Prevalence [correction of prevalance] of functional blindness, visual impairment, and related functional deficits among elderly Mexican Americans.

BACKGROUND: This report describes the prevalence and correlates of functional blindness and visual impairment among older Mexican Americans, using data on 2800 respondents from the Hispanic Established Populations for the Epidemiological Study of the Elderly. METHODS: Bivariate and multivariate logistic regression analyses were used to examine the associations between corrected bilateral distant vision and sociodemographic characteristics, selected health conditions, self-reported health status, health care utilization, and functional dependence on the basis of assistance needed for basic and instrumental activities of daily living (ADLs). RESULTS: Using a modified Snellen test for distance visual acuity, 5% of older Mexican Americans were found to be functionally blind, and 13.5% were found to be visually impaired. Vision loss was significantly associated with older age, lower education, hypertension, diabetes, poor self-rated health, and hospitalization during the year prior to the interview. Over 50% of functionally blind subjects required assistance with at least one basic ADL, compared with 15% of those who were visually impaired and 8% of those who were not visually impaired. CONCLUSIONS: The prevalence of functional blindness in this sample of elderly Mexican Americans was higher than reported for the general elderly population, yet they also have higher rates of adequate vision because of the low prevalence of visual impairment. The results suggest a need for more research on the prevalence and impact of functional blindness and visual impairment on the health of older Mexican Americans.

Ethnic differences in mini-mental state examination (MMSE) scores: where you live makes a difference.

OBJECTIVES: To examine differences in correlates of the Mini-Mental State Examination (MMSE) in a population-based sample of older Mexican Americans and European Americans and to provide empirical validation of the MMSE as an indicator of cognitive impairment in survey research in older Mexican Americans by comparing MMSE classification against performance on timed tasks with varying levels of cognitive demand. DESIGN: A population-based cross-sectional study. SETTING: Trained bilingual staff administered the MMSE as part of the San Antonio Longitudinal Study of Aging (SALSA) home-based assessment battery. PARTICIPANTS: 827 community-dwelling Mexican Americans and European Americans, 65 and older, residing in three socioeconomically and culturally distinct neighborhoods (barrio, transitional, suburban). MEASUREMENTS: The MMSE was compared against a variety of demographic, biomedical, and sociocultural variables ascertained by self-report and against performance-based measures of functional tasks representing varying levels of cognitive demand (Structured Assessment of Independent Living Skills (SAILS) subscales for food manipulation and money management). RESULTS: Mexican Americans were 2.2 times more likely than European Americans to have MMSE scores <24. Multiple logistic regression analysis revealed that neighborhood was an independent predictor of low MMSE scores in Mexican Americans, with the relationship between ethnic group and MMSE explained by neighborhood. After adjusting for neighborhood type, no differences were noted between Mexican Americans and European Americans. Independent of other factors examined, low education was associated with low MMSE scores in both Mexican Americans and European Americans. Mexican Americans with MMSE scores <24 took significantly longer to complete four out of five performance-based food manipulation tasks and all three money management tasks. CONCLUSIONS: Neighborhood type was a predictor of cognitive impairment. Education affected MMSE scores similarly in both ethnic groups. MMSE scores <24, indicative of cognitive impairment, were uniformly associated with functional impairment in both the Mexican Americans and European Americans. Among older Mexican Americans, MMSE-classified cognitive impairment was significantly associated with poorer performance on timed tasks with varying levels of cognitive demand independent of other correlates. A similar pattern of association was observed in European Americans. Thus, the MMSE appears to be a valid indicator of cognitive impairment in survey research in both older Mexican Americans and European Americans.

The Positively Aging teaching materials improve middle school students' images of older people.

