Quality of Life after Subarachnoid Haemorrhage,and its Relationship to Impairments,Disabilities and Depression

This investigation addresses the subjectively experienced Quality of Life (QoL) in long-term survivors (n104) of subarachnoid haemorrhage (SAH). QoL in terms of increase/no—negligible change/decrease was related to prevalence of impairments, disabilities and to occurrence of depression. The perceived QoL had increased for 14% of the sample, was unaltered for 48% and had decreased for 38%. Impairments were neither significantly related to QoL nor to depression. Decreased QoL appeared mainly to reflect decreased ability to socialise while depression was closely associated with disabilities in numerous instrumental activities of daily living, particularly within the domestic and social sphere, and also with work- and leisure disabilities.     

应用OARS问卷对社区老年人ADL功能的调查

目的：了解上海城市社区60岁以上老年人的日常活动能力（ADL）并探索其影响因素。方法：应用OARS问卷对上海某城区两个里委902名社区老年人日常活动能力（ADL）进行调查。结果：老年人各项ADL功能均不需帮助者占64．3％，至少有一项ADL功能下降者占34．2％，有7人（0．8％）完全丧失ADL功能。生理性ADL（PADL）中下降率最高的是沐浴（7．2％），最低的是进食（3．0％），PADL下降率随年龄增加而上升，但无性别差异。工具性ADL（IADL）中下降率最高的是打电话（28．5％），最低的是理财（7．5％）。结论：IADL下降率随年龄增加的趋势更加明显，是PADL的3．9倍，且有性别差异，女性下降率显著高于男性。影响ADL功能的因素主要有年龄、性别，ADL评分与老年人社会资源、经济状况、躯体健康及精神健康评分呈正相关，并有显著统计学意义。     

Homebound status in a community-dwelling elderly population in Japan

The present study investigated the association between sociodemoraphic profiles, health condition and functional disabilities of subjects with a homebound status in a rural community setting. The subjects were residents aged 65 years or over in a mountain village of Japan. A comprehensive questionnaire was used to obtain their data. Among the 1,002 residents, the information of 866 residents (85%), who voluntarily completed the entire survey, was obtained for this study. All the subjects were native Japanese. Of the 866 subjects investigated, 301 (34.8%) were homebound as defined by the parameters of this study. Univariate analysis revealed age, female gender, functional impairment (vision, hearing and memory), all the ADL impairments, and the use of a portable toilet were associated with homebound status. Multivariate analysis revealed that older age, female gender, visual and two ADL impairments (moving inside the home and bathing) and use of a portable toilet remained significantly related to homebound status. Homebound elderly people have more functional limitation and disability related factor than their nonhomebound counterparts. Functional impairment, particularly in the mobility domain and sensory disturbances, was associated with homebound status. These data indicate the importance of assessment in the provision of home care for elderly people.     

Activities of daily living, cognitive impairment and other psychological symptoms among elderly recipients of home help

Previous studies have shown a relationship between physical functioning and having home help. The hypothesis behind this study, carried out on a random community sample of 168 subjects aged 75 years and above, was that having home help would also be associated with cognitive impairment and psychological symptoms. Bivariate analysis showed that cognitive impairment was significantly more frequent among home help clients, whereas indicators of anxiety and depression were not. After multivariate adjustment, living alone, poor perceived health, problems in performing primary activities of daily living (ADL), instrumental ADL and, in particular, experiencing difficulties in cleaning the house remained the only variables independently related to having home help. Of these, difficulties with cleaning the house was the most powerful predictor. The home help seems to be used mainly to compensate for impaired mobility. An association between cognitive functioning and the provision of home help is related to a limitation in the ability to perform ADL associated with cognitive impairment.     

