Quality of life and Parkinson's disease

BACKGROUND

People with Parkinson's disease (PD) have a progressive loss of function eventually leading to severe disability. Although PD would be expected to have a profound impact on an individual's psychosocial health, there is relatively limited research on its psychosocial effect. The purposes of this study were (a) to examine the relationships between physical disability, depression, and control beliefs and quality of life in people with PD and (b) to characterize how these psychosocial variables differ by stage of disease.

METHODS

Eighty-six individuals from five stages based on clinical disability, ages 51-87, were interviewed. Established instruments were used to measure physical disability, depression, and control beliefs. Quality of life (QOL) was rated on a 5-point Likert scale.

RESULTS

A multivariable regression model including physical disability, stage of disease, depression, mastery, and health locus of control predicted QOL (R2 = 0.48), with mastery as the only significant predictor (p = .0001). There were significant differences by PD stage for all variables (p < .05).

CONCLUSIONS

Mastery predicted quality of life in individuals with PD even when depression and physical disability were included in the model. Differences in psychosocial variables by stage of PD suggest that the psychosocial profile of PD patients may change as the disease progresses.

Using a short food frequency questionnaire to estimate dietary calcium consumption: a tool for patient education

OBJECTIVE

To develop a short food frequency questionnaire (FFQ) assessing calcium intake and a prediction equation for estimating total calcium intake from the short FFQ.

METHODS

Data were collected from 536 women via mailed questionnaires at 3 time points. Stepwise regression analyses were used to identify those foods and beverages included in the Black Health Habits and History Questionnaire (HHHQ) that explained the most variance in participants' dietary calcium intake. A prediction equation was developed to estimate total calcium intake based only on information from the foods/beverages identified.

RESULTS

Calcium obtained from 15 foods/beverages explained 97.2% of the variance in total calcium intake. The mean absolute difference between total calcium intake estimated from the 15 foods/beverages and the full HHHQ was less than 50 mg at each time point.

CONCLUSION

Findings suggest that a short FFQ can provide estimates of total dietary calcium consumption comparable to the full Block HHHQ.

Private health insurance coverage and disability among older Americans

OBJECTIVES

This study examines the relationship between the lack of private supplemental health insurance coverage and the development of disability among adults aged 65 and older.

METHODS

Data are from the baseline and six follow-up waves of the Duke Established Populations for Epidemiologic Studies of the Elderly survey (N = 4,000). Discrete-time hazard models were used to estimate the impact of insurance coverage and other risk factors on the incidence of disability among those unimpaired at baseline.

RESULTS

Controlling for education, income, and other potential confounders, the odds of developing disability were 35-49% higher among those without private coverage. Insurance coverage also statistically explained part of the increased risk of disability among low-income persons.

DISCUSSION

The results indicate that changes in health insurance coverage as well as in individual behaviors may be needed to reduce disability generally and disability among the socioeconomically disadvantaged, in particular.

Managing patients with complications of osteoporosis

This article reviews the impact of osteoporosis on quality of life. It defines specific impairments and suggests how best to minimize the impact of osteoporosis on patients' daily lives. Specific issues such as a spinal deformity, limitations on activities of daily living, pain, functionality, social impairment, self esteem, and depression also are addressed. Finally, a multidisciplinary team approach to osteoporosis is advocated.

Peyronie's disease is associated with Paget's disease of bone

Peyronie's disease is an idiopathic disorder in which an inflammatory fibrosis occurs in the tunica albuginea of the corpora cavernosa which causes the erect penis to become deformed. Peyronie's disease has a prevalence of 1% in men over age 50 years. Paget's disease of bone is a chronic skeletal disease with areas of increased bone turnover leading to pain, deformity, and in some cases arthritis. Because of a high rate of Peyronie's disease in subjects in a Paget's disease industry-sponsored drug trial, we asked whether there was an association between Peyronie's disease and Paget's disease of bone. We evaluated 61 men with Paget's disease attending our clinic for metabolic bone disease in a tertiary referral hospital, reviewed hospital records of all men discharged from our three hospitals with the diagnosis of Peyronie's disease, and mailed a validated questionnaire about shape of the erect penis to 1500 male members of the Paget Foundation. In the clinic population of men with Paget's disease of bone, 51 of 61 (83.6%) reported having normal erections; 10 patients (16.4%) were impotent. Sixteen of the 51 men (31.4%) had developed a bend or deformity in their erect penis which was confirmed by a urologist's examination to be Peyronie's disease. When the men with Paget's disease with and without Peyronie's disease were compared, there was no difference in their ages, years with Paget's disease, or serum alkaline phosphatase level. Upon medical record review, 1 patient of 262 (0.4%) with Peyronie's disease was found to have Paget's disease of bone. The men with Paget's disease returned their questionnaires for a response rate of 44.8% and reported Peyronie's disease with a prevalence of 14.5%. We suggest that Peyronie's disease is associated with Paget's disease of bone. Furthermore, we suggest that Peyronie's disease may be a previously unrecognized complication of Paget's disease of bone.