PURPOSE: The Positively Aging program is an innovative set of interdisciplinary teaching materials that uses examples from geriatrics and gerontology to teach sixth through eighth grade curricular elements. The purpose of this study was to determine if use of the Positively Aging teaching materials by regular classroom teachers could change middle school students' images of elders. DESIGN AND METHODS: At the beginning of the 1998-1999 school year, students at two San Antonio, Texas, middle schools were asked to draw a typical older person. These drawings were coded as positive, neutral, or negative portrayals of elders. One school then used the Positively Aging materials as part of the curriculum; the other school served as the control. Second drawings were obtained from the students at the end of the school year and compared to those from baseline. RESULTS: Both drawings were completed by 60% of students at the intervention school and 55% of students at the control school. Of the 782 paired drawings from the intervention school, 34% were more positive at Time 2 compared to 25% of 591 paired drawings from the control school (chi2 = 13.9, p < .001). In addition, only 20% of the second drawings from the intervention school were more negative than the first drawing compared to 27% from the control school (chi2 = 11.3, p < .001). Using a generalized logit model, we adjusted for each student's baseline drawing (positive-neutral-negative), grade level, gender, ethnic group, and socioeconomic status. After adjustment, students in the intervention school were more likely to draw positive (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.13, 1.94) or positive and neutral images (OR 1.58, 95% CI 1.21, 2.19) at follow-up compared to the control school. IMPLICATIONS: This controlled study demonstrated that use of the Positively Aging teaching materials and activities moved middle school students toward a more positive view of elders. Interdisciplinary teaching materials based on geriatrics and gerontology can be successfully developed and tested in public school systems to affect attitudes about aging.

Walking velocity in aged persons: its association with lower extremity joint range of motion.

OBJECTIVE: To measure the association between walking velocity and hip and knee flexion range, ethnic background, anthropometrics, comorbid pathologies, and coimpairments, in a sample of community-dwelling aged persons. METHODS: To reach our objective, we used data from the San Antonio Longitudinal Study of Aging (SALSA), a population-based cohort of Mexican American and European American persons aged 64 to 79. By fitting hierarchical regression models, we measured the variance in the walking velocity over 50 feet explained by hip and knee flexion range, adjusting for the combined influence of demographic and anthropometric variables, coexistent pathologic conditions, impairments, and the examiners who conducted the assessments. RESULTS: The average walking velocity among the 702 subjects for whom data were available was 73.6 meters per minute (range 20 to 121). Bivariate analyses revealed significant associations between walking velocity and age, sex, ethnic background, height, weight, presence of arthritis, diabetes mellitus, stroke, upper leg pain, peripheral vascular disease, left ventricular hypertrophy, and forced expiratory volume at 1 second. The correlation (r) between walking velocity and flexion range of the hip and knee were 0.40 and 0.35, respectively (P < or = 0.001 for each). Multivariate hierarchical models adjusting for demographic and anthropometric characteristics of the subjects, and examiner variation, revealed that hip and knee flexion range explained 6% of the variance in walking velocity. Adjusting for the presence of comorbid conditions and coimpairments reduced the variance attributable to hip and knee flexion range only slightly, to 5%. CONCLUSION: Hip and knee flexion range contribute significantly to walking velocity in the SALSA cohort of community-dwelling aged persons.

New-onset incontinence and markers of frailty: data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly.

BACKGROUND: Urinary incontinence in older adults has many distinct etiologies and is associated with lower self-reported health. However, it is unclear whether the new onset of urinary incontinence marks newly emergent frailty. METHODS: Using a longitudinal population-based survey of older Mexican Americans (N = 2660) across five south-western states, this study compared the strength of association between markers of physical frailty such as activities of daily living (ADLs), instrumental activities of daily living (IADLs), and performance (timed walk, timed chair rise, and tandem balance) with baseline incontinence (prevalent disease) and new-onset incontinence (incident disease). RESULTS: We found that 14.1% of the participants (n = 329) were incontinent at baseline (prevalent cases) and 11.6% (n = 208) were newly incontinent 2 years later (incident cases). Controlling for other covariates, prevalent incontinence was only associated with a 60% increased risk of having difficulty walking 8 ft. Incident incontinence was associated with a twofold increased risk of impairment in ADLs and IADLs, and poor performance on all three physical measures. CONCLUSIONS: Incident incontinence is associated with an increased risk of more global functional impairment. Thus, incident disease may be an important early marker for signaling the onset of frailty among persons who become incontinent after the age of 65 years.

Modeling impairment: using the disablement process as a framework to evaluate determinants of hip and knee flexion.