Ageing and intellectual disability in Israel: a study to compare community residence with living at home

The present study was conducted to compare ageing phenomena in people with intellectual disabilities aged 40 years and above living in community residences (n = 29) with those living with their families (n = 31). The goals were to compare the health status between the two types of settings, to compare the health status between the study sample and the general Israeli population of the same age group, and to investigate whether deterioration occurs among the participants in activities of daily living (ADLs), cognitive ability and leisure activity. Health problems had already appeared by 40 years of age among the participants. The most frequent problems were visual impairment (33%), hearing impairments (20%) and heart problems (20%). Dental problems were found in 30%. The community-based residence group displayed more medical problems than people living at home, whereas individuals living at home had more dental problems. The functioning of the participants in the ADL areas was high, with no evident decline reported during the previous 5 years. Concerning leisure time, a decline in functioning in both residential groups was observed, and interestingly, the scores for social life and leisure activities were better for the community-based residential group. There is a need for better dental service provision for people with intellectual disabilities living at home. The data provided in the current study can serve as a preliminary base for the development of geriatric services for older adults with intellectual disabilities in the community and also provide a basis for further comparison with peers in the general population.     

Impairments in Individual Autonomous Living Tasks and Time to Self-Care Disability in Middle-Aged and Older Adults

ObjectivesImpairments in specific tasks that are necessary for independent living may identify future self-care limitations, and the use of time-varying covariates can better capture the fluidity in functional capacity trajectories over time. The purpose of this study was to determine the associations between individual instrumental activities of daily living (IADL) impairments and time to activities of daily living (ADL) disability for middle-aged and older adults in the United States.DesignLongitudinal panel.SettingDetailed interviews that included physical, biological, and psychosocial measures were completed in person. The core interview was typically completed over the telephone.ParticipantsA nationally representative sample of 15,336 adults aged at least 50 years from the 2006 wave of the Health and Retirement Study was followed for 8 years.MeasuresAbility to perform IADL and ADL were self-reported at each wave. Separate covariate-adjusted Cox models were used to examine the time-varying associations between individual IADL impairments and time to ADL disability.ResultsThe presence of each IADL impairment was associated with a higher hazard ratio for an ADL disability for the following functions: 2.52 [95% confidence interval (CI) 2.35, 2.70] for grocery shopping, 1.91 (CI 1.77, 2.06) for preparing hot meals, 1.55 (CI 1.37, 1.76) for taking medications, 1.48 (CI 1.36, 1.61) for managing money, 1.41 (CI 1.27, 1.57) for using a telephone, and 1.38 (CI 1.29, 1.48) for using a map.Conclusions/ImplicationsOur findings provide insights into the disabling process by revealing how impairments in each IADL are differentially associated with time to ADL disability. Interventions aiming to retain function during aging should be informed by fluctuations in IADL performance and how specific IADL impairments may exacerbate functional capacity declines more so than others.     

Longitudinal Studies of Dependence in Daily Life Activities among the Elderly: Methodological Development,Use of Assistive Devices and Relation to Impairments and Functional Limitations

Ability in activities of daily living (ADL), use of assistive devices, and relation to functional limitations and impairments were studied among persons between 70 and 76 years of age within the Inter Vention study of the Elderly in Göteborg, (IVEG), Sweden.

I and II. An ADL index was developed including instrumental activities (I-ADLs) (cleaning, shopping, transportation and cooking), which were combined with Katz' Index of personal daily life activities (P-ADLs) (bathing, dressing, going to the toilet, transfer, continence and feeding). Independence of and dependence on assistance from another person was assessed and it was possible to classify performance according to an ordinal scale of ADL-steps. The reliability and validity of the scale were tested in an out-patient sample (n = 85) as well as in a population of 76-year-olds (n = 659) and were found to be sufficient (coefficients of reproducibility and scalability, internal consistency, inter-observer reliability, content, construct, and criterion validity). The “Staircase of ADL” can be used for observation and documentation of different levels of ability/disability for individuals, groups and for population studies.

III. Most persons (83%) were independent in all activities at age 70 (n = 617). Among survivors followed longitudinally, the incidence of disability was 8% between 70–73 and 26% between 73–76 years of age. Dependence at age 70 could predict mortality as well as institutionalization. No sex differences were found in the proportion with overall disability.

Assistance given by relatives dominated both at 70, 73 and 76 years of age.

