The choices, choosing model of quality of life: description and rationale

Effects of restriction of activities and social isolation on risk of dementia in the community

OBJECTIVE

Social isolation and emotional isolation, i.e. loneliness, have been associated with dementia or cognitive decline. In contrast, the relationship of restriction of physical and instrumental activities of daily living to cognitive decline and dementia has been less studied.

DESIGN

We examined multiple quality of life (QoL) indicators, including isolation and restriction of activities, utilizing two validated scales in elders without dementia to determine their associations with cognitive decline and incident dementia that were followed longitudinally over 6 years. We comprehensively controlled for other symptom constellations, including depression and anergia.

SETTING

A large multi-ethnic prospective study was conducted in northern Manhattan, NYC.

PARTICIPANTS

An ethnically diverse sample of 855 non-demented individuals at baseline participated.

MEASURES

The following QoL scales were utilized: Restriction, Anergia, Isolation, Loneliness, and Affective Suffering.

RESULTS

Both Restriction (HR = 2.22, 95% CI [1.42, 3.47], P < .001) and Isolation (HR = 1.78, 95% CI [1.17, 2.70], P = 0.007) were associated with episodic memory and incident dementia, controlling for age, sex, and education. Loneliness and Affective Suffering (depression) were not associated with these outcomes (P's > .1) with both Restriction and Isolation in the same model for the prediction of dementia, only Restriction remained significant (HR = 1.97, 95% CI [1.24, 3.14], P = 0.004). In cross-lagged panel analyses, Restriction and Isolation had reciprocal influences (P's < .001), indicating that Restriction at the previous time point influenced current Isolation. Importantly, Restriction (but not Isolation) and Selective Reminding total recall memory demonstrated highly significant direct and reciprocal influences over time (P's < .001).

CONCLUSIONS

Restriction and Isolation were associated with incident dementia. Restriction played a more prominent role in its impact on memory decline. The development of these impairments in QoL, particularly Restriction, may provide warning signs of future cognitive decline and dementia and provide multiple and novel avenues for therapeutic interventions with the goal of delaying the development of cognitive decline and dementia.

Participation as means for adaptation in dementia: a conceptual model

OBJECTIVES

There are a number of conceptual models of dementia, capturing a range of biopsychosocial factors. Few integrate the lived experience of dementia. The aim of this study was to develop a conceptualisation grounded in the first-hand accounts of living with the condition and reflecting its complexity.

METHOD

The study was conducted within an explanatory, critical realist paradigm. An overarching narrative approach, informed by a previously completed systematic review and metasynthesis of research on the lived experience of dementia and the assumptions of complexity theory, was used to guide data collection and analysis. Data were contributed by 31 adults, including 12 people living with dementia and 19 family caregivers.

RESULTS

The experience of living with dementia was conceptualised as a process of adaptation through participation, emerging from ongoing, dynamic and nonlinear interactions between the adaptive capacity of a person with dementia and the adaptive capacity within the environment. The proposed conceptual model describes contexts and mechanisms which shape this capacity. It identifies a range of potential outcomes in dementia. These outcomes reflect interactions and the degree of match between the adaptive capacity of a person and the adaptive capacity within the environment.

CONCLUSION

By recognising and exploring the potential for adaptation and enduring participation in dementia, findings of this research can support practitioners in facilitating positive outcomes for people affected by the condition.

Development of a Short-Form of the Medication Management Test: Evaluation of Dimensionality, Reliability, Information and Measurement Equivalence Using Latent Variable Models

BACKGROUND AND PURPOSE

The Medication Management Test (MMT) measures higher cognitive functioning. The aim of the analyses presented was to reduce assessment burden by developing a short-form version, and describe its psychometric properties.

METHODS

Factor analyses, item response theory (IRT), and differential item functioning (DIF) were performed to examine the dimensionality, reliability information, and measurement equivalence.

RESULTS

The ratio of the first two extracted eigenvalues from the exploratory principal component analysis was 7.62, indicating essential unidimensionality. Although one item "needs prompting for pill regime" evidenced DIF above the threshold for education and race/ethnicity, the magnitude was relatively small and the impact minimal. IRT-based reliability estimates were high (>0.80) across all subgroups.

CONCLUSIONS

Because medication management is an important task associated with independent living, it is critical to assess whether medications can be self-administered safely.