Elders often present to health care providers with multiple inter-related conditions that determine an individual's ability to function. The disablement process provides a generalized sociomedical framework for investigating the complex pathways from chronic disease to disability. At each stage of the main pathway, associations may exist among primary physical factors and modifying variables that ultimately have downstream effects on the progression toward disability. The purpose of the present analysis is to examine the inter-relationships between a cohesive set of variables primarily at the level of impairment that may affect hip and knee flexion range of motion (ROM). The San Antonio Longitudinal Study of Aging enrolled 833 community dwelling Mexican (MA) and European American (EA) elders aged 64-78 years between 1992 and 1996. Of these, 647 had complete data from both a home-based and performance-based battery of assessments for these analyses. Concerning impairments, hip ROM was measured using an inclinometer, and knee ROM using a goniometer. Pain location and intensity were assessed using the McGill Pain Questionnaire. Peripheral vascular disease was assessed using doppler brachial and ankle systolic blood pressures. Ankle and knee reflexes, and vibratory sensation were assessed by a standardized neurological examination. As to diseases, diabetes was assessed using a combination of blood glucose levels and self-report, and arthritis by self-report. Concerning modifying variables, height and weight were directly measured and used to calculate BMI. Activity level was assessed with the Minnesota Leisure Time Questionnaire. Analgesic use was assessed by direct observation of medications taken within the past two weeks. We used structural equation modeling to test associations between the variables that were specified a priori. These analyses demonstrate the central role of BMI as a determinant of hip and knee flexion ROM. For an increase in level of BMI, the coefficients [SEM] for changes in levels of hip and knee ROM were -0.38 [0.05] and -0.26 [0.05], respectively. A higher BMI resulted in lower hip and knee ROM. BMI was also directly associated with prevalent diabetes (0.10 [0.05]) and arthritis (0.17 [0.05]). However, after adjustment for BMI, diabetes and arthritis did not have direct independent associations with either hip or knee ROM. BMI was also indirectly associated with knee, but not hip, ROM through paths including lower-leg pain, pain intensity, and neurosensory impairments. Diabetes had an indirect association with hip, but not knee ROM, through a path including peripheral vascular disease. In conclusion, BMI is a primary direct determinant of hip and knee ROM. The paths by which diabetes and arthritis lead to physical disability may be mediated, in part, at the level of impairment by BMI's association with joint range of motion. Interventions designed to decrease the impact of diabetes and arthritis on disability should track changes in BMI and joint ROM to measure the paths that account for the intervention's success. The observed associations suggest that interventions targeted to decrease BMI itself may lead to improved function in part through improved joint ROM.

The involvement of physicians in VA home care: results from a national survey.

OBJECTIVES: To examine the role of physicians in the Veteran Affairs (VA) home-based primary care (HBPC) program and to identify variables that predict whether physicians make home visits and volume of home visits made. DESIGN: Descriptive and regression analyses of responses from a mail survey. PARTICIPANTS: Forty-five physicians affiliated with VA HBPC programs. MAIN SURVEY TOPICS: Self-reported work load, attitudes toward home care, reasons for home visits, administrative policies regarding physicians' role in patient care management, and time commitment to home care. RESULTS: A majority of physicians believed strongly in the importance of home care and made home visits for reasons consistent with their training. Physician attitude toward home care and preoccupation with office or hospital practice were related to whether or not physicians made home visits. Degree of preoccupation with office practice and amount of salary support from VA HBPC were significant predictors of the number of visits made (R2 = 0.44). CONCLUSIONS: These findings indicate that most physicians will make home visits if they believe that home care is valuable and if their time commitment is supported financially. Managed care plans that own and operate home care programs and have the capacity to transfer primary care management to physicians who derive financial support from the programs should find this information particularly relevant.

Determinants of hip and knee flexion range: results from the San Antonio Longitudinal Study of Aging.