IV. One fifth at age 70 and almost half of the population at age 76 used assistive devices (AD) in daily life activities, and their use was more frequent in women (52%) than men (37%) at age 76 (n = 595). During the studied age interval, 39% “new users” were found, while 22% were “temporary users”. The usage rate was high and the effectiveness of ADs increased the person's ability to master the situation, especially evident as increased safety and reduction of effort in activities of daily living, implying a reduced degree of handicap.

V. Physical impairments and functional limitations had a considerable impact on dependence in daily life activities as persons dependent in ADL had a lower maximal walking speed, grip strength, knee extensor strength, stair-climbing capacity and forward reach than those who were independent in ADL (n = 602). Walking speed in both women and men and sight impairment in men had the greatest influence on dependence in ADL. Women and men who stayed independent over the period (70–76) had a significantly higher maximal walking speed and knee extensor strength at the age of 70 than those who became dependent or were dependent on both occasions.     

Age group differences in depressive symptoms among older adults with functional impairments

This study used data from the 2000 interview wave of the Health and Retirement Study to examine age group differences in the likelihood of self-reported depressive symptomatology among a nationally representative sample of 3,035 adults age 55 years or older who had at least one activities of daily living (ADL) or instrumental activities of daily living (IADL) limitation. Depression was defined as scoring three points or higher on the eight-point Center for Epidemiological Studies Depression Scale. The results show that respondents age 75 years or older with one ADL/IADL impairment or more were significantly less likely to be depressed than were those between ages 55 and 64 with the same degree of functional impairment. It is recommended that doctors, social workers, and other health care and social services providers pay special attention to younger old adults with health problems and functional limitations because they have a greater risk of being depressed.     

The Sunnaas Index of Activities of Daily Living: Responsiveness and Concurrent Validity in Stroke

The aim of this study was to evaluate the responsiveness and concurrent validity of the Sunnaas Index of activities of daily living (ADL) as an instrument for measuring primary and instrumental ADL functions after stroke. Fifty-five consecutive stroke patients were scored using the Sunnaas ADL Index and the Barthel ADL Index on admission and at discharge after median 21 days inpatient rehabilitation. The results of the two indices were compared, and the Barthel Index was used as a gold standard for validity tests. The neurological impairments and motor functions of the patients were scored using the Scandinavian Stroke Scale and the Modified Motor Assessment Scale. The total score of the Sunnaas ADL Index and the subscores reflecting primary and instrumental ADL functions increased significantly (p < 0.0001) during rehabilitation. The Sunnaas score correlated significantly with the scores of the Barthel Index (Spearman correlation coefficient r = 0.83 on admission and 0.88 at discharge), the Scandinavian Stroke Scale (r = 0.81 on admission) and the Modified Motor Assessment Scale (r = 0.79 on admission and 0.76 at discharge). The Sunnaas ADL Index seems able to detect clinically important improvements of primary and instrumental ADL functions after stroke, i.e. its responsiveness is good. These results provide further evidence for the concurrent validity of the Sunnaas Index for measuring functional recovery after stroke.     

Incidence of disability among preretirement adults: the impact of depression

OBJECTIVES: We evaluated the effect of depression on risk, on the basis of standardized assessment, for developing activities of daily living (ADL) disability. METHODS: Depression-related risk on 2-year ADL disability is estimated from 6871 participants in a population-based national sample aged 54-65 years and free of baseline ADL disability. We evaluated the effects of factors amenable to clinical and public health intervention that may explain the relationship between depression and incident disability. RESULTS: The odds of ADL disability were 4.3 times greater for depressed adults than their non-depressed peers (95% confidence interval=3.1, 6.0). Among depressed adults, 18.7% of African Americans, 8.0% of Whites, and 7.8% of His-panics developed disability within 2 years. The attributable population fraction because of depression is 17.3% (95% confidence interval=11%, 24%). Concurrent health factors moderated depression-associated risk. CONCLUSIONS: Elevated risk of ADL disability onset because of depression, in a cohort whose medical costs will imminently be covered via Medicare, is attenuated by factors amenable to public health intervention. Prevention and/or public health/policy programs that lead to more accessible and effective mental health and medical care could reduce the development of ADL disability among depressed adults.     

