Impairment in role functioning in mental and chronic medical disorders in the United States: results from the National Comorbidity Survey Replication

This study presents national data on the comparative role impairments of common mental and chronic medical disorders in the general population. These data come from the National Comorbidity Survey Replication, a nationally representative household survey. Disorder-specific role impairment was assessed with the Sheehan Disability Scales, a multidimensional instrument that asked respondents to attribute impairment to particular conditions. Overall impairment was significantly higher for mental than chronic medical disorders in 74% of pair-wise comparisons between the two groups of conditions, and severe impairment was reported by a significantly higher portion of persons with mental disorders (42.0%) than chronic medical disorders (24.4%). However, treatment was provided for a significantly lower proportion of mental (21.4%) than chronic medical (58.2%) disorders. Although mental disorders were associated with comparable or higher impairment than chronic medical conditions in all domains of function, they showed different patterns of deficits; whereas chronic medical disorders were most likely to be associated with impairment in domains of work and home functioning, mental disorders were most commonly associated with problems in social and close-relation domains. Comorbidity between chronic medical and mental disorders significantly increased the reported impairment associated with each type of disorder. The results indicate a serious mismatch between a high degree of impairment and a low rate of treatment for mental disorders in the United States. Efforts to reduce disability will need to address the disproportionate burden and distinct patterns of deficits of mental disorders and the potentially synergistic impact of comorbid mental and chronic medical disorders.

Translational measures of functioning and disability based on the International Classification of Functioning, Disability and Health

Introduction

Aims

Results

Conclusions

Local, regional and national experiences on bridging: US perspectives

Introduction

Description of policy practice

Conclusions

Discussion

Crossing network lines between ageing and disability in the United States

Introduction

In the US, ageing and disability public policies, programs, and service systems have historically separate origins, age-based categorical eligibility, and distinct funding streams. This division creates barriers in serving persons ageing with disability transitioning from disability to ageing service systems and for older adults obtaining independent living services in disability systems.

Description of policy practice

Professional cross-network collaborations can bridge ageing and disability service networks. Barriers to cross-network collaborations include competition for public funds, lack of professional cross-system knowledge, unfamiliarity with non-traditional consumer groups, and limited organizational interest or administrative knowledge of how to build and maintain collaborative relationships. Demonstrated successful collaborations and coalitions have strong leadership, organizational support, partners with shared interests and goals, clear missions, and strong investment by professional staff and service system clients.

Conclusions

There is growing evidence that the work of crossing network lines is locally implemented and sustained. Large-scale government mandates can help initiate this process.

Discussion

Service networks include governmental (public) and non-governmental (private) organizations. Collaboration is mainly voluntary, but encouraged by: growth in home and community based care, demand for community integration by people with disabilities, and the need for fiscal efficiency and demonstrated performance results in government spending.

Defining disability – Re-defining policy

Introduction

In 2002, an EC study reported that different European countries define disability differently, and this is one of the primary reasons why no common Europe-wide policies on disability exist. The EU-MHADIE project was funded with the aim of producing recommendations and guidelines for future common disability policies. The WHO’s ICF classification and its bio-psycho-social model of disability was the theoretical reference to ground existing and survey data on.

Description of care and policy practice

MHADIE project demonstrated the feasibility and utility of the ICF, as a model of disability and functioning, for the harmonisation of data across populations and sectors in Europe, and for the development of realistic, evidence-based and effective social policies for persons with disabilities that will achieve equality of opportunities and full participation, according to the UN Convention on the Rights of Persons with Disabilities.

Discussion

Disability is an ever-changing experience, and so data that recognize its dynamic nature must be gathered, through longitudinal studies that use a consistent definition of disability. The research performed within MHADIE has demonstrated the feasibility, utility and value of ICF classification and model in harmonising data across populations and sectors in Europe. MHADIE researchers have demonstrated that it is possible to develop realistic, evidence-based and effective social policies for persons with disabilities and that it is essential to share the same disability definition. By providing a common framework for defining and measuring functioning and disability, MHADIE’s results help to improve the accuracy and comparability estimates of prevalence of impairments and disability Europe-wide. MHADIE results show, among other, that family and transportation policies are key factors for all persons with disabilities, and dedicated European policies are needed to improve and emphasize their role.

Conclusions

A definition of disability underlying ICF’s principles was produced, together with policy recommendation divided into statistical, clinical and education sections that have been presented at the European Parliament and are available at http://www.mhadie.it.

Bridging knowledge: reflections on crossing the boundaries between long-term care and support

In March 2009 members of the research, policy and practice communities in the fields of ageing and disability came together in Barcelona for the first international conference on bridging knowledge in long-term care and support. This paper presents a brief snapshot of some of the key themes and ideas that emerged during three days of presentation and debate on methods, policy and practice.

Bridging education and training in ageing and disabilities: towards translational education

Introduction

Translational education takes up the notion of integrating basic research and practice out of a cross-disciplinary perspective given that disciplinary knowledge will no longer be sufficient to account for the complexity of the encountered problem fields. Persons trained in translational education will thus be able to integrate several disciplinary knowledge domains and translate new developments in basic research to their application.

Description of care or policy practice

The concept of translational education has become prominent in medical training and it clearly has implications for the training of care givers given the complexity of the diverse problems associated with care. Care and care giving always imply theory and research from different scientific disciplines; there are medical, legal, sociological, and psychological components of care giving, and care giving also increasingly relies on new developments in the domains of technology. In order to keep an integrative view of all these developments and to finally obtain an integrative approach in care, translational education represents an imperative task for training carers in the domains of ageing and disabilities.

Conclusion and discussion

Caring for a person—be it formal or informal—always has to rely on a sound basis of knowledge in order to prevent failures as well as feelings of stress and strain. Given that the knowledge base for carers becomes increasingly complex as it is fed by several disciplines as well as societal developments, training and education programmes should realise both a translational approach as well as a lifelong learning perspective. Although much is in favour of such an approach, limits of translational education do exist as well and these comprise mainly the production of a common knowledge across multiple domains for the cost of neglecting in-depth understanding of specific knowledge domains.

The Graz Declaration on Disability and Ageing 2006

Introduction

A twin-track model

Conclusion

The concept of ‘functional dependency’

Introduction

In Europe the concepts of ‘functioning/disability’ and ‘autonomy/dependency’ deserve special interest from the point of view of medical ontology. While Functioning/Disability are concepts defined at the WHO International Classification of Functioning (ICF), the autonomy/dependency pair is not even mentioned at this classification system.

Description

The Council of Europe has defined ‘dependency’ as the condition related to the loss of autonomy and the need of support by a third person related to an impairment of activities of daily living, specially self-care. Laws and care services for the elderly and for persons with severe disability have been developed following this paradigm in several EU countries. These concepts are based in the Activities of Daily Living construct (ADLs) which divides these activities in basic and instrumental. This construct cannot be linked to the WHO-ICF paradigm as stated in the Spanish law. WHO has defined ‘personal autonomy’ as equivalent to self-direction, competence and self-empowerment, and there is no equivalent definition of function-related autonomy at the WHO Family of Classifications.

Conclusion

The different background of these concept pairs had a significant impact on the development of health and social services in several European countries during the last decade. This is particularly important for those conditions where impairment is not related directly to basic ADLs but to other functional problems such as severe mental illness or intellectual disability. The ontological disparities need careful review to avoid inequity in access to care for severe disability in Europe.

The burden of late-life generalized anxiety disorder: effects on disability, health-related quality of life, and healthcare utilization

OBJECTIVE

To describe the burden of Generalized Anxiety Disorder (GAD), a common anxiety disorder in older adults.