OBJECTIVE: We analyzed data from the San Antonio Longitudinal Study of Aging, a neighborhood-based study of community-dwelling elderly people, to identify factors that determine the flexion range (FR) of hips and knees. METHODS: The FR of hips and knees was measured in a cohort of 687 subjects aged 65 to 79 years. We used multivariate models to examine the associations among the FR of hips and knees, and between these and age, gender, ethnicity, body mass index (BMI), pain and its location, self-reported arthritis, and diabetes mellitus. The functional relevance of hip and knee FR was tested by measuring its association with 50-foot walking velocity. RESULTS: More than 90 degrees of flexion in both hips and both knees was observed in 619 subjects (90.1%). Correlations among the FR of hips and knees ranged from 0.54 to 0.80 (P < 0.001 for Spearman r values). Multivariate analysis revealed a pattern of significant associations between each of the joints and its contralateral mate and ipsilateral partner joints that was consistent for both hips and both knees. Using each individual joint as the unit of analysis, the following variables were independently associated with hip or knee FR in multivariate models: rising BMI and female sex with reduced FR of both hips and knees, a Mexican American ethnic background with decreased hip FR, and knee pain with decreased knee FR. The functional importance of the FR of these two important joints was supported by its significant association with walking velocity in a model that adjusted for age, gender, ethnic background, BMI, and hip or knee pain. CONCLUSIONS: Most community-dwelling elderly people have a FR of hips and knees that can be considered functional. The ipsilateral and contralateral hip or knee are significant independent determinants of the FR of each of these joints. Obesity, a health problem potentially amenable to preventive and therapeutic interventions, is a factor significantly associated with decreased FR of hips and knees.

The influence of noncognitive factors on the Mini-Mental State Examination in older Mexican-Americans: findings from the Hispanic EPESE. Established Population for the Epidemiologic Study of the Elderly.

Mini-Mental State Examination data from the Hispanic Established Population for the Epidemiologic Study of the Elderly baseline survey, a population-based study of community-dwelling Mexican Americans aged 65 and older, were used to examine the relationship between cognitive impairment, sociodemographics, and health-related characteristics. The rate of cognitive impairment found in this group of older Mexican Americans, using the conventional cut point of 23/24 on the MMSE, was 36.7%. Using a more conservative cut point of 17/18 indicated an overall rate of severe cognitive impairment of 6.7%. Rates of impairment varied significantly with age, education, literacy, marital status, language of interview, and immigrant status and were associated with high and moderate levels of depressive symptoms, and history of stroke. Importantly, although education was strongly related to poor cognitive performance, it was not a significant predictor of severe cognitive impairment. Multivariate analyses further indicated that as a screen for cognitive impairment in older Mexican Americans, the MMSE is strongly influenced by these noncognitive factors. Scores may reflect test bias, secondary to cultural differences or the level of education in this population.

Determinants of shoulder and elbow flexion range: results from the San Antonio Longitudinal Study of Aging.

OBJECTIVE: To gain a knowledge of factors associated with impaired upper extremity range of motion (ROM) in order to understand pathways that lead to disability. METHODS: Shoulder and elbow flexion range was measured in a cohort of 695 community-dwelling subjects aged 65 to 74 years. Associations between subjects' shoulder and elbow flexion ranges and their demographic and anthropometric characteristics, as well as the presence of diabetes mellitus or self-reported physician-diagnosed arthritis, were examined using multivariate regression models. The relationship between shoulder or elbow flexion range and subjects' functional reach was examined to explore the functional significance of ROM in these joints. RESULTS: The flexion range for the 4 joints studied was at least 120 degrees in nearly all subjects (> or = 99% of the subjects for each of the 4 joints). Multivariate models revealed significant associations between male sex, Mexican American ethnic background, the use of oral hypoglycemic drugs or insulin to treat diabetes mellitus, and a lower shoulder flexion range. A lower elbow flexion range was associated with male sex, increasing body mass index, and the use of oral hypoglycemic drugs or insulin. A higher shoulder or elbow flexion range was associated with a lower likelihood of having a short functional reach. CONCLUSIONS: The great majority of community-dwelling elderly have a flexion range of shoulder and elbow joints that can be considered functional. Diabetes mellitus and obesity are two potentially treatable factors associated with reduced flexion range of these two functionally important joints.

Correlates of prescription and over-the-counter medication usage among older Mexican Americans: the Hispanic EPESE study. Established Population for the Epidemiologic Study of the Elderly.

