) in a sub-sample of an international randomised controlled study.

RESULTS

Over eighty percent of invited older persons returned the self-administered HRA-O questionnaire. Fair or poor self-perceived health status and older age were correlated with higher rates of non-return of the questionnaire. Older participants and those with lower educational levels reported more difficulty in completing the HRA-O questionnaire as compared to younger and higher educated persons. However, even among older participants and those with low educational level, more than 80% rated the questionnaire as easy to complete. Prevalence rates of risks for functional decline or problems were between 2% and 91% for the 19 HRA-O domains. Participants' intention to change health behaviour suggested that for some risk factors participants were in a pre-contemplation phase, having no short- or medium-term plans for change. Many participants perceived their health behaviour or preventative care uptake as optimal, despite indications of deficits according to the HRA-O based evaluation.

CONCLUSION

The HRA-O questionnaire was highly accepted by a broad range of community-dwelling non-disabled persons. It identified a high number of risks and problems, and provided information on participants' intention to change health behaviour.

The PRO-AGE study: an international randomised controlled study of health risk appraisal for older persons based in general practice

BACKGROUND

This paper describes the study protocol, the recruitment, and base-line data for evaluating the success of randomisation of the PRO-AGE (PRevention in Older people-Assessment in GEneralists' practices) project.

METHODS/DESIGN

A group of general practitioners (GPs) in London (U.K.), Hamburg (Germany) and Solothurn (Switzerland) were trained in risk identification, health promotion, and prevention in older people. Their non-disabled older patients were invited to participate in a randomised controlled study. Participants allocated to the intervention group were offered the Health Risk Appraisal for Older Persons (HRA-O) instrument with a site-specific method for reinforcement (London: physician reminders in electronic medical record; Hamburg: one group session or two preventive home visits; Solothurn: six-monthly preventive home visits over a two-year period). Participants allocated to the control group received usual care. At each site, an additional group of GPs did not receive the training, and their eligible patients were invited to participate in a concurrent comparison group. Primary outcomes are self-reported health behaviour and preventative care use at one-year follow-up. In Solothurn, an additional follow-up was conducted at two years. The number of older persons agreeing to participate (% of eligible persons) in the randomised controlled study was 2503 (66.0%) in London, 2580 (53.6%) in Hamburg, and 2284 (67.5%) in Solothurn. Base-line findings confirm that randomisation of participants was successful, with comparable characteristics between intervention and control groups. The number of persons (% of eligible) enrolled in the concurrent comparison group was 636 (48.8%) in London, 746 (35.7%) in Hamburg, and 1171 (63.0%) in Solothurn.

DISCUSSION

PRO-AGE is the first large-scale randomised controlled trial of health risk appraisal for older people in Europe. Its results will inform about the effects of implementing HRA-O with different methods of reinforcement.

Performance of an abbreviated version of the Lubben Social Network Scale among three European community-dwelling older adult populations

PURPOSE

There is a need for valid and reliable short scales that can be used to assess social networks and social supports and to screen for social isolation in older persons.

DESIGN AND METHODS

The present study is a cross-national and cross-cultural evaluation of the performance of an abbreviated version of the Lubben Social Network Scale (LSNS-6), which was used to screen for social isolation among community-dwelling older adult populations in three European countries. Based on the concept of lack of redundancy of social ties we defined clinical cut-points of the LSNS-6 for identifying persons deemed at risk for social isolation.

RESULTS

Among all three samples, the LSNS-6 and two subscales (Family and Friends) demonstrated high levels of internal consistency, stable factor structures, and high correlations with criterion variables. The proposed clinical cut-points showed good convergent validity, and classified 20% of the respondents in Hamburg, 11% of those in Solothurn (Switzerland), and 15% of those in London as at risk for social isolation.

IMPLICATIONS

We conclude that abbreviated scales such as the LSNS-6 should be considered for inclusion in practice protocols of gerontological practitioners. Screening older persons based on the LSNS-6 provides quantitative information on their family and friendship ties, and identifies persons at increased risk for social isolation who might benefit from in-depth assessment and targeted interventions.

Self-reported visual function in healthy older people in Britain: an exploratory study of associations with age, sex, depression, education and income

BACKGROUND

Tractable but undetected visual impairment in older people may be relatively common, particularly amongst the very old and in more deprived populations. Measurement of visual acuity is unlikely to be helpful in identifying this impairment, but targeted assessment of visual function may be beneficial. There is uncertainty about the defining characteristics of the target group.

OBJECTIVE

To explore factors associated with self-reported visual impairment in community dwelling older people.

DESIGN

secondary cross sectional analysis of baseline data from a randomised controlled trial.

SETTING

three large group practices in outer London.

PARTICIPANTS

older people aged 65 and over enrolled in a study of health risk appraisal.