Memory complaint as a predictor of cognitive decline: a comparison of African American and White elders

Of a representative, racially mixed community sample of older adults in North Carolina, 59% of Whites and 49% of African Americans reported worsening memory. The complaint about memory was positively correlated with age, depressive symptomatology, and physical function but not with level of cognitive function as measured by the Short Portable Mental Status Questionnaire (SPMSQ) at baseline. In a controlled analysis of longitudinal data, initial SPMSQ score, age, African American race, lower education, depressive symptomatology, and physical deficits at baseline, but not memory complaint, predicted a decline in cognitive function as measured by the SPMSQ 3 years later. Whereas African Americans were less likely to complain of deterioration in memory, actual decline as measured by the SPMSQ was greater for African Americans than for Whites.

Paget's disease of bone and quality of life

Little is known about how Paget's disease of bone affects quality of life. To better understand the relative impact of factors on quality of life, we mailed a brief survey to 2000 people randomly selected from the Paget's Foundation mailing list. The sample was geographically stratified to examine the effects of specialist availability. Nine hundred and fifty-eight persons responded to the questionnaire (53% response rate after adjustment for death, incorrect addresses, and nondeliverable mailings). The sample had equal proportions of males and females, with a mean age of 74 years (SD = 9.0). Most (97%) were white, with high levels of education (mean 13 years; SD 3.7) and income (60% earned more than $20,000 annually). They reported pagetic bone in the skull (34%), spine (35%), pelvis (49%), and leg (48%). The most frequently mentioned complications were hearing loss (37%) and bowed limbs (31%). Comorbidity included arthritis (64%), hypertension (32%), and heart problems (28%). Nearly half (47%) reported feelings of depression, and 42% said that their health was fair or poor. Only 21% reported that quality of life was very good or excellent. In multiple partial F-test regression analyses, variables were divided into four domains (social, psychological, care, and biomedical). The psychological domain explained 19% of the variance beyond that explained by all other variables; the social domain explained 3%, the biomedical domain explained 3% and the care domain explained 1%. The importance of the psychological aspects of Paget's disease suggests that treatment protocols should include psychological intervention to improve quality of life.

Global self-ratings of health and mortality: hazard in the North Carolina Piedmont

We analyzed the first 5 years of surveillance data from the Established Population for the Epidemiologic Studies of the Elderly (EPESE) in the Piedmont of North Carolina (n = 4162) to estimate the effect of a global self-rating of health on survival. Covariates used in Cox proportional hazard models included sociodemographic factors, chronic medical conditions, activities of daily living, use of health services, health risk behaviors, cognitive function, affective mood, and negative life events. Adjusted risk of mortality associated with poor (compared to excellent) self-ratings of health was significantly elevated among urban men only. Confounders of the association between survival and overall health assessment varied widely by subgroup. Pooled estimates from heterogeneous populations may mask significant subgroup differences both in the pattern of variables that mediate crude risk and also in the magnitude of residual risk of global self-ratings of health.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Do racial differences in hypertension persist in successful agers? Findings from the MacArthur Study of Successful Aging

The objective of this study was to determine whether racial differences in hypertension in a random sample of community-dwelling older adults also remained significant in a sample of successful agers. Data for the random sample of community-dwelling older adults came from the Duke University Established Populations for Epidemiologic Studies of the Elderly (4,162 community-dwelling adults age 65 and older) and showed strong racial differences in hypertension. Data for successful agers came from the Duke MacArthur (428 of EPESE respondents in the top 30% in terms of physical, cognitive, and psychosocial performance). The mean of two sitting blood pressure measurements was the dependent variable for both sets of analyses. Independent variables included demographics and health factors. Using logistic regression, odds ratios in the Duke EPESE and Duke MacArthur samples for race were similar (Duke EPESE odds ratio = 1.30; Duke MacArthur odds ratio = 1.29). Sample size differences affected statistical significance. However, race differences in hypertension in older adults appear to be unexplained by socioeconomic status or other usual explanatory variables. Even among successful agers, racial differences in hypertension persist.

