Development and evaluation of the quality of life instrument in chronic liver disease patients with minimal hepatic encephalopathy

Objectives:  The objective was to develop a valid and reliable health-related quality of life (HRQOL) assessment tool to measure the functional and health status of patients with minimal hepatic encephalopathy (mHE).
Methods:  Items potentially affecting the HRQOL of these patients were identified, based on the responses from 53 patients with minimal hepatic encephalopathy, from seven liver experts, four epidemiologists and from a PubMed search of the literature. Results were explored using factor analysis and redundant questions were eliminated. The final stated questionnaire was used in 178 patients with mHE to evaluate its reliability and validity.
Results:  Thirty-five items proved to be important for 32 respondents in the item reduction sample. The final instrument included five domains (30 items) which were shown as follows: physical functioning (8 items), psychological well-being (7 items), symptoms/side effects (7 items), social functioning (4 items) and general-health (4 items). An inter-item correlation for each of the five domains ranged from 0.220 to 0.776, with a mean of 0.280. Cronbach's alpha for above five domains was 0.8775, 0.8446, 0.8360, 0.7087 and 0.7016 respectively. The test-retest coefficients for the five domains were 0.94, 0.93, 0.96, 0.82 and 0.83 respectively. Factor analysis showed preservation of five components structure. Cumulative variance of principal components was 63.12%. Patients with more advanced disease seemed to have more impairment of their well-being, especially in the symptoms/side effects domain.
Conclusions:  The instrument is short, easy to administer and is of good validity and reliability in patients with mHE.     

老年医学与衰弱老年人的医疗服务

目的 随着年龄的增长.人们发生多种健康问题的可能性增大.这些问题可被称作健康缺陷.健康缺陷越多.越容易引发健康方面的不良后果,例如健康状况恶化,甚至死亡.所渭衰弱,是指能够增加不良健康后果的危险的身体状态.健康缺陷度越高,身体衰弱度就越大.在临床上,通过临床衰弱量表-09的使用,可以对衰弱度进行逐级描述(此量表是加拿大健康与衰老研究课题所设计使用的临床衰弱量表的修订版).衰弱导致了健康问题的复杂化.由于老年人的健康问题较为复杂,而临床服务一般只侧重于诊治单一的问题,造成对老年患者的服务不够全面.老年专科医生应该是能够综合处理复杂问题的专家,应擅长诊治并存多种健康问题的老年患者.充分了解和认真研究健康需求的复杂性问题,老年专科医生才能最有效地帮助那些身体衰弱的老年患者.模式识别就是对付老年疾病复杂性的一种重要手段,它借助于老年综合性评估和对实际发病的衰弱老年人所表现出的症状特征的识别而加以实现.     

Angiotensin-Converting Enzyme Inhibitor Use and Incident Frailty in Women Aged 65 and Older: Prospective Findings from the Women's Health Initiative Observational Study

OBJECTIVES: To examine the associations between current use, duration, and potency of angiotensin-converting enzyme (ACE) inhibitors and incident frailty in women aged 65 and older who were not frail at baseline.
DESIGN: Data were from the Women's Health Initiative Observational Study (WHI-OS), a prospective study conducted at 40 U.S. clinical centers.
PARTICIPANTS: Women aged 65 to 79 at baseline who were not frail (N=27,378).
MEASUREMENTS: Current ACE inhibitor use was ascertained through direct inspection of medicine containers at baseline. Components of frailty were self-reported low physical function or impaired walking, exhaustion, low physical activity, and unintended weight. Frailty was ascertained through self-reported and physical measurements data at baseline and 3-year clinic contacts.
RESULTS: By the 3-year follow-up, 3,950 (14.4%) women had developed frailty. Current ACE inhibitor use had no association with incident frailty (multivariate adjusted odds ratio=0.96, 95% confidence interval=0.82–1.13). Duration and potency of ACE inhibitor use were also not significantly associated with incident frailty. A similar pattern of results was observed when incident cardiovascular disease events were studied as a separate outcome or when the sample was restricted to subjects with hypertension.
CONCLUSION: Overall, incidence of frailty was similar in current ACE inhibitor users and nonusers.     