OBJECTIVES: To determine the prevalence rates of prescription and over-the-counter (OTC) medication usage among community-dwelling older Mexican Americans. DESIGN: Cross-sectional survey of a regional probability sample of older Mexican Americans. SETTING: The 1992-1997 Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE), a probability sample of noninstitutionalized Mexican Americans, age 65 and over, living in the five Southwestern states of Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: 2899 persons, age 65 and over, considered Mexican American, using appropriate weighting procedures to produce regional estimates. OUTCOME MEASURES: Use of prescription and OTC medication within the last 2 weeks before the survey confirmed by in-home review of medication containers. RESULTS: Medication users consumed a mean of 2.9 prescription and 1.3 OTC medications. Over half (58.9%, n = 1,798) of the participants used at least one prescribed medication, and 31.3% (n = 847) used at least one OTC medication within the 2 weeks before their participation in the study. Factors associated with both prescription and OTC medication usage were self-perceived health and number of co-morbid conditions. Factors associated only with prescription medication usage included female gender, alcohol usage, ADL dependency, and presence of additional insurance. Structural assimilation was associated only with OTC medication usage. CONCLUSIONS: These data show lower prevalence rates of prescription medication usage among Mexican American older men and lower rates of OTC medication usage in older Mexican Americans of both genders than previously reported in other ethnic groups. This may reflect differences in time and geographic location of the Hispanic EPESE relative to other EPESE studies, ethnic differences in access to care as reflected by insurance in addition to Medicare, ethnic differences in survival, especially among males, or ethnic differences in medication preferences.

Disaggregating pain and its effect on physical functional limitations.

BACKGROUND: Pain is a common impairment that limits the abilities of older persons. The purposes of this article are to: (i) describe the distribution of pain location using the McGill Pain Map (MPM) in a community-based cohort of aged subjects; (ii) investigate whether individual areas of pain could be sensibly grouped into regions of pain; (iii) determine whether intensity, frequency, and location constitute independent dimensions of pain; and (iv) determine whether these three pain dimensions make differential contributions to the presence of self-reported physical functional limitations. METHODS: A total of 833 Mexican American and European American subjects, aged 65-79 years, were enrolled in the San Antonio Longitudinal Study of Aging and were interviewed in their homes between 1992 and 1996. A total of 373 (46%) of the subjects reported having pain in the past week. Physical functional limitations were ascertained using the nine items from the Nagi scale. Three composite scales were created: upper extremity, lower extremity, and total. Pain intensity and frequency were ascertained using the McGill Pain Questionnaire. Pain location was ascertained by using the MPM. RESULTS: Pain was reported in every area of the MPM. Using multiple groups confirmatory factor analysis, the 36 areas were grouped into 7 regions of pain: head, arms, hands and wrists, trunk, back, upper leg, and lower leg. Among persons with pain, pain frequency, intensity, and location were weakly associated with each other. Pain regions were primarily independent of each other, yet weak associations existed between 6 of the 21 pair-wise correlations between regions. Pain regions were differentially associated with individual physical functional limitations. Pain in the upper leg was associated with 8 of the 9 physical tasks. In multivariate analyses, age, gender, and ethnic group accounted for only 2-3% of the variance in physical tasks. In multivariate analyses, age, gender, and ethnic group accounted for only 2-3% of the variance in physical functional limitations. Pain intensity accounted for 5-6% of the variance in the composite scores of functional limitation. Pain frequency accounted for 4-5% of the variance in upper extremity limitations but did not contribute to the modeling of lower extremity limitations. In contrast, pain location accounted for 9-14% of the variance in physical functional limitations. CONCLUSIONS: We tested a method for ascertaining pain location and clearly demonstrated that pain location is an important determinant of self-reported physical functional limitations. The MPM methodology may be used in population-based studies or in clinical samples that focus on specific impairments and seek to control for pain frequency and intensity. Future studies can link specific diseases with the common impairment of pain and tease out the pathways that lead to other impairments (e.g., weakness), functional limitations, and disability.

Distribution and observed associations of orthostatic blood pressure changes in elderly general medicine outpatients.