The clinical impact of vertebral fractures: quality of life in women with osteoporosis

Osteoporosis has obvious physical and functional consequences such as kyphosis, restricted range of motion, and pain. What are not so obvious are the psychosocial sequelae that result from this metabolic bone disease. Many patients in the initial phases of the disease express substantial anxiety, especially about the possibility of future fractures and physical deformity. As the disease progresses, depression can become profound for those who experience hip or multiple vertebral fractures. The effects of the chronicity of osteoporosis, its disabling and disfiguring aspects, and the chronic postural pain that develops as time passes challenge even the most stable individuals. In addition, osteoporosis has substantial impact on interpersonal relationships and social roles. The dependency created by this disease affects close relationships, because the patient with osteoporosis cannot reciprocate in social support. Today's older women find the restrictions of the disease socially devastating. These women, unlikely to work in the labor force, took pride in their roles of housekeeper and cook. Unfortunately, severe osteoporosis can force women to relinquish even these social roles, leaving them with no source of self-esteem or accomplishment. In all, osteoporosis is devastating both psychologically and socially.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Black-white and urban-rural differences in stability of household composition among elderly persons

The dynamic nature of household composition in a population of elderly persons, with particular focus on Black-White and urban-rural differences, is described in this study. The Duke EPESE is a stratified, random household sample (N = 4,162) of elderly persons in a five-county mixed urban-rural area of North Carolina with respondents contacted annually to report on health and social factors. Between 1986 and 1990, 35 percent of the households underwent some change in composition, with 14 percent contracting and/or expanding more than once. Where elders lived alone and where married elders lived with the spouse and/or others, Black elders were significantly more likely to experience a net expansion of their household than were White elders of the same age, gender, socioeconomic, and functional status. Elderly residents of rural areas who lived alone were slightly more likely to add one or more persons to their households than were comparable elderly urban residents. No additional risk of household instability was noted in sociodemographic or health-related subgroups by race or residence. Future analyses should examine the outcomes of instability.

Functional and mobility impairments associated with Paget's disease of bone

OBJECTIVE

To determine if patients with Paget's disease of bone involving the tibia, femur, and/or acetabular portion of the ilium had more impairments in function and mobility than age- and sex-matched control subjects.

PATIENTS AND METHODS

A case control study with Paget's disease patients selected from a center for bone disease at a tertiary medical center; control subjects were volunteers from the Duke University Aging Center subject registry. Demographic characteristics, physical examination and serum alkaline phosphatase levels were obtained. Radiographs of the pelvis and lower extremities were evaluated by a radiologist. All participants completed a Functional Status Questionnaire (FSQ). Mobility measures included mobility skills protocol, 10-foot walk time, 360-degree turn left (number of steps), and 6-minute walk distance.

RESULTS

The 12 Paget's disease patients were no different in age (70.7 +/- 6.2 years) than the 12 control subjects (69.5 +/- 6.2 years). Serum alkaline phosphatase levels were elevated in Paget's patients (539 +/- 530 IU/L), and normal in control subjects (85 +/- 17 IU/L). In addition to Paget's disease, radiographs showed joint space loss in joints proximate to the diseased bone. On the FSQ scales Paget's disease patients had significantly lower scores in basic activities of daily living (P < .05), instrumental activities of daily living (P < .001), and social activity than control subjects (P < .05). There was no difference between the groups on scales measuring mental health and quality of social interaction. On mobility measurements, Paget's disease patients showed significant impairments when compared with control subjects: mobility skills protocol score (22.5 +/- 2.5 vs 25.6 +/- 0.7, P < .001); 10-foot walk (3.96 +/- 1.3 vs 2.55 +/- 0.5 seconds, P < .001); 360 degree turn left (8.0 +/- 1.0 vs 5.9 +/- 0.6 steps, P < .001); and 6-minute walk (342.0 +/- 108.5 vs 519.4 +/- 100 meters, P < .001).

CONCLUSION

When compared with control subjects, patients who have Paget's disease of bone involving the tibia, femur, or acetabular portion of the ilium have clinically and statistically significant functional and mobility impairments compared to age- and gender-matched controls.

Self-rated health and mortality in the high-functioning elderly--a closer look at healthy individuals: MacArthur field study of successful aging

BACKGROUND

This study tested the predictive value of self-rated health on 3-year mortality, with attention focused on healthy, high-functioning elders.