2011年济宁市城区部分老年人日常生活活动能力评价

[目的]了解济宁市老年人基本日常生活活动能力和工具性日常生活活动能力,为社区及乡镇卫生服务机构有效开展老年卫生服务和健康维护提供参考。[方法]2011年3～4月,采用多阶段随机抽样方法,在济宁市城区抽取≥65岁常住户口的老年504人应用Katz日常生活活动量表(Katz-ADL)和工具性日常生活活动量表(Lawton-IADL)进行调查。[结果]测评人504人,Katz-ADL得分为5.66±0.91分。6项功能均保持的占80.95%,6项功能均丧失的占0.79%。6项功能均保持者所占比例,男性为86.67%,女性为74.36%(P<0.01)。测试的504人中,Lawton-IADL得分:男性为3.72±1.59分,女性为5.06±2.83分。其中,男女相同的5项功能均保持者所占比例为33.53%,男性为44.08%,女性为21.37%(P<0.01);5项功能均丧失者所占比例为11.31%,男性为7.78%,女性为15.38%(P<0.01)。[结论]济宁市城区老年人日常生活活动能力和工具使用生活能力较高,多项生活活动能力保持率男性高于女性。     

2015—2018年湖北省抽样点老年人日常生活活动能力受损发生情况及其影响因素队列研究

目的 了解湖北省抽样点荆门市东宝区、黄冈市蕲春县老年人2015—2018年日常生活活动(activities of daily living,ADL)能力受损情况及其影响因素。 方法 依据多阶段分层整群抽样,2015年基线调查在湖北省抽取2个代表点共计4 041名研究对象,2018年随访,剔除2015年基线ADL已受损对象及3年间失访、死亡、数据不完整人群,最终纳入2 927名≥60岁老年人作为研究对象,对其进行问卷调查、身体测量、日常生活活动能力评估,采用单因素χ²检验及多因素logistic回归模型分析日常生活活动能力受损的影响因素。 结果 湖北省抽样点老年人3年ADL累计受损发生率为5.47%,3年基本生活能力(basic living ability scale,BADL)累计受损率为1.91%,3年仅工具性日常生活活动能力(instrumental activity of daily life scale,IADL)累计受损率为3.55%。多因素logistic分析结果表明:年龄增加(70～79岁OR=1.784,95%CI:1.208～2.634;≥80岁OR=3.124,95%CI:1.859～5.25)、自评生活状态不太好(OR=3.201,95%CI:1.805～5.678)、自觉家庭累赘感(OR=3.532,95%CI:2.01～6.205)、听力受损(OR=4.787,95%CI:1.978～11.588)、脑卒中(OR=3.571,95%CI:2.00～6.377)及一年内跌倒3次及以上(OR=6.226,95%CI:1.333～29.072)是老年人ADL受损发生的危险因素,城市居住(OR=0.418,95%CI:0.272～0.64)、非文盲(OR=0.546,95%CI:0.368～0.809)、喜欢参与社会活动(OR=0.417,95%CI:0.293～0.593)为老年人ADL受损发生的保护因素。14项功能受损率中,BADL功能受损排名第一的为如厕(2.25%),IADL功能受损排名第一的为打理钱财(3.59%)。除服药外,每一项IADL功能的受损率均高于BADL功能的受损率。 结论 改善老年人日常生活活动能力应重点关注农村居住、高龄、文盲、自评生活状态不佳、自觉家庭累赘感,不喜社交、患有听力受损、脑卒中及一年内多次跌倒的老年人群,建议尽早对其采取有针对性的防控措施,提高这一群体的生活质量。     