DESIGN

Cross-sectional.

SETTING

Late-life depression and anxiety research clinic in Pittsburgh, PA.

PARTICIPANTS

One hundred sixty-four older adults with GAD and 42 healthy comparison participants with no lifetime history of psychiatric disorder were recruited from primary care and mental health settings as well as advertisements.

MEASUREMENTS

Participants were evaluated with the Late Life Function and Disability Index to assess disability, the MOS 36-Item Short Form Survey Instrument to assess health-related quality of life (HRQOL), and the Cornell Service Index to assess healthcare utilization.

RESULTS

Older adults with GAD were more disabled, had worse HRQOL, and had greater healthcare utilization, than nonanxious comparison participants, even in the absence of psychiatric comorbidity. After controlling for medical burden and depressive symptoms, higher severity of anxiety symptoms was associated with greater disability and poorer HRQOL in several domains. The greatest decrements in HRQOL and function were observed in measures assessing role functioning, including social function.

CONCLUSION

This study, the largest ever of GAD in older adults, provides evidence of the significant burden of this disorder in late life. Given the high prevalence and chronicity of GAD in the elderly, these data provide a public health imperative for finding and implementing effective management strategies for this typically undiagnosed and untreated disorder.

SCIRehab Project series: the social work/case management taxonomy

CONTEXT

Social work and case management (SW/CM) are integral components of acute inpatient spinal cord injury (SCI) rehabilitation. However, evidence is sparse regarding the impact of SW/CM interventions on outcomes. To advance research on SW/CM clinical practice in SCI rehabilitation, SW/CM providers and researchers first must have standard classifications for SW/CM interventions.

BACKGROUND/OBJECTIVE

To develop a taxonomy (classification) of the various interventions and services that comprise SW/CM.

METHODS

A group of SW/CM clinicians compiled a list of activities performed as routine practice at the participating rehabilitation facilities. These activities were grouped and defined systematically.

RESULTS

The resulting taxonomy includes 8 major activity topics (financial planning, discharge planning, discharge services, supportive counseling, information about and referral to peer/advocacy groups, education about SCI and other relevant topics, information about and referral to community/in-house services, and team conferences), which were further stratified into specific content areas. Interactions with the patient, family, or other team members and resources, along with descriptions of the interactions that are applicable to each of the 8 activity topics, were included as well.

CONCLUSION

An intervention taxonomy is required to study the SW/CM interventions and the potential association with positive rehabilitation outcomes for patients with SCI. The SW/CM taxonomy developed for the SCIRehab project, which will be used with 1,500 patients admitted to 6 SCIRehab centers over 2.5 years, will provide an infrastructure for such research.

"This is a kind of betrayal": a qualitative study of disability after breast cancer

OBJECTIVE

We proposed to document the effect of arm morbidity and disability in 40 Canadian women who were 12-24 months post breast cancer surgery.

METHODS

We completed 40 qualitative interviews as one component of a multidisciplinary national longitudinal study of arm morbidity after breast cancer (n = 745) involving four research sites (Fredericton/Saint John, Montreal, Winnipeg, Surrey). During semi-structured interviews, participants who had reported arm morbidity and disability in earlier surveys were asked to discuss the effects of these conditions on everyday life.

RESULTS

The interviewees reported making major adjustments to paid and unpaid work, which often involved the assistance of family members, thus demonstrating the effect of disability. Interview data resulted in the creation of a model that addresses arm morbidity and disability, and that holds implications for health care professionals.

CONCLUSIONS

Based on the interview findings, we conclude that a robust measure of disability after breast cancer should be developed. In the absence of a validated measure of the effect of disability, evaluating qualitative responses to questions about everyday activities could provide the impetus for provision of physical therapy and emotional support.

Abbreviated neuropsychological assessment in schizophrenia: prediction of different aspects of outcome

The aim of this study was to identify the best subset of neuropsychological tests for prediction of several different aspects of functioning in a large (n = 236) sample of older people with schizophrenia. While the validity of abbreviated assessment methods has been examined before, there has never been a comparative study of the prediction of different elements of cognitive impairment, real-world outcomes, and performance-based measures of functional capacity. Scores on 10 different tests from a neuropsychological assessment battery were used to predict global neuropsychological (NP) performance (indexed with averaged scores or calculated general deficit scores), performance-based indices of everyday-living skills and social competence, and case-manager ratings of real-world functioning. Forward entry stepwise regression analyses were used to identify the best predictors for each of the outcomes measures. Then, the analyses were adjusted for estimated premorbid IQ, which reduced the magnitude, but not the structure, of the correlations. Substantial amounts (over 70%) of the variance in overall NP performance were accounted for by a limited number of NP tests. Considerable variance in measures of functional capacity was also accounted for by a limited number of tests. Different tests constituted the best predictor set for each outcome measure. A substantial proportion of the variance in several different NP and functional outcomes can be accounted for by a small number of NP tests that can be completed in a few minutes, although there is considerable unexplained variance. However, the abbreviated assessments that best predict different outcomes vary across outcomes. Future studies should determine whether responses to pharmacological and remediation treatments can be captured with brief assessments as well.

A latent variable structural path model of health behaviors after spinal cord injury

BACKGROUND/OBJECTIVE

To develop a latent behavioral model by identifying and confirming the factor structure of health behaviors of people with spinal cord injury (SCI) and their relationships with biographic, injury, and educational characteristics.

RESEARCH DESIGN

Survey data were collected from 1388 adults with traumatic SCI of at least 1 year duration.

MAIN OUTCOME MEASURES

Selection of health behaviors was based on a bidimensional behavioral risk model. Behaviors were measured by core item sets from the Behavioral Risk Factor Surveillance System and supplemented by an alcohol screening measure, select fitness proxies, and the SCI Health Survey.

RESULTS

Latent variable structural equation modeling was used to identify underlying factors and their relationship with participant characteristics. Seven specific factors were identified by exploratory factor analysis and were cross-validated using confirmatory factor analysis. They included: (a) healthy nutrition, (b) unhealthy nutrition, (c) fitness, (d) smoking, (e) alcohol use, (f) psychotropic prescription medications, and (g) SCI healthy activities. Two higher-order dimensions were also identified, including a risk dimension (b, d, e) and a protective dimension (a, c, g). Participant characteristics were associated with the domains. For instance, participants with the most severe injuries scored lower on smoking and alcohol but higher on psychotropic medications; age was positively correlated with healthy nutrition and negatively correlated with alcohol and tobacco use but also negatively correlated with fitness.

CONCLUSION

Behaviors can be meaningfully combined into underlying dimensions to more efficiently use them as predictors of secondary conditions.

Influence of sport participation on community integration and quality of life: a comparison between sport participants and non-sport participants with spinal cord injury

BACKGROUND/OBJECTIVE

To determine whether community integration and/or quality of life (QoL) among people living with chronic spinal cord injury (SCI) are superior among sport participants vs non-sport participants.

STUDY DESIGN

Cross-sectional study.

PARTICIPANTS/METHODS

Persons (n=90) living in the community with SCI (ASIA Impairment Scale A-D), level C5 or below, > 15 years of age, >12 months postinjury, and requiring a wheelchair for >1 hours/day were divided into 2 groups based on their self-reported sport participation at interview: sport participants (n=45) and non-sport participants (n 5).