METHOD

postal questionnaire using questions from the National Eye Institute Visual Function questionnaire.

RESULTS

Moderate or extreme visual function loss occurred in 4 to 12% of community-dwelling older people in this population reporting less than excellent vision, depending on which aspect of visual function is considered. Visual function loss in this subgroup increases in prevalence with advancing age, but is not associated with female sex, low educational attainment or low income. It is associated with depressed mood.

CONCLUSION

Questions about visual function identify a group of older people whose vision and mental state needs further investigation.

Validity and reliability of SCREEN II (Seniors in the Community: Risk evaluation for eating and nutrition, Version II)

BACKGROUND

Nutrition risk screening for community-living seniors is of great interest in the health arena. However, to be useful, nutrition risk indices need to be valid and reliable. The following three studies describe construct validation, test-retest and inter-rater reliability of SCREEN II.

METHODS

Study (1) seniors were recruited from the general community and from a geriatrician's clinic to complete a nutritional assessment and SCREEN II. 193 older adults provided medical and nutritional history, 3 days of dietary recall and anthropometric measurements. A dietitian reviewed all information collected and ranked seniors on risk: 1 (low) to 10 (high risk). Receiver operating characteristic curves were completed. An abbreviated SCREEN II was developed through statistical analysis and expert ranking of the 17 items. Studies (2) and (3) seniors were recruited from the community to self-administer (n = 149) or be interviewed (n = 97) using SCREEN II twice within 2 weeks. For self-administration one index was completed via mail. Interviewer administration was completed via telephone with two interviewers. Intra-class correlations were calculated.

RESULTS

(1) Total and abbreviated SCREEN II have increased sensitivity and specificity as compared to SCREEN I in identifying seniors at nutritional risk. (2) Test-retest reliability was adequate (intra-class correlation (ICC) = 0.83). (3) Inter-rater reliability was adequate (ICC = 0.83).

CONCLUSIONS

SCREEN II appears to be a valid and reliable tool for the identification of risk for impaired nutritional states in community-living older adults, and is an improvement over SCREEN I.

Arzneimittelgebrauch und gesundheitliche Selbsteinschätzung selbstständig lebender, älterer Hamburger

Self-perceived health as reported by elderly persons is of prognostic value and corresponds with morbidity and mortality. In the present study, information about the utilisation of medication, visits to the doctor, and self-perceived health was provided by standardised self-reports. The study sample included 804 independent community-dwelling persons 60 years and older. These persons were recruited from the patient lists of 14 general practices in Hamburg. Exclusion criteria were dementive disorders and the need of personal care. On average, there were 3 prescribed drugs and 1 over-the-counter medication per person. The number of medications corresponds to a mean of 2 chronic disorders. Almost 50% of the participants reported suffering from pain, with more than one-third rating their pain intensity as moderate or high. Furthermore, nearly half of the study population stated their self-reported health as moderate or poor, and one-fifth reported symptoms of depressed mood. There were discrepancies between the reports of pain or depressed mood and the corresponding use of medication. It seems that self-reported symptoms and self-perceived health in elderly persons should be considered more often in drug prescribing.

Health risk appraisal for older people in general practice using an expert system: a pilot study

The prevention of disability in later life is a major challenge facing industrialised societies. Primary care practitioners are well positioned to maintain and promote health in older people, but the British experience of population-wide preventive interventions has been disappointing. Health risk appraisal (HRA), an emergent information-technology-based approach from the USA, has the potential for fulfilling some of the objectives of the National Service Framework for Older People. Information technology and expert systems allow the perspectives of older people on their health and health risk behaviours to be collated, analysed and converted into tailored health promotion advice without adding to the workload of primary care practitioners. The present paper describes a preliminary study of the portability of HRA to British settings. Cultural adaptation and feasibility testing of a comprehensive health risk assessment questionnaire was carried out in a single group practice with 12,500 patients, in which 58% of the registered population aged 65 years and over participated in the study. Eight out of 10 respondents at all ages found the questionnaire easy or very easy to understand and complete, although more than one-third had or would have liked assistance. More than half felt that the length of the questionnaire was about right, and one respondent in 10 disliked some questions. Of those who completed the questionnaire and received tailored, written health promotion advice, 39% provided feedback on this with comments that can be used for increasing the acceptability of tailored advice. These findings have informed a wider exploratory study in general practice.

Are there differences between older persons who screen positive on the CAGE questionnaire and the Short Michigan Alcoholism Screening Test-Geriatric Version?

OBJECTIVES

To determine (1) the extent of agreement between the CAGE (acronym for cut down, annoyed by criticism, guilty about drinking, eye-opener drinks) and the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) in identifying older persons who may have possible alcohol use disorders (AUDs) and (2) whether persons identified as having possible AUDs by each of these screening measures differ in their drinking, demographic, or health-related characteristics.

