Proxy reporting of quality of life using the EQ-5D

BACKGROUND

The economic evaluation of health interventions for older people is complicated by the difficulty in obtaining self-reports of quality of life from persons with cognitive impairments, physical impairments, or both.

OBJECTIVES

Using the EQ-5D (EuroQoL) measures, to assess: (1) agreement between subjects and proxies on subject's quality of life ratings at different points in time; (2) agreement between subjects and proxies on change of subject's quality of life ratings over time; and (3) subject and proxy characteristics related to agreement.

RESEARCH DESIGN

Prospective study of subjects visiting hospital emergency departments (ED). Data were collected at enrollment in the ED and at follow-up, 1 and 4 months after the ED visit.

SUBJECTS

The study comprised 231 pairs of cognitively intact patients aged 65 years or older and their primary caregivers.

MEASURES

Quality of life was measured using both components of the EQ-5D scale, the index score and the Visual Analogue Scale (VAS). Demographic characteristics and health status (physical and mental) were measured for both subjects and proxies. Subjects and proxies were interviewed either in English or French.

RESULTS

There was low to moderate agreement between subjects and proxies at different points in time (intraclass correlation coefficient [ICC] = 0.22 to 0.59), and between subject and proxy change scores over time (ICC = 0-0.50), on both the index score and the VAS. Better agreement between subjects and proxies was found at the 4 months follow-up, when the subject was less depressed, and when the proxy's native language was English.

CONCLUSIONS

Proxy EQ-5D responses, either for a specific point in time or for assessing change over time, may not be valid measures of self-reported quality of life among older medically-ill patients.

Symptoms of delirium among elderly medical inpatients with or without dementia

This study examined the frequencies of the 10 symptoms of delirium identified in DSM-III-R among patients with delirium (DSM-III-R criteria) who did or did not have dementia. The prevalence of each symptom, the numbers of symptoms, and the combinations of symptoms were determined among 322 elderly medical inpatients classified into one of four groups: delirium and dementia (n=128), delirium only (n=40), dementia only (n=94), or neither (n=60). Symptoms were assessed at the time of diagnosis and independently (by use of a different scale) within 24 hours of diagnosis. Delirium appeared to be phenomenologically similar among patients with and those without dementia, although patients with dementia had more psychomotor agitation at the time of diagnosis and more disorganized thinking and disorientation at the second assessment.

Inhaled corticosteroids and the risk of diabetes among the elderly

AIMS

There is evidence that large doses of inhaled corticosteroids lead to an increased risk of glaucoma, cataracts and other problems associated with oral corticosteroid use. However, no formal investigation so far has been conducted into the relationship between inhaled corticosteroids and diabetes.

METHODS

Our nested case-control design studied the association between current use of inhaled corticosteroids and the risk of using antidiabetic medications among a cohort of 21 645 elderly subjects. We also investigated the possibility of a dose-response relationship in users of beclomethasone. Data were obtained from the medical and pharmaceutical databases of the Regie de l'assurance maladie du Québec.

RESULTS

Within the cohort, we identified 1494 cases and we selected 14 931 controls using density sampling. The unadjusted rate ratio (and 95% confidence interval, CI) for developing diabetes among current users of inhaled corticosteroids was 1.4 (1.2, 1.5). After adjusting for covariates, the rate ratio (95% CI) decreased to 0.9 (0.8, 1.1). The loss of statistical significance was due in large part to adjusting for the current use of oral corticosteroids. We also did not observe a statistically significant increase in risk among users of high-dose beclomethasone compared to nonusers, after adjusting for covariates.

CONCLUSIONS

Our results do not indicate an increased risk of diabetes among current users of inhaled corticosteroids.

The prevalence and phenomenology of auditory hallucinations among elderly subjects attending an audiology clinic

BACKGROUND

Studies of auditory hallucinations are scant.

METHOD

To determine the prevalence and phenomenology of auditory hallucinations among elderly subjects with hearing impairment.

OBJECTIVE

We surveyed 125 men and women aged 65 years and over referred to the Audiology department of a university-affiliated primary acute-care hospital.

RESULTS

The prevalence of auditory hallucinations was 32.8% (95% confidence interval (CI) 24.7-41.8). These hallucinations represented a spectrum of phenomenology from elementary personal impressions to complex percepts. The types of auditory hallucinations included humming or buzzing (35.9%), shushing (12.8%), beating or tapping (10.6%), ringing (7.7%), other individual sounds (15.4%), multiple sounds (12.6%), voices (2.5%) or music (2.5%). Subjects with any type of hallucination were younger and had poorer discrimination scores in the left ear and impaired binaural discrimination with lip-reading. Subjects with hallucinations that had more qualities of a true percept heard different types of sounds and had lower reflex thresholds and better air conduction in the right ear.

CONCLUSION

Auditory hallucinations are frequent in elderly subjects with hearing impairment and seem to be associated with younger age and asymmetrical hearing impairment.

Rapid emergency department intervention for older people reduces risk of functional decline: results of a multicenter randomized trial

OBJECTIVES

To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for older patients in the emergency department (ED) who are at increased risk of functional decline and other adverse outcomes.