RESULTS

Independent-sample t tests revealed that both Community Integration Questionnaire (CIQ) and Reintegration to Normal Living Index (RNL) total mean scores were higher among sport participants vs nonsport participants (P < 0.05). Significant correlation between CIQ and RNL total scores was found for all participants (Pearson correlation coefficients, P < 0.01). Logistic regression analysis revealed that the unadjusted odds ratio of a high CIQ mean score was 4.75 (95% CI 1.7, 13.5) among current sport participants. Similarly, the unadjusted odds ratio of a high RNL score was 7.00 (95% CI 2.3, 21.0) among current sport participants. Regression-adjusted odds ratios of high CIQ and high RNL scores were 1.36 (95% CI 0.09, 1.45) and 0.15 (95% CI 0.04, 0.55), respectively. The odds ratio for pre-SCI sport participation predicting post-SCI sport participation was 3.06 (95% CI 1.23, 7.65).

CONCLUSIONS

CIQ and QoL scores were higher among sport participants compared to non-sport participants. There was an association between mean CIQ and RNL scores for both groups. Sport participants were 4.75 and 7.00 times as likely to have high CIQ and QoL scores. Both groups had a similar likelihood of high CIQ and RNL scores after adjusting for important confounders. Individuals who participated in sports prior to SCI were more likely to participate in sports post-SCI.

Clinical recovery in first-episode psychosis

INTRODUCTION

Generally agreed outcome criteria in psychosis are required to evaluate the effectiveness of new treatment strategies. The aim of this study is to explore clinical recovery in first-episode patients, defined by meeting criteria for both symptomatic and functional remission.

METHOD

In a sample of first-episode patients (N = 125), symptomatic and functional remission during the last 9 months of a 2-year follow-up period were examined, as well as recovery and its predictors.

RESULTS

Half the patients (52.0%) showed symptomatic remission and a quarter (26.4%) functional remission, while one-fifth (19.2%) met both criteria sets and were considered recovered. Recovery was significantly associated with short duration of untreated psychosis and better baseline functioning.

CONCLUSION

Most functionally remitted patients were also symptomatically remitted, while a minority of symptomatically remitted patients were also functionally remitted. Treatment delay may affect chance of recovery.

Long-term sick-leavers with fibromyalgia: Comparing their multidisciplinarily assessed characteristics with those of others with chronic pain conditions and depression

Objective:

The aim was to gain knowledge of fibromyalgia (FM) patients on long-term sick leave and with particular difficulties in resuming work, and to compare them with patients with myalgia, back or joint diagnoses, and depression.

Methods:

Patients were identified by and referred from social insurance offices and were multidisciplinarily examined by three board-certified specialists in psychiatry, orthopedic surgery and rehabilitation medicine. Ninety-two women were diagnosed with FM only. Three female comparison groups were chosen: depression, back/joint diagnoses, and myalgia.

Results and conclusions:

Ceaseless pain was reported by 73% of FM patients, 54% of back/joint diagnoses patients, 43% of myalgia patients, and 35% of depression patients. The distribution of pain (>50%) in FM patients was to almost all regions of the body, and in depression patients to the lower dorsal neck, upper shoulders and lumbosacral back but not in the anterior body. Reduced sleep was more evident in FM patients. FM patients did not meet more criteria for personality disorder than patients with the other somatic pain conditions. The most common dimension of “personality traits” of somatic pain conditions was the “obsessive compulsive” but at a level clearly below that indicating a personality disorder. More FM patients experienced disabilities, the most common being in the mobility and domestic-life areas.

Health disparities among Latinas aging with disabilities

Latinas with disabilities report greater levels of disablement than non-Hispanic, White women with disabilities. Over the life course, Latinas experience increased numbers of functional limitations, more difficulties with activities of daily living, and more unemployment due to impairments. The reasons for this health disparity are unclear. The purpose of this article is to explore the empirical evidence surrounding health disparities in disablement among Mexican American women. From this exploration, recommendations are made, including moving beyond the correlational documentation of disparities, to building a knowledge base that provides theoretical reasons for disparities amenable to intervention.

Physical function improvements after laparoscopic Roux-en-Y gastric bypass surgery

BACKGROUND

Obesity is a risk factor for impaired physical function and disability, with the degree of impairment most compromised in extreme obesity. Mild-to-moderate weight loss has been shown to improve function in older adults. The impact of laparoscopic Roux-en-Y gastric bypass surgery on weight loss and physical function in morbidly obese individuals was assessed.

METHODS

This longitudinal, observational study followed up 28 morbidly obese men and women (body mass index > or = 40.0 kg/m(2)) for 12 months after laparoscopic Roux-en-Y gastric bypass. Physical function (self-report using the Fitness Arthritis and Seniors Trial disability questionnaire; performance tasks using the Short Physical Performance Battery and a lateral mobility task); strength (maximal isometric knee torque); and body composition measured using bioelectrical impedance were determined before surgery (baseline) and at 3 weeks, 3 months, 6 months, and 12 months after surgery.

RESULTS

The 12-month weight loss was 34.2% (excess weight loss 59.8%), with a mean fat mass loss of 46 kg and a loss of fat free mass of 6.6 kg. The performance tasks and self-reported questionnaire scores had improved by 3 months after surgery compared with baseline, with selected measures showing less impairment and disability in as few as 3 weeks after surgery. Muscle quality, as measured using the maximal torque per kilogram body weight, was greater at 6 months than at baseline.

CONCLUSION

The results of our study have shown that in morbidly obese individuals with a high risk of mobility impairments, surgical procedures to reduce body weight increase mobility and improve performance of daily activities in as few as 3 weeks after gastric bypass surgery.

The impact of physical activity level on SF-36 role-physical and bodily pain indices in midlife women

BACKGROUND

This study was done to determine whether physical activity at baseline is independently associated with musculoskeletal pain and fulfilling one's physical role over 3 subsequent years.

METHODS

Our research involved a 3-year longitudinal study of over 2400 community-dwelling, midlife women from the Study of Women's Health Across the Nation (SWAN). Measurements included baseline physical activity using the Kaiser Permanente Health Plan Activity Survey and SF-36 role-physical and bodily pain indices at each of 3 annual follow-up visits.

RESULTS

Each 1-point increase on the physical activity score was associated with a 7% greater likelihood of a high role-physical score (95% CI=1.02-1.13) and a 10% greater likelihood of a low bodily pain score (95% CI=1.04-1.17) after adjusting for age, race, menopausal status, educational level, body mass index, depressive symptoms, smoking, and chronic medical conditions. The association between physical activity level and role-physical score was eliminated in the fully adjusted model after adjustment for pain level in post hoc analysis [OR=1.04 (95% CI=0.98-1.09)].

CONCLUSION

This study demonstrates that women who are more physically active at midlife experience less bodily pain over time regardless of menopausal status, sociodemographics, and medical conditions. Higher physical activity level positively impacts fulfilling one's physical role; however, this is mediated by pain level.

Mental-physical co-morbidity and its relationship with disability: results from the World Mental Health Surveys

BACKGROUND

The relationship between mental and physical disorders is well established, but there is less consensus as to the nature of their joint association with disability, in part because additive and interactive models of co-morbidity have not always been clearly differentiated in prior research.

METHOD

Eighteen general population surveys were carried out among adults as part of the World Mental Health (WMH) Survey Initiative (n=42 697). DSM-IV disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). Chronic physical conditions (arthritis, heart disease, respiratory disease, chronic back/neck pain, chronic headache, and diabetes) were ascertained using a standard checklist. Severe disability was defined as on or above the 90th percentile of the WMH version of the World Health Organization Disability Assessment Schedule (WHODAS-II).