The Abrams geriatric self-neglect scale: introduction, validation and psychometric properties

OBJECTIVE

Self-neglect is an imprecisely defined entity with multiple clinical expressions and adverse health consequences, especially in the elderly. However, research has been limited by the absence of a measurement instrument that is both inclusive and specific. Our goal was to establish the psychometric properties of a quantitative instrument, the Abrams Geriatric Self-Neglect Scale (AGSS).

METHODS

We analyzed data from a 2007 case-control study of 71 cognitively intact community-dwelling older self-neglectors that had used the AGSS. The AGSS was validated against two "gold standards": a categorical definition of self-neglect developed by expert consensus; and the clinical judgment of a geriatric psychiatrist using chart review. Frequencies were examined for the six scale domains by source (Subject, Observer, and Overall Impression). Internal consistency was estimated for each source, and associations among the sources were evaluated.

RESULTS

Internal consistency estimates for the AGSS were rated as "good," with the Subject responses having the lowest alpha and omega (0.681 and 0.692) and the Observer responses the highest (0.758 and 0.765). Subject and Observer scores had the lowest association (0.578, p < 0.001). Using expert consensus criteria as the primary "gold standard," the Observer and Overall Impression subscales were "good" at classifying self-neglect, while the Subject subscale was "fair."

CONCLUSIONS

The AGSS correctly classified and quantified self-neglect against two "gold standards." Sufficient correlations among multiple sources of information allow investigators and clinicians to choose flexibly from Subject, Observer, or Overall Impression. The lower internal consistency estimates for Subject responses are consistent with self-neglectors' propensity to disavow symptoms. Copyright © 2017 John Wiley & Sons, Ltd.

Methodological issues in measuring subjective well-being and quality-of-life: Applications to assessment of affect in older, chronically and cognitively impaired, ethnically diverse groups using the Feeling Tone Questionnaire

Quality of life assessment includes measurement of positive affect. Methods artifacts associated with positively and negatively worded items can manifest as negative items loading on a second factor, despite the conceptual view that the items are measuring one underlying latent construct. Negatively worded items may elicit biased responses. Additionally, item-level response bias across ethnically diverse groups may compromise group comparisons. The aim was to illustrate methodological approaches to examining method factors and measurement equivalence in an affect measure with 9 positively and 7 negatively worded items: The Feeling Tone Questionnaire (FTQ). The sample included 4,960 non-Hispanic White, 1,144 non-Hispanic Black, and 517 Hispanic community and institutional residents receiving long-term supportive services. The mean age was 82 (s.d.=11.0); 73% were female. Two thirds were cognitively impaired. Methods effects were assessed using confirmatory factor analyses (CFA), and reliability with McDonald's omega and item response theory (IRT) generated estimates. Measurement equivalence was examined using IRT-based Wald tests. Methods effects associated with negatively worded items were observed; these provided little IRT information, and as a composite evidenced lower reliability. Both 13 and 9 item positive affect scales performed well in terms of model fit, reliability, IRT information, and evidenced little differential item functioning of high magnitude or impact. Both CFA and IRT approaches provided complementary methodological information about scale performance. The 9-item affect scale based on the FTQ can be recommended as a brief quality-of-life measure among frail and cognitively impaired individuals in palliative and long-term care settings.

What to Expect From the Evolving Field of Geriatric Cardiology

The population of older adults is expanding rapidly, and aging predisposes to cardiovascular disease. The principle of patient-centered care must respond to the preponderance of cardiac disease that now occurs in combination with the complexities of old age. Geriatric cardiology melds cardiovascular perspectives with multimorbidity, polypharmacy, frailty, cognitive decline, and other clinical, social, financial, and psychological dimensions of aging. Although some assume that a cardiologist may instinctively cultivate some of these skills over the course of a career, we assert that the volume and complexity of older cardiovascular patients in contemporary practice warrants a more direct approach to achieve suitable training and a more reliable process of care. We present a rationale and vision for geriatric cardiology as a melding of primary cardiovascular and geriatrics skills, thereby infusing cardiology practice with expanded proficiencies in diagnosis, risks, care coordination, communications, end-of-life, and other competences required to best manage older cardiovascular patients.