DESIGN

Secondary analysis of a cross-sectional study using data from a self-administered mailed survey sample.

SETTING

Three organizations were surveyed: (1) members of the American Association of Retired Persons and, in southern California, (2) managed care enrollees in a large medical group and (3) attendees of a community-based senior health center.

PARTICIPANTS

One thousand eight hundred eighty-nine persons aged 55 and older completing a health risk appraisal for older persons (Health Risk Appraisal for the Elderly (HRA-E)).

MEASUREMENTS

The HRA-E included items on drinking behaviors (including amount of alcohol use, the CAGE, and the SMAST-G) and health and demographic characteristics.

RESULTS

Twenty-six percent of all persons screened positive on the CAGE or the SMAST-G. Fewer than half of all persons screening positive on either the CAGE or the SMAST-G, screened positive on both measures. Among current drinkers, persons screening positive on the SMAST-G alone drank less than persons screening positive on the CAGE alone, and these persons drank less than those screening positive on both the SMAST-G and the CAGE. More men screened positive on the CAGE alone than on the SMAST-G alone.

CONCLUSION

Fewer than half of persons screening positive on either the CAGE or the SMAST-G screened positive on both measures, suggesting that these instruments may be capturing different aspects of unsafe drinking. A screening strategy employing both brief measures may identify more AUDs among older persons having differing demographic and health characteristics.

Are older hazardous and harmful drinkers less likely to participate in health-related behaviors and practices as compared with nonhazardous drinkers?

OBJECTIVES

To describe the (1) prevalence of at-risk drinking and participation in health-related behaviors and practices and (2) associations of at-risk drinking with other health-related behaviors and practices among older persons completing a health-risk appraisal for the elderly (HRA-E).

DESIGN

Cross-sectional study using data from a self-administered, mailed survey sample.

SETTINGS

Persons from three organizations were surveyed: (1) the American Association of Retired Persons; and (2) a large medical group and (3) a community-based senior health center in southern California.

PARTICIPANTS

1,889 persons age 55 years and older.

MEASUREMENTS

The HRA-E included items on health characteristics, drinking behaviors (including amount of alcohol use and two alcoholism screening measures: the CAGE (Cut down, Annoyed, Guilty, Eye opener) and Short Michigan Alcoholism Screening Test-Geriatric version (SMAST-G), and participation in selected health-related behaviors and practices. Social drinkers were defined as those who drank fewer than 14 drinks weekly and screened negative on the CAGE (defined as two or more "no" responses) and SMAST-G. Hazardous drinkers drank fewer than 14 drinks weekly and screened negative. Harmful drinkers drank fewer than 14 drinks weekly and screened positive. Possible at-risk drinkers drank 14 or more drinks weekly and screened positive. Least squares regression models were used to assess the effects of hazardous, harmful, and possible at-risk drinking on each of the health-related practices and behaviors. We also conducted these analyses using three other definitions of social, possible at-risk, hazardous, and harmful drinking.

RESULTS

Of all respondents, 40% were social drinkers, 3% were harmful drinkers, 2% were hazardous drinkers, and 11% were possible at-risk drinkers. Hazardous, harmful, and possible at-risk drinkers commonly reported driving after drinking or being driven by someone who had been drinking (67%, 76%, and 64% respectively). Harmful and possible at-risk drinkers were more likely than social drinkers to smoke and were less likely to use seatbelts regularly. These findings were observed regardless of how the drinking groups were defined.

CONCLUSION

All groups of at-risk drinkers more commonly engaged in selected adverse health-related behaviors and practices than did social drinkers.

Correlates of knowledge of one's blood pressure and cholesterol levels among older members of a managed care plan

We examined factors predicting knowledge of one's blood pressure, total cholesterol, and high-density lipoprotein levels (HDL) among older persons who reported a recent blood pressure or cholesterol test. Data come from a self-administered, health risk assessment that was mailed to health plan members, age 55 and older, in a Santa Barbara, California medical group. Despite their universal access to health care and high levels of reported compliance with preventive health care screening practices, 41%, 49%, and 77% of respondents reported that they did not know their blood pressure, cholesterol, or HDL levels, respectively. After controlling for potential confounders, age and low income were inversely associated with the respondents' ability to report each level. In addition, current smoking and obesity were inversely associated with self-reported knowledge of both cholesterol measures. Persons taking medication for hypertension or hypercholesterolemia were much more likely than those not taking medication to be able to report their blood pressure and cholesterol levels. Except for persons currently undergoing treatment for related conditions, these results suggest that a substantial proportion of the older persons at high risk for cardiovascular disease do not know their levels of these important biological risk factors. This lack of knowledge has important implications for public health education, and may hinder risk-reduction efforts among the elderly.