RESULTS

The odds of severe disability among those with both mental disorder and each of the physical conditions (with the exception of heart disease) were significantly greater than the sum of the odds of the single conditions. The evidence for synergy was model dependent: it was observed in the additive interaction models but not in models assessing multiplicative interactions. Mental disorders were more likely to be associated with severe disability than were the chronic physical conditions.

CONCLUSIONS

This first cross-national study of the joint effect of mental and physical conditions on the probability of severe disability finds that co-morbidity exerts modest synergistic effects. Clinicians need to accord both mental and physical conditions equal priority, in order for co-morbidity to be adequately managed and disability reduced.

The SF-36: a simple, effective measure of mobility-disability for epidemiological studies

BACKGROUND

Mobility disability is a major problem in older people. Numerous scales exist for the measurement of disability but often these do not permit comparisons between study groups. The physical functioning (PF) domain of the established and widely used Short Form-36 (SF-36) questionnaire asks about limitations on ten mobility activities.

OBJECTIVES

To describe prevalence of mobility disability in an elderly population, investigate the validity of the SF-36 PF score as a measure of mobility disability, and to establish age and sex specific norms for the PF score.

METHODS

We explored relationships between the SF-36 PF score and objectively measured physical performance variables among 349 men and 280 women, 59-72 years of age, who participated in the Hertfordshire Cohort Study (HCS). Normative data were derived from the Health Survey for England (HSE) 1996.

RESULTS

32% of men and 46% of women had at least some limitation in PF scale items. Poor SF-36 PF scores (lowest fifth of the gender-specific distribution) were related to: lower grip strength; longer timed-up-and-go, 3m walk, and chair rises test times in men and women; and lower quadriceps peak torque in women but not men. HSE normative data showed that median PF scores declined with increasing age in men and women.

CONCLUSION

Our results are consistent with the SF-36 PF score being a valid measure of mobility disability in epidemiological studies. This approach might be a first step towards enabling simple comparisons of prevalence of mobility disability between different studies of older people. The SF-36 PF score could usefully complement existing detailed schemes for classification of disability and it now requires validation against them.

Headache Impact Test-6 (HIT-6) scores for migraine patients: Their relation to disability as measured from a headache diary

Background and Purpose

Complete information on migraine-related disabilities facilitate the making of appropriate treatment decisions. Although the accessibility and ease of use of the Headache Impact Test-6 (HIT-6) make it a very promising instrument, there are few data available for comparing HIT-6 scores with the actual amount of disability.

Methods

To determine whether the disability measured using the HIT-6 questionnaire realistically reflects the amount of disability as extracted from a headache diary, which would help when deciding a management plan, 130 patients with migraine without aura were instructed to complete a headache diary on the days on which headache occurred. Each diary booklet also contained questions on the resulting disability, and comprised five items originating from the Migraine Disability Assessment Scale. After submitting their diaries, the participants completed the HIT-6 for the same time period.

Results

Disability as recorded in diaries was present for a mean of 2.7 days per month, and its duration differed significantly with HIT-6 score: 0.9, 2.6, and 4.6 days per month for littleto-no impact, moderate impact, and severe impact, respectively. The summed disability score from diaries was also related to the HIT-6 score. Headache frequency was the only headache characteristic that contributed significantly to the HIT-6 score.

Conclusions

This study demonstrates that the HIT-6 could be useful for assessing headache-related disability in migraine patients, especially given that the questionnaire is both simple and ease of use.

Current migraine management - patient acceptability and future approaches

Despite its high prevalence and individual as well as societal burden, migraine remains underdiagnosed and undertreated. In recent years, the options for the management of migraine patients have greatly expanded. A number of drugs belonging to various pharmacological classes and deliverable by several routes are now available both for the acute and the preventive treatments of migraine. Nevertheless, disability and satisfaction remain low in many subjects because treatments are not accessible, not optimized, not effective, or simply not tolerated. There is thus still considerable room for better education, for more efficient therapies and for greater support from national health systems. In spite of useful internationally accepted guidelines, anti-migraine treatment has to be individually tailored to each patient taking into account the migraine subtype, the ensuing disability, the patient's previous history and present expectations, and the co-morbid disorders. In this article we will summarize the phenotypic presentations of migraine and review recommendations for acute and preventive treatment, highlighting recent advances which are relevant for clinical practice in terms of both diagnosis and management.

Incidence and burden of road traffic injuries in urban India

BACKGROUND

The scale of road traffic injuries (RTIs) in India is uncertain because of limitations in the availability and reliability of incidence data.

OBJECTIVE

To report these data for Hyderabad city in southern India.

METHODS

In a cross-sectional population-based survey, 10 459 participants aged 5-49 years (94.3% participation), selected using three-stage systematic cluster sampling, were interviewed. Participants recalled RTIs in the preceding 3 months and RTI-related death and disability in the household in the preceding 3 years. RTI was defined as an injury resulting from a road traffic crash irrespective of the severity.

RESULTS

The age/sex-adjusted annual incidence of non-fatal RTI requiring a recovery period of < or =7, 8-29, and > or =30 days was 13% (95% CI 12.6% to 13.4%), 5.8% (95% CI 5.5% to 6.0%), and 1.2% (95% CI 1.1% to 1.4%), respectively. The overall adjusted rate for non-fatal RTI was 20.7% (95% CI 20.0% to 21.3%). The relative risk of RTI requiring a recovery period of >7 days was significantly higher in the third per capita monthly income quartile (1.24 (95% CI 1.12 to 1.37); p<0.05). The incidence of non-fatal RTI was highest in pedestrians, motorized two-wheeled vehicle users, and cyclists: 6.4, 6.3, and 5.1/100 persons/year, respectively. Annual RTI mortality and disability rates were 38.2 (95% CI 17.5 to 58.8) and 35.1 (95% CI 12.4 to 57.7) per 100,000 population, respectively.

CONCLUSIONS

There is a high burden of RTI in this urban population. With the recent attention focused on RTI by the Government of India, these findings may assist in planning appropriate initiatives to reduce the RTI burden.

Neurological and functional status following cardiac arrest: method and tool utility

INTRODUCTION

Assessing the neurological and disability status of cardiac arrest (CA) survivors is important for evaluating the outcomes of resuscitation interventions. The Cerebral Performance Category (CPC)--the standard outcome measurement after CA--has been criticized for its poorly defined, subjective criteria, lack of information regarding its psychometric properties, and poor relationships with long-term measures of disability and quality of life (QOL). This study examined the relationships among the CPC and measures of global disability and QOL at discharge from the hospital and at 1 month after CA.

METHODS

Twenty-one CA survivors participated in the study. A medical chart review was conducted at the time of discharge to determine CPC and Modified Rankin Scale (mRS) scores, while 1-month in-person interview was conducted to collect mRS and Health Utilities Index Mark 3 (HUI3) scores. Data collected during the interview were used to determine follow-up CPC scores.

RESULTS

The strength of relationships among measures at discharge and 1 month ranged between fair to good. An examination of scatter plots revealed substantial variability and a wide distribution of chart review and 1-month mRS and HUI3 scores within each CPC category. CPC scores obtained through chart review were significantly better than the CPC 1-month scores, thus overestimating the participants' cognitive and disability status 1 month later.

CONCLUSION

When compared to disability and quality of life measures, it is apparent that the CPC has limited ability to discriminate between mild and moderate brain injury. The validity of using the chart review method for obtaining scores is questionable.