Factors associated with orthostatic blood pressure change in elderly outpatients were determined by surveying 398 medical clinical outpatients aged 65 years and older. Blood pressure was measured with random-zero sphygmomanometers after patients were 5 minutes in a supine and 5 minutes in a standing position. Orthostatic blood pressure changes were at normally distributed levels with systolic and diastolic pressures dropping an average of 4 mm Hg (standard deviation [SD]=15 mm Hg) and 2 mm Hg (SD=11 mm Hg), respectively. Orthostatic blood pressure changes were unassociated with age, race, sex, body mass, time since eating, symptoms, or other factors. According to multiple linear regression analysis, supine systolic pressure, chronic obstructive pulmonary disease (COPD), and diabetes mellitus were associated with a decrease in systolic pressure on standing. Hypertension, antiarthritic drugs, and abnormal heartbeat were associated with an increase in systolic pressure on standing. For orthostatic diastolic pressure changes, supine diastolic pressure and COPD were associated with a decrease in diastolic pressure on standing. Congestive heart failure was associated with an increase in standing diastolic pressure. Using logistic regression analysis, only supine systolic pressure was associated with a greater than 20-mm Hg drop in systolic pressure (n=53, prevalence=13%). Supine diastolic pressure and COPD were the only variables associated with a greater than 20-mm Hg drop in diastolic pressure (n=16, prevalence=4%). These factors may help physicians in identifying older persons at risk for having orthostatic hypotension.

Lower-extremity functioning in older Mexican Americans and its association with medical problems.

OBJECTIVE: To describe lower-extremity functioning in community-dwelling older Mexican Americans and to examine its relationship with medical problems. DESIGN: Cross-sectional analyses of survey and performance-based data obtained in a population-based study employing area probability sampling. SETTING: Households within selected census tracts of five Southwestern states: Arizona, California, Colorado, New Mexico, and Texas. PARTICIPANTS: A total of 2873 Mexican Americans aged 65 years and older. MEASUREMENTS: A multidimensional questionnaire assessing demographic, sociocultural, and health variables. Standardized tests of lower-extremity physical functioning included measures of standing balance, repeated chair stands, walking, and an overall summary measure. RESULTS: Regression analyses revealed that being more than age 75 and female, having arthritis diabetes, visual impairments, or being obese or underweight were all significantly associated with performance on both individual and summary tests of lower-extremity functioning. In separate regression analyses, the total number of medical conditions was also associated with performance. CONCLUSIONS: The likelihood of predicting performance or inability to complete tests of lower-extremity functioning was greatest for those aged 80 and older, those with arthritis or diabetes, and those with three or more medical conditions. Because of the high prevalence of diabetes in Mexican Americans, documentation of the association of diabetes with performance-based tests of lower-extremity functioning may help guide early interventions targeted to prevent progression to more severe limitations or disability.

Thioridazine dose-related effects on biomechanical force platform measures of sway in young and old men.

OBJECTIVE: Thioridazine (TDZ) is associated with an increased risk of falls. The purpose of this study was to determine whether (1) thioridazine increases Biomechanics Force Platform (BFP) measures of sway in a dose-related manner, (2) there is a difference in sway between young and old men, (3) there is a correlation between sway and orthostatic changes in BP and HR. DESIGN: Seven younger (aged 20-42) and five older (aged 70-76) healthy male volunteers received, in a randomized order double-blind design, a single oral dose of 0, 25, and 50 mg of TDZ on three separate days at least 7 days apart and 75 mg on the fourth day of the study. Sway and blood pressure were measured for 24 hours. SETTING: A general clinical research center. MEASUREMENTS: Biomechanics force platform measures of postural sway were measured as the movement of the center of pressure. The elliptical area (EA) and average velocity (AV) were calculated with eyes open and eyes closed. Blood pressure and heart rate were measured for 5 minutes supine and 5 minutes standing. RESULTS: Thioridazine increases BFP sway in a dose-dependent manner. EA increased from 0.56 (SD = .51) cm2 for placebo to 0.88 (SD = 1.09) cm2 for 75 mg TDZ. AV increased from 1.07 (SD = .27) cm/sec, placebo, to 1.43 (SD = .55) cm/sec, 75 mg TDZ. Older men swayed more than younger men. Changes followed the expected time course for TDZ. EA and AV were associated with HR and BP, e.g., SBP versus ln(EA) and ln(AV) (r = -0.21 and r = -0.22, respectively; P < .0001). CONCLUSIONS: Thioridazine increases validated measures of fall risk dose dependently in young and old men. This may explain the effects of neuroleptic drugs on fall risk in older people.