Quality of life impacts on 16-year survival of an older ethnically diverse cohort

OBJECTIVE

The objective of this study is to examine the prediction of mortality, over 16 years, by the domains and domain elements underlying generic measures of quality of life (QoL).

METHODS

The method used was an analysis of mortality in an older (65 + years) representative sample (N = 2130) of a multicultural community in North Manhattan. Five conventional QoL domains were measured by in-home, rater-administered, and computer-assisted questionnaire: depressed mood, pain, self-perceived health, and function and social relationships.

RESULTS

Some domain scales that qualitatively express distress, such as depressed mood and widespread pain, significantly predicted lower mortality (were protective) and felt isolation trended in that direction, whereas domains indicating quantitative limitations such as impairment of functioning in daily tasks, stair climbing, as well as social disengagements and lack of support network significantly predicted higher mortality. Domain elements also mattered; contrary to their domain predictions, increased mortality was predicted by the domain elements of somatic symptoms of depression. Self-perceived poor health reflected the predictive (higher mortality) direction of the limitations cluster.

CONCLUSIONS

The internal complexity of QoL is underscored by differential impacts of domains and elements on mortality. Clinical implications include setting distress domains as important clinical goals, whereas strengthening limiting domains could result in lengthening life and secondarily relieving distress. The relative weighting of these goals could be derived from patient preferences and clinical efficacy. Fundamental implications lie in the interaction between the person's qualitative evaluations of choices and the quantitative building of desired choices for a better QoL.

Changing nature of cardiac interventions in older adults

Older adults represent a rapidly growing segment of the population in developed countries. Advancing age is the most powerful risk factor for the development of cardiovascular disease (CVD), and CVD-related mortality increases markedly in older individuals. Procedures for patients with CVD, including percutaneous coronary intervention, aortic valve replacement and implantable cardioverter defibrillators were all initially validated in younger individuals but are increasingly being applied in older adults who for the most part have been significantly understudied in clinical trials. While advanced age alone is not a contraindication to these procedures, with the advent of less invasive methods to manage CVD including percutaneous techniques to treat both coronary artery disease and valvular heart disease, future research will need to weigh the potential harms of intervention in a population of older adults with multiple medical comorbidities and complex physiologic phenotypes against outcomes that include preventing functional decline and improving quality of life.

Health-related restrictions of choices and choosing: implications for quality of life and clinical interventions

Background:

The process of “accessing choices and choosing among them” (c-c) has been proposed as a model for understanding, evaluating, and assisting a patient’s management of quality of life. If desired choices are freely accessible, and the act of choosing is efficient and unconstrained, then the outcome is optimized quality of life. The c-c model fits many clinical situations where improved quality of life is a goal, and interventions may be aimed at relieving health-related restrictions of the patient’s desired activities.

Aims:

To determine the impact of health restrictions of choices and choosing on indicators and outcomes reflecting quality of life.

Method:

Secondary analysis of a community-based health survey of three ethnic groups, 65 years and older (n = 2,130), repeated after 18 months, with mortality over 6 years.

Findings:

Complaints of health restrictions of desired activities accounted for about half the variance of all determinants of a quality of life proxy indicator, and had a high frequency. Such complaints also predicted declines in mood and function, higher death rates, and increased service use.

Conclusions:

Clinical trials are warranted of the efficacy for quality of life improvement of interventions that focus on the relief of health-induced restrictions of desired activities.

The choices, choosing model of quality of life: clinical evaluation and intervention

Two previous papers presented a conjectured model of quality of life featuring the personal management of accessing choices and choosing among them (the c-c process). Those papers made the case that this model unifies the pathways leading to impaired quality of life, especially with regard to age associated multiple co-morbidities, changes in perception and functioning, and the effects of long term care environments; it also introduces a science base for understanding and guiding interventions that can assist people to achieve their quality-of-life goals. Our aim in this paper is to outline interprofessional strategies that could relieve restrictions or distortions of the c-c process imposed by aging, ill-health, or a restricting environment. We do so by outlining potential deficits in the c-c process and matching these with restorative person-centered interprofessional interventions including interprofessional teamwork. Findings suggest that interprofessional assessment and team work is well suited to assisting the c-c process. We conclude that the groundwork has been prepared for developing training programs and clinical trials for interprofessional interventions targeting the c-c process.