METHODS

Data from the MacArthur Field Study of Successful Aging were utilized. Subjects were 70-79-year-old (at baseline) residents of the communities of East Boston, MA, New Haven, CT, and a five-county area in and around Durham County, NC (N = 1192) which comprise three sites of the Established Populations for Epidemiologic Studies of the Elderly (EPESE). In-home interviews were conducted in 1988 and 1991. Logistic regression was performed to create odds ratios adjusted for age, sex, race, marital status, education, alcohol consumption, cigarette smoking, chronic diseases, past hospitalizations, and cognitive function. The sample was then divided into healthy and less healthy cohorts based on number of chronic diseases, and the analyses were repeated.

RESULTS

The adjusted odds ratios for self-rated health (poor/bad ratings compared to excellent ratings) in relation to mortality were 19.56 in the general sample, 93.51 in the healthy cohort, and 2.75 in the less healthy cohort.

CONCLUSION

Self-rated health is predictive of mortality in controlled analyses, with the greatest impact seen in healthy individuals. Health care professionals should be sensitive to the significance of poor self-rated health in apparently healthy patients.

Recurrent syncope as a chronic disease: preliminary validation of a disease-specific measure of functional impairment

BACKGROUND

A disease-specific measure of functional health in syncope would provide an important outcome measure for use either in clinical trials or in the clinical management of patients with recurrent syncope.

METHODS AND MEASUREMENTS

In a previous study the authors used formal functional status measures to determine physical and psychosocial impairment in recurrent syncope. This study provides a preliminary assessment of a disease-specific measure of function. The measure was pilot tested on 84 subjects, and validated in a separate cohort of 49 patients. The measure consists of 1) an 11-question matrix of yes/no questions, assessing the ways that syncope interferes with a patient's life (the result is expressed as a proportion of the total number of ways that syncope might interfere and is called the Impairment Score), and 2) three Likert-scale questions that assess the patient's fear and worry about syncope. Correlations were obtained between scores on the disease-specific measure and other measures of functional health.

RESULTS

Among the 49 patients in the test cohort, final scores on the disease-specific measure correlated with both physical and psychosocial dimension scores on a measure of functional status, the Sickness Impact Profile (r = 0.35-0.36, p = 0.01), and with five of ten subscale scores on a measure of psychological distress, the Symptom Checklist 90-R (r = 0.30-0.43, p = 0.004-0.02).

CONCLUSIONS

This new disease-specific quality-of-life measure in syncope measures both physical and psychosocial components of impairment and could be a valuable adjunct in measuring outcomes in syncope patients.

Association of osteoporotic vertebral compression fractures with impaired functional status

PURPOSE

To determine if vertebral compression fractures in elderly women were associated with impairments in physical, functional, and psychosocial performance.

SUBJECTS AND METHODS

Ten white women with confirmed vertebral compression fractures were age- and race-matched with 10 control subjects without fractures in a case-control design. All subjects invited to participate in this study were patients of the Geriatrics Division of the Department of Medicine at Duke University Medical Center. All study participants lived either in the community or in the independent-living sections of local retirement communities in and around Durham, NC. Subjects with fractures (mean age = 81.9 years, SD = 5.9 years) had two or more vertebral compression fractures in their medical records, whereas control subjects (mean age = 79.6 years, SD = 6.5 years) had no history of vertebral fractures. Spinal radiographs of all women confirmed group assignment. Physical, functional, and psychosocial performances were evaluated. Physical performance was assessed by measurements of maximal trunk extension torque and thoracic and lumbar spinal motion in the sagittal plane, functional reach, mobility skills, 10-ft timed walk, and 6-minute walk test. Thoracic and lumbar spinal configurations were also determined. Functional performance was assessed using the Functional Status Index. Psychosocial performance was assessed with the following scales: Hopkins Symptom Checklist 90 Revised, Rosenberg Self-Esteem Scale, West Haven-Yale Pain Inventory, Beck Depression Inventory, and single-item health-belief questions.

RESULTS

Control subjects were not significantly different from patients with fractures in age, weight, number of current illnesses, number of prescribed medications, number of pain medications, ratings of lumbar spine degenerative disc disease, or lumbar spine facet joint arthritis. Activity levels and exercise participation were similar in both groups. Control subjects had no vertebral fractures, whereas fracture subjects had 4.2 +/- 2.6 fractures (range: 2 to 10). Thoracic kyphosis was increased and lumbar lordosis was reduced in fracture subjects. Fracture subjects had reduced maximal trunk extension torque, thoracic and lumbar spine sagittal plane motion, functional reach, mobility skills, and 6-minute walk test. The Functional Status Index showed reduced levels of functional performance in fracture subjects compared with controls with increased levels of assistance, pain with activity, and difficulty in activities. Psychosocial performance was limited in fracture subjects with increased psychiatric symptoms, increased pain, and greater perception of problems caused by health.