Sarcopenic obesity: definition, cause and consequences

PURPOSE OF REVIEW

Older obese persons with decreased muscle mass or strength are at special risk for adverse outcomes. We discuss potential pathways to muscle impairment in obese individuals and the consequences that joint obesity and muscle impairment may have on health and disability. Tantamount to this discussion is whether low muscle mass or, rather, muscle weakness should be used for the definition.

RECENT FINDINGS

Excess energy intake, physical inactivity, low-grade inflammation, insulin resistance and changes in hormonal milieu may lead to the development of so-called 'sarcopenic obesity'. It was originally believed that the culprit of age-related muscle weakness was a reduction in muscle mass, but it is now clear that changes in muscle composition and quality are predominant. We propose that the risk of adverse outcomes, such as functional limitation and mortality, is better estimated by considering jointly obesity and muscle strength rather than obesity and muscle mass and the term 'sarcopenic obesity' should be revisited.

SUMMARY

Recognition of obese patients who have associated muscle problems is an essential goal for clinicians. Further research is needed to identify new target for prevention and cure of this important geriatric syndrome.

PARENTING A CHILD WITH A DISABILITY: AN EXAMINATION OF RESIDENT AND NON-RESIDENT FATHERS

Children with disabilities often require more extensive family involvement and greater paternal support than other children. Yet these children are the children least likely to live with their fathers. This paper uses data from the National Longitudinal Survey of Youth 1997 from the United States to examine the association between child disability and resident and non-resident biological fathers' supportiveness, relationship, and monitoring of their children. Regression analyses indicate significant challenges for all fathers of children with disabilities. Children of resident fathers report more positive interactions than children of non-resident fathers. However, earlier co-residence and more frequent contact significantly improve the quality of father-youth relationships among men who do not live with their children.

Medicare capitation model, functional status, and multiple comorbidities: model accuracy

OBJECTIVE

To examine financial implications of the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) risk-adjustment model on Medicare payments for individuals with comorbid chronic conditions.

STUDY DESIGN

The study used 1992-2000 data from the Medicare Current Beneficiary Survey and corresponding Medicare claims. Pairs of comorbidities were formed based on prior evidence about possible synergy between these conditions and activities of daily living (ADLs) deficiencies, and included heart disease and cancer, lung disease and cancer, stroke and hypertension, stroke and arthritis, congestive heart failure (CHF) and osteoporosis, diabetes and coronary artery disease, and CHF and dementia.

METHODS

For each beneficiary, we calculated the actual Medicare cost ratio as the ratio of the individual's annualized costs to the mean annual Medicare cost for all people in the study. The actual Medicare cost ratios, by ADLs, were compared with HCC ratios under the CMS-HCC payment model. Using multivariate regression models, we tested whether having the identified pairs of comorbidities affected the accuracy of CMS-HCC model predictions.

RESULTS

The CMS-HCC model underpredicted Medicare capitation payments for patients with hypertension, lung disease, CHF, and dementia. The difference between the actual costs and predicted payments was partially explained by beneficiary functional status and less-than-optimal adjustment for these chronic conditions.

CONCLUSION

Information about beneficiary functional status should be incorporated in reimbursement models. Underpaying providers who care for populations with multiple comorbidities may provide severe disincentives for managed care plans to enroll such individuals and to appropriately manage their complex and costly conditions.

FOXO3A genotype is strongly associated with human longevity

Human longevity is a complex phenotype with a significant familial component, yet little is known about its genetic antecedents. Increasing evidence from animal models suggests that the insulin/IGF-1 signaling (IIS) pathway is an important, evolutionarily conserved biological pathway that influences aging and longevity. However, to date human data have been scarce. Studies have been hampered by small sample sizes, lack of precise phenotyping, and population stratification, among other challenges. Therefore, to more precisely assess potential genetic contributions to human longevity from genes linked to IIS signaling, we chose a large, homogeneous, long-lived population of men well-characterized for aging phenotypes, and we performed a nested-case control study of 5 candidate longevity genes. Genetic variation within the FOXO3A gene was strongly associated with human longevity. The OR for homozygous minor vs. homozygous major alleles between the cases and controls was 2.75 (P = 0.00009; adjusted P = 0.00135). Long-lived men also presented several additional phenotypes linked to healthy aging, including lower prevalence of cancer and cardiovascular disease, better self-reported health, and high physical and cognitive function, despite significantly older ages than controls. Several of these aging phenotypes were associated with FOXO3A genotype. Long-lived men also exhibited several biological markers indicative of greater insulin sensitivity and this was associated with homozygosity for the FOXO3A GG genotype. Further exploration of the FOXO3A gene, human longevity and other aging phenotypes is warranted in other populations.

Self-reported symptoms of cold intolerance in workers with injuries of the hand

Cold intolerance is a well-recognized complication of crushing injuries and amputations in the hand. These symptoms are usually thought to resolve within 2 years of injury. The objectives of our study were to determine the prevalence and course over time of self-reported symptoms of cold intolerance in workers with hand injuries. Files from a large worker's compensation carrier were randomly selected from index years 2, 4, 6, and 10 after a claim was made. Cohorts comprising cases with diagnostic codes corresponding to traumatic hand injuries and codes referring to non-trauma diagnoses in the hand were assembled for each of the years under consideration. A questionnaire was mailed to a total of 7,088 asking questions related to the symptom of cold intolerance. Twenty-five percent of the surveys were returned. Over 90% of trauma patients from all 4 years reported symptoms of cold intolerance. The rate of cold intolerance in the non-trauma group was between 59% and 69%. Individuals reporting cold intolerance indicated worsening over time in 50% of cases and improvement in only 9%. The severity of injury did not appear to be a factor in the development of cold intolerance. Symptoms of cold intolerance are highly prevalent in workers with significant hand injuries. Workers with non-trauma hand conditions also report a substantial prevalence of this symptom. The development of cold intolerance is not related to injury severity. The symptoms remain either static or deteriorate slightly over time. Improvement is experienced by less than 10% of patients.

Physical and mental comorbidity of headache in a nationally representative sample of US adults

OBJECTIVE

To investigate the contribution of comorbidity to health utilization and negative health perception in a large-scale population-based study. Comorbidity of headache with physical and mental disorders has been reported frequently in clinical samples.

METHODS

This concern was addressed using combined 6-year data from the 1999 to 2004 National Health Examination and Nutrition Survey (n = 31,126 adults), nationally representative datasets of the US population. Measures of physical disorders were based on standardized interviews of chronic conditions, and mental disorders were assessed by the Composite International Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.

RESULTS

The 3-month prevalence of severe headaches or migraine in the US general population was 22.73%, with females and young adults having greater rates than males and older adults. Adults with headache had increased odds for a variety of physical disorders (including asthma, rheumatoid arthritis, and stroke) and mental disorders (including depression, generalized anxiety disorder, and panic disorder). Adults with headache were more likely to rate their health as "fair or poor" (17.9% versus 6.1%), to seek health care four or more times in a year (43.3% versus 22.7%), and to endorse physical and mental limitations. Health utilization and negative health perception were more strongly influenced by comorbid mental disorders than physical disorders.

CONCLUSIONS

The results from this nationally representative sample provide new information on the interrelationships of headache with mental and physical disorders. The greater impact of comorbid mental compared with physical disorders on healthcare utilization and health perception has important implications for the clinical evaluation and treatment of headache in the population.

Perceived participation restriction in middle-aged and older persons with schizophrenia

OBJECTIVE

The purpose of this study was to examine clinical characteristics associated with participation restriction in middle-aged and older persons with schizophrenia.