上海某社区老年人综合健康功能状况及主要健康问题

[目的 ]　了解社区老年人群的健康功能状况及最主要的健康问题。　 [方法 ]　老年综合健康功能评价的横断面调查研究。　 [结果 ]　该社区老年人群中综合健康损害率为 34.5 %。其中 5 8.1%的老年人至少有一项健康功能损害。 5个单项功能中损害率居前 3位的是躯体健康、经济维持能力和日常活动能力 (ADL) ,损害率分别为 41.0 %、35 .4%、15 .4%。进一步分析发现 ,这 3项功能损害各自又分别以慢性病患病率高、工具性日常活动能力 (IADL)损害和经济收入低、缺乏经济储备能力、医疗保障差为主。不同年龄、性别、文化程度、职业和婚姻状况的老年人之间 ,5项功能损害率差异都有统计学意义。　 [结论 ]　躯体健康、ADL和经济维持能力损害是该社区老年人中最主要的健康问题 ,三者往往同时出现在同一老年人身上。     

Prevalence of impairments and social inequalities

BACKGROUND: Population ageing and longer duration of the working career could increase the prevalence of impairments and disabilities whereas there have been few data to help prevention and care. This study aimed at describing the prevalence of various types of impairments and assessing their social inequalities in the Lorraine population (north-eastern France). METHODS: The sample included 6.214 subjects aged 15 or more from 8.000 households randomly selected in the Lorraine population. A mailed questionnaire including socio-demographical characteristics, job, and various types of impairments was used. The data were analysed with the chi2 independence test, the adjusted odds ratio (OR) and the Mantel-Haenszel test. RESULTS: The prevalence of at least one impairment was 30% in both sexes. It varied from about 20% for subjects aged less than 40 years to about 60% for the subjects aged 70 years or more. It was higher in men than in women among the individuals aged more than 50 years (OR adjusted on age: 1.22, 95% CI: 1.04-1.44). The impairments were generally multiple for the subjects aged over 50. The prevalence of at least one impairment was higher for workmen (OR adjusted on age: 2.11, 95% CI: 1.68-2.66), farmers, craftsmen, traders and heads of firms (OR adjusted on age: 1.60, 95% CI: 1.17-2.18) and for employees (OR adjusted on age: 1.62, 95% CI: 1.29-2.03) in comparison with executives, intellectual professionals and teachers. For workmen a higher prevalence was observed for all types of impairments: intellectual and psychological functions, language, hearing, vision, visceral functions, and skeleton and posture. Farmers, craftsmen, traders, heads of firms and employees showed an excess for most types of impairments. Social inequalities were significant for various age groups during their period of occupational activity, but not after retirement. Unemployed people also had an excess of impairments. CONCLUSION: The prevalence of impairments strongly increased with advancing age. Marked inequalities were observed between various socio-occupational categories. Men were more affected than the women over 50 years of age. Impairments represent a health index which is useful for prevention to reduce their causes and consequences.     

Exploration of life satisfaction of Korean people with sensory impairments across the lifespan

BackgroundApproximately, 600,000 people in South Korea have registered as people with either visual or hearing impairment or both. Individuals with sensory impairments are more likely to have limited physical and social functioning, which consequently affected their health, well-being and life satisfaction. While diverse elements were considered as critical determinants of life satisfaction among individuals with sensory impairments, only few studies examined the relationships between life domains and life satisfaction of the population.ObjectivesThis study investigated the relationships between life domains and life satisfactions among Korean individuals with sensory impairments.MethodsThis study used 2015 national data from Korea to explore the relationships across different age groups. A total of 965 participants were selected, and they were divided into three groups: (a) middle aged group (MAG; 54 and below, 35.2%), (b) late-middle aged group (L-MAG; 55–64; 35.2%), and (c) older adult group (OAG; 65 and older; 29.5%). Demographic variables (e.g., perceived socioeconomic status, the severity of disabilities), the satisfaction of seven life domains, and the overall life satisfaction were measured.ResultsAlthough most of the life domains were significant predictors of overall life satisfaction, the leisure domain was the strongest determinant of the overall life satisfaction to MAG and OAG and the second strongest predictor to L-MAG.ConclusionThis study highlights the importance of leisure for quality of life of individuals with sensory impairments and suggests an implication to researchers and practitioners to increase accessibility for individuals with sensory impairments to leisure facilities and programs.     