Assessment of Capacity to Consent to Treatment: Challenges, the "ACCT" Approach, Future Directions

OBJECTIVE: To review approaches to assessing consent capacity in patients with neurocognitive or neuropsychiatric illness; to summarize the rationale behind our structured interview for consent capacity; and to outline questions for future research. METHOD: After reviewing legal and clinical literature, and empirically comparing three leading consent capacity instruments, we developed the Assessment of Capacity to Consent to Treatment (ACCT) interview and administered it to adults with dementia (n=20), schizophrenia (n=20), and controls (n=19). Capacity ratings by primary care clinicians and experts blind to the patients' status were obtained for a subsample. RESULTS: Interscorer reliability was r=.90; internal consistency reliability was .α=96. ACCT scores agreed 82% of the time (kappa = .44; p<.01) with primary care clinician ratings of capacity and 75% of the time (kappa = .50; p<.05) with expert ratings of capacity. Patients with dementia and schizophrenia could express treatment choices but performed worse than controls on measures of understanding, appreciation as problems with foresight, rational reasoning, and values-based reasoning. Only patients with schizophrenia performed worse on a measure of appreciation as problems with distrust. CONCLUSION: The method of assessing consent capacity described here has adequate reliability and validity, and may provide a useful starting point for clinicians and researchers. Many questions remain about the nature of consent capacity, its component constructs, and the meaning of instrument versus clinician ratings of capacity. Future adaptations, particularly in the assessment of appreciation and reasoning, and additional studies in more diverse samples, are needed.     

Allostatic Load and Frailty in Older Adults

OBJECTIVES: To examine the association between allostatic load (AL), an index of multisystem physiological dysregulation, and frailty development over a 3-year follow-up in a sample of older adults.
DESIGN: Longitudinal cohort study.
SETTING: Community.
PARTICIPANTS: High-functioning men and women aged 70 to 79 at study entry.
MEASUREMENTS: Multisystem physiological dysregulation, or AL, was assessed according to 13 biomarkers of cardiovascular, endocrine, immune, and metabolic function. An AL score was computed as the total number of biomarkers for which participant values fell into high-risk biomarker quartiles. Frailty status (not frail, intermediate frail, frail) was determined according to the total number of five indicators of frailty: weight loss, exhaustion, weak grip, slow gait, and low physical activity. The association between level of AL at baseline and frailty status 3 years later was examined using ordinal logistic regression in 803 participants not frail at baseline.
RESULTS: In a multivariable model adjusting for sociodemographic, health, and behavioral characteristics, each 1-unit increase in AL at baseline was associated with a 10% greater likelihood of frailty at the 3-year follow-up (cumulative adjusted odds ratio=1.10, 95% confidence interval=1.03–1.19).
CONCLUSION: These findings support the hypothesis that dysregulation across multiple physiological systems is associated with greater risk of frailty. Greater levels of multisystem physiological dysregulation may serve as a warning sign of frailty development in later life.     

Standardizing assessment of elderly people in acute care: the interRAI Acute Care instrument

OBJECTIVES: To examine the frequency distributions and interrater reliability of individual items of the interRAI Acute Care instrument.
DESIGN: Observational study of a representative sample of older inpatients; duplicate assessments conducted on a subsample by independent assessors to examine interrater reliability.
SETTING: Acute medical, acute geriatric and orthopedic units in 13 hospitals in nine countries.
PARTICIPANTS: Five hundred thirty-three patients aged 70 and older (mean age 82.4, range 70–102) with an anticipated stay of 48 hours or longer of whom 161 received duplicate assessments.
MEASUREMENTS: Sixty-two clinical items across 11 domains. Premorbid (3-day observation period before onset of the acute illness) and admission (the first 24 hours of hospital stay) assessments were conducted.
RESULTS: The frequency of deficits exceeded 30% for most items, ranging from 1% for physically abusive behavior to 86% for the need for support in activities of daily living after discharge. Common deficits were in cognitive skills for daily decision-making (38% premorbid, 54% at admission), personal hygiene (37%, 65%), and walking (39%, 71%). Interrater reliability was substantial in the premorbid period (average κ=0.61) and admission period (average κ=0.66). Of the 69 items tested, less than moderate agreement (κ<0.4) was recorded for six (9%), moderate agreement (κ=0.41–0.6) for 14 (20%), substantial agreement (κ=0.61–0.8) for 40 (58%), and almost perfect agreement (κ>0.8) for nine (13%).
CONCLUSION: Initial assessment of the psychometric properties of the interRAI Acute Care instrument provided evidence that item selection and interrater reliability are appropriate for clinical application. Further studies are required to examine the validity of embedded scales, diagnostic algorithms, and clinical protocols.     