METHOD

Seventy-eight patients with schizophrenia or schizoaffective disorder, ranging in age from 40 to 81 were included in the study. Participants completed an assessment consisting of sociodemographics, psychiatric symptom severity, depressive symptom severity, cognitive functioning, and participation restriction.

RESULTS

A majority of patients reported experiencing participation restriction. Greater severity of participation restriction was predicted by more severe depressive symptoms, less severe general psychiatric symptoms, and better cognitive functioning. Together, these variables accounted for 45% of variance in participation restriction scores with depressive symptoms accounting for the largest proportion of variance. Participation restriction was not associated with age.

CONCLUSIONS

Participation restriction and depressive symptoms are related in individuals with schizophrenia; however, the direction of their relationship is unclear and requires further investigation.

Measuring money mismanagement among dually diagnosed clients

Clients dually diagnosed with psychiatric and substance abuse disorders may be adversely affected if they mismanage their Social Security or public support benefits. Assistance managing funds, including assignment of a representative payee, is available but there are no objective assessments of money mismanagement. In this study, a Structured Clinical Interview for Money Mismanagement was administered twice at 1-week intervals to 46 clients receiving disability payments and was compared with clinician's judgment that the client was incapable of managing funds, the frequent basis for payee assignment by the Social Security Administration and Veterans Affairs. Clinician's judgment and structured interview were concordant on 71% of capability judgments. The interview had high test-retest reliability and was correlated with self-reported money mismanagement and global assessment of functioning scale scores, but clinician judgment was not associated with these measures. Results suggest that the interview is sensitive in detecting money mismanagement and raises questions concerning the validity of clinicians' judgments.

Neighborhoods and disability in later life

This paper uses the US Health and Retirement Study to explore linkages between neighborhood conditions and stages of the disablement process among adults aged 55 years and older in the United States. We consider multiple dimensions of the neighborhood including the built environment as well as social and economic conditions. In doing so, we use factor analysis to reduce indicators into eight neighborhood scales, which we incorporate into two-level logistic regression models along with controls for individual-level factors. We find evidence that economic conditions and the built environment, but not social conditions, matter. Neighborhood economic advantage is associated with a reduced risk of lower body limitations for both men and women. We also find for men that neighborhood economic disadvantage is linked to increased chances of reporting personal care limitations, particularly for those aged 55-64 years, and that high connectivity of the built environment is associated with reduced risk of limitations in instrumental activities. Our findings highlight the distinctive benefits of neighborhood economic advantage early in the disablement process. In addition, findings underscore the need for attention in the design and evaluation of disability-prevention efforts to the benefits that accrue from more physically connected communities and to the potential harm that may arise in later life from living in economically disadvantaged areas.

A physiologic index of comorbidity: relationship to mortality and disability

BACKGROUND

In older adults, there is often substantial undiagnosed chronic disease detectable on noninvasive testing, not accounted for by most comorbidity indices. We developed a simple physiologic index of comorbidity by scoring five noninvasive tests across the full range of values. We examined the predictive validity of this index for mortality and disability.

METHODS

There were 2928 (mean age 74.5 years, 60% women, 85% white, and 15% black) participants in the Cardiovascular Health Study (1992-1993) who had carotid ultrasound, pulmonary function testing, brain magnetic resonance scan, serum cystatin-C, and fasting glucose. These were combined into a single physiologic index of comorbid chronic disease on a scale of 0-10. Cox proportional hazard models were used to predict mortality, mobility limitation, and activities of daily living (ADL) difficulty after a maximum of 9 years.

RESULTS

The range of the physiologic index was quite broad, with very few individuals having total scores of either 0 or 10. Those with an index of 7-10 had a hazard ratio of 3.80 (95% confidence interval, 2.82-5.13) for mortality compared to those with scores of 0-2, after adjustment for demographics, behavioral risk factors, and clinically diagnosed conditions. Associations with mobility limitation and ADL difficulty were also significant. The index explained about 40% of the age effect on mortality risk.

CONCLUSION

Older adults with low levels of markers of chronic disease are rather rare but have remarkably good health outcomes. The ability of such an index to distinguish usual from low risk might provide an opportunity to better understand optimal health in old age.

Functional MRI correlates of lower limb function in stroke victims with gait impairment

BACKGROUND AND PURPOSE

Although knowledge concerning cortical reorganization related to upper limb function after ischemic stroke is growing, similar data for lower limb movements are limited. Previous studies with hand movement suggested increasing recruitment of motor areas in the unlesioned hemisphere with increasing disability. We used ankle movement as a lower limb analog to test for similarities and differences in recovery patterns.

METHODS

Eighteen subjects were selected with chronic residual gait impairment due to a single subcortical ischemic stroke. Functional MRI scans were obtained at 3.0 T during active and passive ankle dorsiflexion in the patients (8 females, 10 males; mean age, 59.9+/-13.5 years; range, 32 to 74 years) and 18 age-matched healthy control subjects.

RESULTS

We observed substantial neocortical activity associated with foot movement both in the patients with stroke and in the healthy control subjects. Our primary finding was increased cortical activation with increasing functional impairment. The extent of activation (particularly in the primary sensorimotor cortex and the supplementary motor area of the unlesioned hemisphere) increased with disability. The changes were most prominent with the active movement task.

CONCLUSIONS

Using ankle movement, we observed increased activation in the unlesioned hemisphere associated with worse function of the paretic leg, consistent with studies on movement of paretic upper limbs. We interpret this finding as potentially adaptive recruitment of undamaged ipsilateral motor control pathways from the supplementary motor area and (possibly maladaptive) disinhibition of the ipsilateral sensorimotor cortex.

Declines in late-life disability: the role of early- and mid-life factors

Investigations into the reasons for declines in late-life disability have largely focused on the role of contemporaneous factors. Adopting a life-course perspective as a backdrop, in this paper we ask whether there also has been a role for selected early- and mid-life factors in the decline, and if so whether these factors have been operating through changes in the risks of disability onset or recovery. Drawing on five waves from 1995 to 2004 of the U.S. Health and Retirement Study, we found for the 75 years and older population in the United States that the prevalence of difficulty with activities of daily living (ADL) declined from 30.2% in 1995 to 26.0% in 2004, whereas the trend in difficulty with instrumental activities of daily living (IADL) was flat. Onset of ADL limitations also was reduced during this period while recovery increased. Changes in the educational composition of the older population were linked to declines in the prevalence of ADL limitations, but there were also modest contributions of changes in mother's education, self-rated childhood health, and lifetime occupation. Declines in late-life vision impairments and increases in wealth also contributed substantially to the downward trend, and had chronic conditions not increased, it would have been even larger. Reductions in the onset of ADL limitations were partly driven by changes in educational attainment of respondents and their mothers and, in late-life, better vision and wealth. In contrast, the recovery trend was not accounted for by changes in early- or mid-life factors. We conclude that early- and mid-life factors have contributed along with late-life factors to U.S. late-life disability trends mainly through their influence on the onset of, rather than recovery from, limitations.

Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials

STUDY DESIGN

Secondary analysis.

OBJECTIVE

To investigate the Fear-Avoidance Beliefs Questionnaire (FABQ) for its ability to predict 6-month outcomes for patients with low back pain (LBP) participating in physical therapy clinical trials.

BACKGROUND

Consistent evidence suggests that fear-avoidance beliefs are predictive of short-term outcomes for patients with LBP. However, proposed cut-off scores have not been widely investigated for longer-term outcomes in samples of patients receiving physical therapy.