Cross-cultural adaptation of the hearing handicap inventory for the Elderly-Screening Version (HHIE-S) for use with Spanish-speaking Mexican Americans.

OBJECTIVE: To cross-culturally adapt the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S) for use with older Spanish-speaking Mexican Americans. SUBJECTS AND SETTING: Two different samples were used. First, a convenience sample of 100 older community-dwelling Mexican American men and women in San Antonio, Texas, was used to test technical equivalence of the Spanish and English language versions of the HHIE-S. Second, a neighborhood-based sample of older Mexican Americans was used to establish conceptual (n = 433) and criterion equivalence (n = 381) of the two HHIE-S language versions. METHODS: Independent forward and back translations were done to create a Spanish language version of the HHIE-S. In the convenience sample, subjects were administered the English and Spanish HHIE-S in random order on separate days. In the neighborhood sample, the HHIE-S was given on one occasion in the language of the subject's preference. Depressive symptoms were assessed using the Geriatric Depression scale to see if the two language versions of the HHIE-S were similarly associated with depression (conceptual equivalence). Hearing impairment was assessed using the Welch-Allyn Audioscope to see if the two language versions were similarly associated with an audiometric measure for hearing loss (criterion equivalence). RESULTS: In the convenience sample, the overall mean (SD) Spanish and English HHIE-S scores were 6.2 (8.7) and 6.2 (9.3), respectively (P = 1.00). Total scores of the English and Spanish versions were highly correlated (r = .89), and regression analysis indicated that the two language versions gave nearly identical results. In the neighborhood-based sample, men had higher HHIE-S scores than women (OR 2.0, 95% CI = 1.3-3.5). Having depressive symptoms (OR 3.2, 95% CI = 1.9-5.5) or hearing impairment (OR 6.1, 95% CI = 3.5-10.5) was associated with higher HHIE-S scores. After adjustment for gender, depressive symptoms, and/or hearing impairment, the language of interview was not associated with HHIE-S score. CONCLUSION: We have developed and tested a Spanish translation of the HHIE-S that yields equivalent results to those obtained with the English version in bilingual Mexican Americans. The Spanish HHIE-S presented here is suitable for clinical use and research studies involving older Mexican Americans.

Management of problematic behavioral symptoms associated with dementia: a cognitive developmental approach.

The purpose of this 3-year study was to test the efficacy of using a theoretical model based on Piaget's cognitive developmental stages for consistent behavioral and environmental interventions for persons at all stages of Alzheimer's disease and related disorders (ADRD) in nursing home and special care units. The specific aims were to reduce problematic behavioral symptoms and the number, amount and frequency of use of psychotropic medications. After 18 months, problem behaviors and some types of psychotropic medications significantly decreased in the treatment group but not in the control group. Results of the study indicate that using behavioral and environmental interventions based on Piaget levels of cognitive development may be an effective method of managing problematic behavioral symptoms and decreasing the use of psychotropic medications in institutionalized ADRD patients.

Measuring chronic rheumatic pain in Mexican Americans: cross-cultural adaptation of the McGill Pain Questionnaire.