Development of the Risk Appraisal Measure: A Brief Screen to Identify Risk Areas and Guide Interventions for Dementia Caregivers

OBJECTIVES: To develop and validate a brief screening measure for use in research, healthcare, and community settings to systematically assess well-being and identify needed areas of support for caregivers of patients with dementia.
DESIGN: This study used data from Resources for Enhancing Alzheimer's Caregiver Health (REACH II), a multisite randomized clinical trial of a behavioral intervention designed to improve the quality of life of caregivers in multiple domains.
SETTING: REACH II.
PARTICIPANTS: Two hundred twelve Hispanic, 211 black, and 219 white family caregivers providing in-home care to patients with dementia.
MEASUREMENT: Based on conceptual and psychometric analyses, a 16-item measure was developed that assesses six domains linked to caregiver risk and amenable to intervention: depression, burden, self-care and health behaviors, social support, safety, and patient problem behaviors. The reliability and validity of the instrument was evaluated with 642 dementia caregiver dyads from the REACH II program.
RESULTS: The measure was found to have acceptable internal consistency for a multidimensional scale and similar measurement properties for each of the racial and ethnic groups. Concurrent validity was also demonstrated for the measure.
CONCLUSION: The REACH Risk Appraisal Measure developed in this study shows promise as an assessment tool that can be used in research, clinical, and community settings to guide, prioritize, and target needed areas of support for caregivers of patients with dementia.     

The clinical care of frail, older adults

Frailty and its management represent an emerging area of clinical care in older adults. Geriatricians have long recognized a syndrome of multiple comorbid conditions, immobility, weakness, and poor tolerance of physiologic stressors in older adults. Patients with these characteristics are described as frail and suffer increased adverse clinical outcomes. This article reviews the clinical spectrum of frailty in older adults, its biologic etiology, and potential clinical interventions. Several operational definitions of frailty and the associated clinical signs, symptoms, and outcomes are outlined. The biologic mechanisms hypothesized to underlie frailty are explored, particularly in the musculoskeletal, endocrine, and immune systems. Treatment options for frail, older adults are discussed, including physiologic system-targeted interventions and geriatric models of care.     

Psychometric properties of the activities-specific balance confidence scale and the survey of activities and fear of falling in older women

OBJECTIVES: To compare the psychometric properties of the Activities-specific Balance Confidence Scale (ABC) and the Survey of Activities and Fear of Falling in the Elderly (SAFE).
DESIGN: Secondary analysis using baseline and 12-week data from a randomized, controlled trial on fall prevention.
SETTING: Upper Midwest metropolitan area with assessments conducted in participants' homes.
PARTICIPANTS: Population-based sample of 272 noninstitutionalized female Medicare beneficiaries aged 70 and older at risk of falling.
MEASUREMENTS: Participants self-administered the ABC, SAFE, Geriatric Depression Scale, and Medical Outcomes Study 36-item Short Form Survey. During a home visit, a nurse practitioner administered the Berg Balance Test and Timed Up and Go, measured gait speed, and asked about falls and chronic illnesses.
RESULTS: Baseline internal consistency measured using Cronbach alpha was 0.95 for the ABC and 0.82 for the SAFE. Baseline concurrent validity between the ABC and SAFE measured using a correlation coefficient was −0.65 ( P <.001). ABC and SAFE scores were significantly correlated at baseline with physical performance tests and self-reported health status. The ABC had stronger baseline correlations than the SAFE with most measures. Neither instrument demonstrated responsiveness to change at 12 weeks.
CONCLUSION: The ABC and SAFE demonstrated strong internal-consistency reliability and validity when self-administered. The ABC had stronger associations with physical functioning and may be more appropriate for studies focused on improving physical function. Both instruments demonstrated ceiling effects, which may explain the lack of responsiveness to change in relatively nonfrail older women. Instruments sensitive to measuring lower levels of fear of falling are needed to capture the full range of this phenomenon in this population.     

Perspectives and Future Directions

Background:  Mechanisms of behavior change (MOBC) in treating drinking problems is a topic of growing importance.
Methods:  This article identifies salient themes presented in talks during the first Annual RSA Satellite on Mechanisms of Behavior Change in Alcoholism Treatment.
Results:  Themes focused on the need to move beyond a passive approach to identifying MOBC in alcoholism treatment and a number of conceptual and methodological advances were proposed.
Conclusions:  While a consensus has emerged that more attention should be paid to MOBC in alcoholism treatment research, a subgroup of experts are calling for MOBC to be the primary focus in future efforts.