DESIGN

Controlled trial, randomized by day of ED visit, with follow-up at 1 and 4 months.

SETTING

Four university-affiliated hospitals in Montreal.

PARTICIPANTS

Patients age 65 and older expected to be released from the ED to the community with a score of 2 or more on the Identification of Seniors At Risk (ISAR) screening tool and their primary family caregivers. One hundred seventy-eight were randomized to the intervention, 210 to usual care.

INTERVENTION

The intervention consisted of disclosure of results of the ISAR screen, a brief standardized nursing assessment in the ED, notification of the primary care physician and home care providers, and other referrals as needed. The control group received usual care, without disclosure of the screening result.

MEASUREMENTS

Patient outcomes assessed at 4 months after enrollment included functional decline (increased dependence on the Older American Resources and Services activities of daily living scale or death) and depressive symptoms (as assessed by the short Geriatric Depression Scale). Caregiver outcomes, also assessed at baseline and 4 months, included the physical and mental summary scales of the Medical Outcomes Study Short Form-36. Patient and caregiver satisfaction with care were assessed 1 month after enrollment.

RESULTS

The intervention increased the rate of referral to the primary care physician and to home care services. The intervention was associated with a significantly reduced rate of functional decline at 4 months, in both unadjusted (odds ratio (OR) = 0.60, 95% confidence interval (CI) = 0.36-0.99) and adjusted (OR = 0.53, 95% CI = 0.31-0.91) analyses. There was no intervention effect on patient depressive symptoms, caregiver outcomes, or satisfaction with care.

CONCLUSION

A two-stage ED intervention, consisting of screening with the ISAR tool followed by a brief, standardized nursing assessment and referral to primary and home care services, significantly reduced the rate of subsequent functional decline.

Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study

BACKGROUND

Delirium in older hospital inpatients appears to be associated with various adverse outcomes. The limitations of previous research on this association have included small sample sizes, short follow-up periods and lack of consideration of important confounders or modifiers, such as severity of illness, comorbidity and dementia. The objective of this study was to determine the prognostic significance of delirium, with or without dementia, for cognitive and functional status during the 12 months after hospital admission, independent of premorbid function, comorbidity, severity of illness and other potentially confounding variables.

METHODS

Patients 65 years of age and older who were admitted from the emergency department to the medical services were screened for delirium during their first week in hospital. Two cohorts were enrolled: patients with prevalent or incident delirium and patients without delirium, but similar in age and cognitive impairment. The patients were followed up at 2, 6 and 12 months after hospital admission. Analyses were conducted for 4 patient groups: 56 with delirium, 53 with dementia, 164 with both conditions and 42 with neither. Baseline measures included delirium (Confusion Assessment Method), dementia (Informant Questionnaire on Cognitive Decline in the Elderly), physical function (Barthel Index [BI] and premorbid instrumental activities of daily living, IADL), the Mini-Mental State Examination (MMSE), comorbidity, and physiologic and clinical severity of illness. Outcome variables measured at follow-up were the MMSe, Barthel Index, IADL and admission to a long-term care facility.

RESULTS

After adjustment for covariates, the mean differences in MMSE scores at follow-up between patients with and without delirium were -4.99 (95% confidence interval [CI] -7.17 to -2.81) for patients with dementia and -3.36 (95% CI -6.15 to -0.58) for those without dementia. At 12 months, the adjusted mean differences in the BI were -16.45 (95% CI -27.42 to -5.50) and -13.89 (95% CI -28.39 to 0.61) for patients with and without dementia respectively. Patients with both delirium and dementia were more likely to be admitted to long-term care than those with neither condition (adjusted odds ratio 3.18, 95% CI 1.19 to 8.49). Dementia but not delirium predicted worse IADL scores at follow-up. Unadjusted analyses yielded similar results.

INTERPRETATION

For older patients with and without dementia, delirium is an independent predictor of sustained poor cognitive and functional status during the year after a medical admission to hospital.

Bayesian approaches to modeling the conditional dependence between multiple diagnostic tests

Many analyses of results from multiple diagnostic tests assume the tests are statistically independent conditional on the true disease status of the subject. This assumption may be violated in practice, especially in situations where none of the tests is a perfectly accurate gold standard. Classical inference for models accounting for the conditional dependence between tests requires that results from at least four different tests be used in order to obtain an identifiable solution, but it is not always feasible to have results from this many tests. We use a Bayesian approach to draw inferences about the disease prevalence and test properties while adjusting for the possibility of conditional dependence between tests, particularly when we have only two tests. We propose both fixed and random effects models. Since with fewer than four tests the problem is nonidentifiable, the posterior distributions are strongly dependent on the prior information about the test properties and the disease prevalence, even with large sample sizes. If the degree of correlation between the tests is known a priori with high precision, then our methods adjust for the dependence between the tests. Otherwise, our methods provide adjusted inferences that incorporate all of the uncertainty inherent in the problem, typically resulting in wider interval estimates. We illustrate our methods using data from a study on the prevalence of Strongyloides infection among Cambodian refugees to Canada.