METHODS AND MEASURES

Subjects (n = 160) were participants in 2 separate randomized trials that used standard methodology and investigated the efficacy of physical therapy interventions for LBP. Subjects completed baseline measures of pain, disability, fear-avoidance beliefs, and physical impairment. They completed 4 weeks of randomly assigned physical therapy and were reassessed at 6 months with standard examination techniques. The accuracy of previously proposed cut-offs for elevated FABQ scores were determined by independent t tests and chi-square analysis on raw 6-month Oswestry Disability Questionnaire (ODQ) scores, 6-month ODQ change scores, and minimally clinical important difference (MCID) in ODQ scores (6 points). Next, a hierarchical regression model determined which FABQ scale better predicted 6-month ODQ scores after controlling for previously reported prognostic factors and relevant treatment parameters. Last, receiver operating characteristic curve analyses were planned to generate a range of FABQ cut-off scores that predicted 6-month MCID in the ODQ.

RESULTS

The previously reported cut-off score for the FABQ physical activity scale (>14) resulted in 111 (69.4%) of 160 patients being classified as having elevated baseline scores, while the previously reported cut-off score for the FABQ work scale (>29) resulted in 19 (11.9%) of 160 patients being classified as having elevated baseline scores. Patients with elevated FABQ physical activity scale scores (>14) had no significant differences in 6-month ODQ outcomes. Patients with elevated FABQ work scale (>29) scores reported higher 6-month ODQ scores and were more likely to have reported no improvement in ODQ score. The final regression model explained 24.4% of the variance in 6-month ODQ scores, with only manipulation and exercise and the FABQ work scale as unique predictors. Fifteen of the subjects (12.7%) had a 6-month change in ODQ that indicated no improvement. The area under the receiver operating characteristic curve for the FABQ physical activity scale predicting this outcome was 0.562 (95% CI: 0.415-0.710) and for the FABQ work scale was 0.694 (95% CI: 0.542-0.846). Cut-off scores were explored for the FABQ work scale only, with positive likelihood ratios that ranged from 1.19 to 5.15 and negative likelihood ratios that ranged from 0.30 to 0.83.

CONCLUSIONS

The FABQ work scale was the better predictor of self-report of disability in this sample of patients participating in physical therapy clinical trials. Future studies are necessary to further test and refine the FABQ work scale as a screening tool alone, and in combination with other examination findings.

Explaining the effect of gender on functional transitions in older persons

BACKGROUND

Women live longer but experience greater disability than men. The reasons for this gender difference in disability are not well understood.

OBJECTIVE

Our objectives were to determine if the higher prevalence of disability in women is due to greater incidence of disability, longer duration of disability, or both, and to identify factors that potentially explain these gender differences.

METHODS

754 community-living persons aged 70 and older who were non-disabled (required no personal assistance) in four essential activities of daily living (ADLs) were assessed monthly for disability for up to 6 years. A multi-state extension of the proportional hazards model was used to determine the effects of gender on transitions between states of no disability, mild disability, severe disability, and death, and to evaluate potential mediators of these effects.

RESULTS

Women were more likely to make the transition from no disability to mild disability and less likely to make the transitions from mild to no disability and from both mild and severe disability to death. The gender difference in the transitions between no disability and mild disability was largely explained by differences in gait speed and physical activity, but gender difference in transitions to death persisted despite adjustment for multiple potential mediators.

CONCLUSION

The higher prevalence of disability in women versus men is due to a combination of higher incidence and longer duration, resulting from lower rates of recovery and mortality among disabled women.

An example of a longitudinal study of functional disability among older persons

OBJECTIVES

Researchers have often used rather simple approaches to analyze repeated time-to-event health conditions that either examine time to the first event or treat multiple events as independent. More sophisticated models have been developed, although previous applications have focused largely on such outcomes having continuous risk intervals. Limitations of applying these models include their difficulty in implementation without careful attention to forming the data structures.

METHODS

We first review time-to-event models for repeated events that are extensions of the Cox model and frailty models. Next, we develop a way to efficiently set up the data structures with discontinuous risk intervals for such models, which are more appropriate for many applications than the continuous alternatives. Finally, we apply these models to a real dataset to investigate the effect of gender on functional disability in a cohort of older persons. For comparison, we demonstrate modeling time to the first event.

RESULTS

The GEE Poisson, the Cox counting process, and the frailty models provided similar parameter estimates of gender effect on functional disability, that is, women had increased risk of bathing disability and other disability (disability in walking, dressing, or transferring) as compared to men. These results, especially for other disabilities, were quite different from those provided by an analysis of the first-event outcomes. However, the effect of gender was no longer significant in the counting process model fully adjusted for covariates.

CONCLUSION

Modeling time to only the first event may not be adequate. After properly setting up the data structures, repeated event models that account for the correlation between multiple events within subjects can be easily implemented with common statistical software packages.

Degree of disability and patterns of caregiving among older Americans with congestive heart failure

OBJECTIVES

Although congestive heart failure (CHF) is a common condition, the extent of disability and caregiving needs for those with CHF are unclear. We sought to determine: (1) prevalence of physical disability and geriatric conditions, (2) whether CHF is independently associated with disability, (3) rates of nursing home admission, and (4) formal and informal in-home care received in the older CHF population.

METHODS

We used cross-sectional data from the 2000 wave of the Health and Retirement Study. We compared outcomes among three categories of older adults: (1) no coronary heart disease (CHD), (2) CHD, without CHF, and (3) CHF. Compared to those without CHF, respondents reporting CHF were more likely to be disabled (P < 0.001) and to have geriatric conditions (P < 0.001). Respondents reporting CHF were more likely to have been admitted to a nursing home (P < 0.05). CHF respondents were more functionally impaired than respondents without CHF.

RESULTS

The adjusted average weekly informal care hours for respondents reporting CHF was higher than for those reporting CHD but without CHF and those reporting no CHD (6.7 vs 4.1 vs 5.1, respectively; P < 0.05). Average weekly formal caregiving hours also differed among the three groups (1.3 CHF vs 0.9 CHD without CHF vs 0.7 no CHD; P > 0.05).

CONCLUSIONS

CHF imposes a significant burden on patients, families, and the long-term care system. Older adults with CHF have higher rates of disability, geriatric conditions, and nursing home admission.

Towards guidelines for evaluation of measures: an introduction with application to spinal cord injury

BACKGROUND

Both clinical practice and research in spinal cord injury (SCI) continue to struggle with issues of the quality and utility of outcome measures employed. Despite widespread deference to dicta on "reliability and validity," systematic means of grading the level of evidence for measures are lacking.

OBJECTIVES

This paper explains the methods and principles for use in systematic reviews of measures in SCI. It explains how extant measurement standards and principles can be elaborated for extant labels on various types of reliability and validity to define a more judicious method of grading level of evidence. We aim to initiate a process of discussion that will lead to improved systematic review of the measurement quality as a basis for long-term improvements in outcomes measures and their application.

METHODS

This paper is a conceptual review, based on established measurement standards and principles and the incorporation of recent advances in measurement methodology. The scheme of grading of measurement quality is illustrated by examples of measures of health, function, activity/participation, and quality of life after SCI.

RESULTS AND CONCLUSIONS

It is possible to grade the quality of outcome measure in terms of level of evidence, provided the nature of the construct being measured is defined as well as its main use. Definite means of grading the level of evidence for measurement will help to identify priorities for measure development and facilitate more appropriate uses of measures.