We performed a cross-cultural adaptation of the McGill Pain Questionnaire (MPQ) from English to Spanish for studying Mexican Americans in South Texas. Each of the 78 single-word pain descriptors in the original MPQ was translated into Spanish by a panel of nine bilingual health researchers, preserving the original structure of the questionnaire. The pain-intensity content (PIC) of the words in each language was then rated on a 100 mm visual analog scale by 8 bilingual health care providers and 10 bilingual health-care consumers. The correlation between Spanish and English average PIC ratings was strong (r = 0.85 for providers, r = 0.80 for consumers). The translated Spanish version was compared to the original English in a group of 50 bilingual Mexican-American patients with musculoskeletal pain, who completed the MPQ in both languages. There was no difference in Average Pain Rating Index between the Spanish and English versions (29.8 +/- 14.7 vs 29.1 +/- 15.8, p = 0.55), and agreement between the two language versions was almost perfect (ri = 0.85). Test-retest reliability was measured in two groups of hospitalized patients (25 per group), one composed of monolingual Spanish speakers and the other of monolingual English speakers. Each subject completed the MPQ, the McGill Pain Map, two 10-cm visual analog scales measuring pain now and within the past week, the bodily pain items of the MOS-SF36 survey, and the Modified Health Assessment Questionnaire, on two occasions one day apart. Test-retest reliability of the Spanish and English components of the MPQ was not significantly different and was comparable to that of the other pain and health status instruments. We conclude that the Spanish MPQ is cross-culturally equivalent to the original English and has similar concurrent validity and reliability. This questionnaire is suitable for cross-cultural studies of pain comparing Spanish-speaking Mexican Americans with English-speaking members of the same and other ethnic groups.

Where does it hurt? Stability of recordings of pain location using the McGill Pain Map.

OBJECTIVE: To evaluate the validity and reliability of recordings of pain location among patients with pain from 2 different sources, using the McGill Pain Map (MPM). METHODS: Consecutive outpatients from a rheumatology clinic and inpatients recovering from surgical interventions participated in a structured interview during which the McGill Pain Questionnaire and the MPM were administered. After an interval of 3 to 6 weeks for the rheumatology patients and 1 to 2 days for the postoperative patients, a 2nd identical interview was administered. Criterion related validity was examined by testing whether the extent [total number of painful areas (NPA)] and distribution (individual body areas affected) of pain differed significantly between the 2 patient groups and whether, among postoperative patients, the distribution of pain was consistent with the site of surgical incision. Test-retest reliability of the recordings on the MPM was measured by calculating a kappa coefficient for each individual body area on the MPM, and an intraclass correlation coefficient for the NPA. RESULTS: 51 rheumatology and 47 postoperative patients were interviewed. Significant differences in the total NPA (4.1 +/- 3.0 vs 11.5 +/- 6.2; p < 0.001) and in the distribution of the painful areas were observed between the 2 groups. Among postoperative patients, there was no significant difference in the NPA between the 2 interviews (4.1 +/- 3.0 vs 4.3 +/- 3.5; p = 0.53), while among rheumatology patients, there was a reduction in the NPA at the second interview (11.5 +/- 6.2 vs 9.8 +/- 5.3; p = 0.007). Reliability of the recordings of pain location by individual areas averaged 0.50 (range 0.04 to 0.76). The reliability of the NPA was 0.82 for the combined group of patients (0.71 and 0.84, respectively). CONCLUSION: Recordings of pain location using the MPM are valid and reliable. The MPM is a valuable instrument for studies of the distribution of pain in populations.

Increased baseline sway contributes to increased losses of balance in older people following triazolam.

OBJECTIVE: Although it has been stated frequently that older people are more sensitive to benzodiazepines, the relative roles of impaired baseline performance, impaired elimination, and altered responsiveness have not been defined. We evaluated postural sway and plasma triazolam concentrations after administration of placebo and triazolam 0.375 mg in both young and older healthy subjects. DESIGN: Double-blind placebo-controlled trial. PARTICIPANTS: Nine young and nine older healthy men. INTERVENTION: All subjects received triazolam 0.375 mg or placebo on different study days, which were separated by at least 48 hours. MEASUREMENTS: Postural sway, visual analog scale of drowsiness, and plasma triazolam levels. RESULTS: The older subjects swayed more during triazolam than did the younger subjects, and this resulted in an increased number of losses of balance. This difference appeared to be caused by greater baseline sway in the older subjects rather than higher concentrations or increased responsiveness. A subset of older people had a much greater number of losses of balance during triazolam than did the rest of the subjects, and these individuals could be identified from their baseline sway. CONCLUSIONS: In this study, the increase in drug effect seen in the older subjects was of similar magnitude to that of the young, but it resulted in greater postural sway after drug administration than was seen in the young. The higher postural sway and the corresponding increased instability seen in the older subjects may put these older persons at increased risk of drug-related falls. This study also suggests that it should be possible to develop techniques that will identify individuals at particular risk of drug-induced postural instability.