老年脑卒中后抑郁状况评估及其相关因素分析

目的 探讨老年脑卒中后抑郁(post-stroke depression, PSD)的发生率及其相关因素,为早期心理干预提供相关参考。方法 收集2015年1月至2018年12月首诊于三峡大学附属仁和医院神经内科的200例老年脑卒中患者,采用老年抑郁量表(Geriatric Depression Scale, GDS)评估老年脑卒中患者的抑郁状况,采用神经功能缺损量表(NIH Stroke Scale, NIHSS)、日常行为能力量表(Activity of Daily Living Scale , ADL)和Barthel指数评估患者的临床症状,同时测定患者血清脑源性神经营养因子(brain-derived neurotrophic factor, BDNF)水平。结果 老年PSD的发生率为42.5%(85/200),其中轻度占44.7%、中重度占55.3%。PSD患者脑卒中病变部位多居于左侧,而非PSD患者脑卒中病变部位以右侧居多(〖XC小五号.EPS;P〗=32.853, P<0.001);PSD患者神经功能缺损评分高于非PSD患者(t=20.168, P<0.001),而ADL评分和血清BDNF水平为PSD组低于非PSD组(t=-11.071, P<0.001; t=-16.755, P<0.001)。PSD患者的NIHSS评分随着抑郁程度的增加而升高(t=-18.227, P<0.001),ADL评分及血清BDNF水平则随着抑郁程度的增加而下降(t=20.366, P<0.001; t=9.197, P<0.001)。老年脑卒中患者抑郁GDS评分与NIHSS评分呈正相关关系(r=0.926, P=0.034),与ADL评分及血清BDNF水平呈负相关关系(r=-0.917, P=0.011; r=-0.952, P=0.005)。Logistic回归分析显示:脑卒中病变部位左侧是其发生PSD的危险因素、右侧是其保护因素;NIHSS评分越高、ADL评分越低、血清BDNF水平越低是老年脑卒中患者发生PSD的危险因素。结论 神经功能缺损程度越严重、日常生活能力越差,则PSD的发生率越高、抑郁症状也越重;同时,BDNF可以作为PSD发生及抑郁严重程度的重要预测指标。     

Early evaluation of the risk of functional decline following hospitalization of older patients: development of a predictive tool

OBJECTIVE: To develop a predictive tool that could be used on admission to identify older hospitalized people at risk of functional decline 3 months after discharge. METHODS: This was a prospective cohort study that included 625 patients aged 70 years and older (mean age 80.0 +/- 5.6 years) hospitalized by the way of the emergency room, for at least 48 h, in two academic hospitals. Three months after discharge, 550 patients remained for analysis. On admission, people were assessed for premorbid functional status with the activities of daily living (ADL) scale and instrumental ADL scale. Demographic and medical data, including cognitive function, falls, polypharmacy, comorbidity, continence, mobility and self-rated health, were collected. ADL functioning was re-assessed at discharge and 1 and 3 months later. Functional decline was defined as the loss of at least one point on the ADL scale between the premorbid and 3-month evaluation. Univariate analyses were used to select variables associated with functional decline. A logistic regression model was then constructed to predict functional status 3 months after discharge. RESULTS: Three months after discharge, 165 (31.5%) patients had declined. The predictive tool SHERPA includes five factors: age, impairment in premorbid instrumental ADLs, falls in the year before hospitalization, cognitive impairment (Abbreviated Mini Mental State below 15/21) and poor self-rated health. Sensitivity and specificity were 67.9% and 70.8%, respectively. CONCLUSIONS: Older people are at high risk of functional decline following hospitalization. On admission, a simple instrument can easily identify these patients, even though the performance of this instrument is moderate.     