Exploring the personal reality of disability and recovery: a tool for empowering the rehabilitation process

People experiencing disability and chronic disease often feel powerless, relinquishing medical control to "more knowledgeable" professionals. This article presents qualitative and quantitative results from three individual patients experiencing an emerging procedure called Recovery Preference Exploration (RPE). To inspire greater patient involvement, self-direction, and individual choice, we instructed participants to create an imagined recovery path, exposing recovery preferences while learning about clinical rehabilitation concepts. Results uncovered important values and feelings about disability, providing a richer context for patient evaluation and treatment goal modification. Applying mixed methods, RPE is presented as an explanatory process for quantifying recovery preferences in a way that stimulates rich narrative of how people see different types of disabilities. RPE shows promise for increasing depth of discussions among patients, family, and clinicians. RPE may promote greater quality of life through patient empowerment by directed learning, increased communication, and enhanced self-knowledge.

A cross-sectional comparison of disability and quality of life in euthymic patients with bipolar affective or recurrent depressive disorder with and without comorbid chronic medical illness

BACKGROUND

There are major health care implications of quality of life (QOL) and disability in long-standing disorders such as bipolar affective disorder (BAD) and recurrent depressive disorder (RDD).

OBJECTIVES

To compare the inter-episode QOL and disability in patients with the diagnosis of BAD or RDD in remission with and without comorbid chronic medical illness.

MATERIALS AND METHODS

Cross-sectional assessments of the four groups were carried out. Euthymic bipolar or RDD subjects with chronic comorbid medical illnesses were included in the study. QOL assessment was carried out using the World Health Organization (WHO)-QOL - Bref Kannada version. Disability was assessed using the Schedule for Assessment of Psychiatric Disability (SAPD), which is an Indian modification of the WHO Disability Assessment Schedule-II.

RESULTS

Eighty patients were enrolled into the study (20 patients in each group). The mean disability scores in the BAD group was significantly more in 'social role' (P = 0.038), and in the RDD group it was more in 'home atmosphere' (P = 0.001) in the two groups (n = 40) with chronic comorbid medical illness. In the other group without comorbid chronic medical illness (n = 40), the BAD group had significantly more disability in 'overall behavior' (P = 0.002) and 'social role' (P = 0.001), and the RDD group had significantly more disability in 'assets and/or liabilities' (P = 0.004) and 'home atmosphere' (P = 0.001). The QOL measures did not differ significantly between the two disorders.

CONCLUSIONS

The presence of chronic comorbid medical illness did not cause a difference in the QOL between the two groups in periods of euthymia. However, disability measures differed significantly between the groups.

Participation following traumatic spinal cord injury: an evidence-based review for research

BACKGROUND/OBJECTIVE

To report an evidence-based review of participation instruments that have been used in spinal cord injury (SCI) clinical practice and research.

METHODS

Rehabilitation literature was searched for instruments used by at least 2 independent SCI researchers since 2000. Each instrument was reviewed by 2 committee members. One person reviewed the scale and documented the level of use and psychometric properties. The second committee member verified the values and made suggestions for changes.

RESULTS

Three instruments met the review criteria: Craig Handicap Assessment and Reporting Technique (CHART), Assessment of Life Habits (LIFE-H), and the Impact on Participation and Autonomy (IPA). Each instrument incorporates different perspectives in the measurement of participation. The LIFE-H uses a qualitative approach, whereas the CHART adopts a quantitative approach; both are based on societal norms of participation. In contrast, the IPA integrates individual choice and control in defining participation. CHART is the most widely used instrument, although its development predates the development of the ICF. The IPA is a relatively new instrument, and its psychometric properties have only recently published.

CONCLUSIONS

Continuing research is needed to develop conceptually and psychometric valid measures of participation for use with people with SCI. Priorities include understanding the relationship between objective and subjective indicators of participation, describing the dimensions of participation, and identifying appropriate measurement models and psychometric approaches to evaluate the nonhierarchical character of participation. Researchers and clinicians should be aware of the strengths and limitations of existing measures to make informed decisions about appropriate instruments.

Neuropsychiatric symptoms are associated with disability in cognitively impaired Latino elderly with and without dementia: results from the Sacramento Area Latino study on Aging

OBJECTIVE

To examine the relationship between neuropsychiatric symptoms burden and disability in cognitively impaired older Latinos.

METHODS

Subjects in the cross-sectional study were 95 cognitively impaired (both demented and non-demented) non-institutionalized Latino elderly participating in an epidemiological cohort study and their family caregivers. Care recipient neuropsychiatric symptoms (Neuropsychiatric Inventory) and level of functional impairment (i.e. impairment in activities of daily living and instrumental activities of daily living) were assessed through interviews with family caregivers.

RESULTS

Both NPI total score and NPI depression subscale score were significantly associated with disability before and after controlling for potential confounding variables. The strength of the association between higher neuropsychiatric symptom levels and higher disability was similar for both the cognitively impaired not demented and demented groups.

CONCLUSIONS

Neuropsychiatric symptoms are associated with increased disability in a community sample of cognitively impaired Latino elderly. More effective identification and treatment of neuropsychiatric symptoms may improve functioning in older Latinos and reduce health disparities for this population.

From chronic low back pain to disability, a multifactorial mediated pathway: the InCHIANTI study

STUDY DESIGN

Clinicoepidemiologic study in the Chianti area (Tuscany, Italy).

OBJECTIVE

To evaluate whether performance measures of lower extremity function confounds the association of low back pain (LBP) with self-report disability in specific basic and instrumental activities of daily living (IADLs).

SUMMARY OF BACKGROUND DATA

LBP is high prevalent in older population and has a negative impact on functional status. Studies on the pathway leading from LBP to disability are limited and often the role played by important confounders is not considered.

METHODS

A total of 956 InCHIANTI study participants aged 65 and older able to complete performance-based tests of lower extremity function were included in this analysis. LBP was defined as a self-report of back pain "quite often-almost every day" in the past 12 months. Lower extremity function was evaluated administering the Short Physical Performance Battery. In addition, participants were asked to walk on a 7-m course and collect an object from the ground. Depressive symptoms (CES-D score), trunk flexion-extension range of motion, and hip-knee-foot pain were also considered in the pathway from LBP to disability.

RESULTS

Compared with participants who did not report LBP, those with LBP were more likely to report difficulty in performing most activities of daily living. LBP was also associated with disability in the activities of bathing, doing the laundry, performing heavy household chores, cutting toenails, shopping, and carrying a shopping bag. The association between LBP and disability in selected ADLs and IADLs was no longer statistical significant, after adjustment for performance in lower extremity function, with exception of the activity of "carrying a shopping bag".

CONCLUSION

The cross-sectional association between LBP and self-reported disability, in specific tasks is modulated by performance measures. Specific performance-based tests that explore the functional consequences of LBP may help design specific interventions of disability prevention and treatment in patients with LBP.

Work, disability and rehabilitation: making the best job of it

The relationship between a person's health and their work was recognised as central to the good practice of medicine by Charles Turner Thackrah (1795-1833) in his seminal work, The effects of arts, trades and professions on health and longevity (1823). The connection is largely forgotten in current clinical practice; the UK has a high level of dependence on benefits mainly in those with non-severe disabilities. Recognition of the value of preventing this by access to early, usually multidisciplinary, rehabilitation and prevocational rehabilitation via a general practitioner and in hospital practice is needed as a priority. This requires that all NHS staff adopt a biopsychosocial approach to illness and are taught about the workplace needs of patients and the value of early rehabilitation. Communications within the NHS and with other agencies have to be improved by the development of better pathways with dedicated staff time for this activity. The creation of the Director of Health and Work position and the refocusing of occupational medicine present an unrivalled opportunity to improve our practice.