CONCLUSION

Vertebral compression fractures are associated with significant performance impairments in physical, functional, and psychosocial domains in older women.

Expenditures in caring for patients with dementia who live at home

OBJECTIVES

Given the national interest in progressive dementia, we estimated expenditures incurred in caring for dementia patients who live at home.

METHODS

Primary caregivers of 264 patients from a university-based memory disorders clinic were interviewed at baseline and asked to keep service use diaries for 6 months; 141 caregivers who returned the diaries are the focus of this report. We examined both formal and informal services (distinguished by whether money was exchanged) and associated expenditures.

RESULTS

Neither caregivers returning diaries nor their patients differed at baseline from those not returning diaries and their patients. Expenditures incurred over 6 months were extensive for both formal ($6986) and informal ($786) services. Out-of-pocket expenditures were high (e.g., in-home companion or sitter, adult day care, visiting nurse). Multivariable analyses indicated that patients with more severe symptoms of dementia and families with higher incomes reported significantly higher expenditures.

CONCLUSIONS

The expense of caring for patients with progressive dementia living at home may be higher than previously estimated and frequently involves expenses paid directly by patients and their families.

Social service interventions for caregivers of patients with dementia: impact on health care utilization and expenditures

OBJECTIVES

An intervention, which had as its primary goal the enhancement of compliance to social work recommendations, was shown to produce extremely high rates of compliance. This report addresses the secondary objective of the study: to evaluate the impact of the intervention on short-term (ie, 6-month) health services utilization and expenditures.

DESIGN

Randomized controlled trial.

SETTING

University-based memory disorders clinic.

PARTICIPANTS

Caregivers of patients with progressive memory disorders.

MAIN OUTCOME MEASURES

Service utilization and expenditures.

RESULTS

The intervention did not have a statistically significant impact on utilization of either health care or community resources. The intervention group had $903 less expenditures during the study period, a difference that did not achieve statistical significance. The results were consistent when controlling for caregiver characteristics that differed at baseline.

CONCLUSIONS

Although the intervention was successful in enhancing compliance with recommendations, more intensive interventions may be required to increase subsequent service utilization. Future investigations may wish to target the appropriateness of services used over a period longer than 6 months.

Physician-related barriers to breast cancer screening in older women

Despite evidence that annual mammographic screening in women 50 years and older reduces mortality, surveys of physicians and patients have repeatedly demonstrated that annual screening mammography is not performed. The fundamental question addressed in this chapter is: If the assumption is made that the scientific evidence supports the use of mammography, what, then, are physician-related barriers to mammographic screening of elderly women? Using a model that classifies barriers to implementing prevention protocols into three categories (predisposing, enabling, and reinforcing factors), literature is reviewed to help identify reasons for low mammographic screening rates, especially in elderly women. This article concludes with a discussion of strategies that may help overcome barriers to mammographic screening in elderly women.

Special care units: a typology of care settings for memory-impaired older adults

After rating 55 nursing homes in five states, we created a typology of care settings that included eight distinct types of units designed to care for memory-impaired older adults. SCUs appeared to be associated with higher quality care than were traditional units, although quality of SCU care was not uniformly outstanding. This typology provides guidelines that can be used in preresidential analysis of prospective care units for demented older adults.

Osteoporosis in late life: does health locus of control affect psychosocial adaptation?

Osteoporosis, a metabolic bone disease most prevalent in older adults, is a major public health problem. Although management of osteoporosis through diet, exercise, and medication has improved, little is known about the psychosocial consequences of this disabling disease. In an attempt to identify patient characteristics that would provide physicians with insight into appropriate management styles for older osteoporotics, we assessed 103 patients with osteoporosis for their health locus of control (HLOC) orientation. We examined the relationship between HLOC and patient outcomes after participation in the Duke University Preventive and Therapeutic Program for Osteoporosis (DUPATPO) to determine whether HLOC was associated with functioning after program participation. More specifically, we asked whether internal or external HLOC was associated with decreases in depression, psychiatric symptoms, and stress symptoms, or with increases in self-esteem, exercise, and disease knowledge. We have shown in our earlier work (Gold et al, J Am Geriatr Soc 1989; 37:417) that program participation is associated with improved functioning in older adults. We now asked whether knowledge of a patient's HLOC would help predict these improvements. A comparison group (ie, older osteoporotics who did not participate in DUPATPO) was also assessed for HLOC to examine the possible association between HLOC and health behaviors regardless of the DUPATPO intervention. Our findings indicate that HLOC provided little useful information regarding patient outcomes. Although improvements were seen in the mental health of program participants, no association between these improvements and HLOC could be found.