Pilot study exploring quality of life and barriers to leisure-time physical activity in persons with moderate to severe multiple sclerosis

BackgroundWe sought to assess how impairment (physiological/psychological) and disability (social/environmental) are associated with physical and leisure/recreation activity levels and quality of life (QOL) in people with moderate/severe multiple sclerosis (MS). We conducted a cross-sectional survey at the MS Comprehensive Care Center, Stony Brook University Hospital, Stony Brook, NY, of a convenience sample of 43 people (50 eligible) with MS and Expanded Disability Status Scale scores of 6.0 to 8.0. The main outcome measures were QOL measured by MSQOL-54, physical activity measured by Physical Activity Disability Scale, and leisure/recreation activity measured by Nottingham Leisure Questionnaire. We analyzed the canonical correlations among physical and leisure/recreation activity levels and (1) impairment and (2) QOL.ResultsHigher levels of physical and leisure/recreation activity were associated with lower levels of apathy and depression and higher levels of cognition, self-efficacy, and QOL (physical and mental). Major barriers reported included fatigue, lack of motivation, and cost.ConclusionImpairments and social/environmental disabilities create barriers to physical and leisure/recreation activity. Additional research is needed to determine, for people with MS, what supports might increase participation in physical and leisure/recreation activities and whether this increase yields improved QOL.     

Eligibility for publicly financed home care.

OBJECTIVES. Proposals for publicly financed home care for the elderly now tend to include cognitive impairment criteria as well as activities of daily living (ADL) criteria. The numbers of elderly deemed eligible for services will depend on the definitions of ADL and cognitive impairment used. METHODS. Data from the 1984 National Long-Term Care Survey were used to generate a series of estimates of the community-dwelling elderly with ADL disabilities and cognitive impairment. RESULTS. When only ADL criteria are used, estimates of disability range from 472,000 to over 3 million (1.6% to 12.5% of the community-dwelling elderly). These estimates increase to approximately 1 million to 4.2 million (3.5% to 14.0% of the community-dwelling elderly) when cognitive impairment criteria are added. CONCLUSIONS. The use of more stringent or more liberal eligibility criteria will have dramatic effects on the number of elders who qualify for services. The nature of the eligibility criteria employed in any expansion of federally financed home care benefits will be a major factor in determining the costs of such a program.     

Improved detection of depression in primary care through severity evaluation

OBJECTIVES: To determine whether the use of a symptom severity measure to augment an existing Diagnostic and Statistical Manual of Mental Disorders-Third Edition, Revised (DSM-III-R) criteria-based depression screener (PRIME-MD) would decrease the difficulties associated with depression screening in primary care by filtering out patients with minimal impairment. STUDY DESIGN: The study design was secondary data analysis. POPULATION: The study sample comprised 1317 patients, with intentional oversampling by ethnicity and sex, presenting for routine care at a university family practice center in Galveston, Texas. OUTCOMES MEASURED: The primary outcomes were cross-sectional, health-related quality-of-life outcomes of subjects who met symptom severity criteria as well as criteria for a DSM-III-R mood disorder. Health care utilization outcomes were examined as secondary outcomes. RESULTS: The combination of a 6-item depression severity instrument and the PRIME-MD resulted in 71% of depressed subjects being categorized as severely symptomatic and 29% as minimally symptomatic. Severely symptomatic subjects had significantly worse SF-36 Mental Health Component Summary scale (MCS) scores than did minimally symptomatic subjects (32.8 vs 43.5, P <.05). Minimally symptomatic subjects had MCS scores similar to those of a third group of subjects who did not meet DSM-III-R "threshold" criteria for mood disorder but who were severely symptomatic. Adjusted health care utilization was higher for the initial 3-month charge period in the severely symptomatic depressed subjects compared with minimally symptomatic depressed subjects ($679.20 vs $462.38, P <.05). CONCLUSIONS: The 6-item depression severity measure effectively separated patients meeting DSM-III-R "threshold" depression criteria into 2 groups: one presenting with severe symptoms and impairment and the other presenting with mild symptoms and significantly less impairment. A strategy of initial screening using a brief depression severity instrument, followed with a DSM criteria-based instrument, could decrease the immediate clinician workload by one third and focus treatment on those most likely to benefit.