Guinea pig or rabbit lung flavin-containing monooxygenases with distinct mobilities in SDS-PAGE are allelic variants that differ at only two positions.

Both guinea pig and rabbit express two variants of the 'lung' flavin-containing monooxygenase (FMO), observed as three distinct phenotypes based on mobility differences in SDS-PAGE. Samples of messenger RNA prepared from lungs of the two homozygous phenotypes of the guinea pig were used for the construction of two cDNA libraries. The libraries were screened with a cDNA encoding the rabbit lung FMO, and positive clones for each guinea pig lung FMO variant were isolated and sequenced. A full length clone from each library was found to encode a protein of 535 amino acids containing two pyrophosphate binding sites. Comparison of the sequences of the guinea pig and rabbit lung FMOs shows that their primary structures are 86% identical. The coding region sequences of the guinea pig variants differ at only two positions, and both differences result in amino acid substitutions. Sequence analysis has also been completed on a partially characterized variant of the rabbit lung FMO. As with the guinea pig, the nucleotide and amino acid sequences of the rabbit variants differ at only two positions. The cDNAs encoding the guinea pig variants were expressed in yeast. The activities of the enzymes are characteristic of the lung FMO, and the mobilities of the expressed enzymes are the same as those observed for the variants present in guinea pig pulmonary microsomal preparations. Similar to findings for the rabbit, analysis of genomic DNA indicates that the guinea pig lung FMO is associated with a single gene. The results of cDNA sequence analysis, expression in yeast, and analysis of genomic DNA indicate that the multiple lung FMOs in guinea pig and rabbit are allelic variants whose mobilities in SDS-PAGE are markedly altered by minimal changes in primary structure.

Planning for a mental hospital phasedown.

The authors studied the patients and community facilities in an area for which a mental hospital phasedown was contemplated. They found that patients who were continuously hospitalized during a 9-month period were highly dependent and judged unlikely to be candidates for community placement. By contrast, the patients who had been discharged during this 9-month period were judged relocatable by staff and constituted a select group in terms of independence. The authors' survey of community facilities indicated few placement possibilities for the majority of the continuously hospitalized patients.

Psychometric characteristics of the minimum data set I: confirmatory factor analysis.

OBJECTIVE: To determine the structure and statistical reliability of the federally mandated Minimum Data Set (MDS). DESIGN: Confirmatory, hypothesis-testing factor analysis was performed on MDS protocols of 733 nursing home residents. SETTING: All participants were residents of the Philadelphia Geriatric Center. PARTICIPANTS: Participants represented consecutively admitted skilled and intermediate care residents and another pool of residents with probable dementia. MEASUREMENTS: MDS protocols were completed by nurse care coordinators. Item composites hypothesized represented the domains of cognition, activities of daily living, time use, social quality, depression, and problem behaviors. RESULTS: For higher functioning residents (n = 336) and for all residents together, all domain clusters except social quality were confirmed. None of the domain clusters were confirmed within the more impaired (n = 391) group. CONCLUSIONS: The MDS does provide usable indicators of five areas of basic competence of nursing home residents. Lack of reliability in rating many aspects of the behavior and states of cognitively impaired residents is evident, however. Improvement of such measures and rating procedures constitutes a major research priority.

Validation of the Cumulative Illness Rating Scale in a geriatric residential population.

OBJECTIVE: To evaluate the validity of the Cumulative Illness Rating Scale (CIRS) in a geriatric institutional population by examining its associations with mortality, hospitalization, medication usage, laboratory findings and disability. DESIGN: A validation of the CIRS using self- and physician-report surveys, with archival data drawn from medical charts and facility records. SETTING: Long-term care facility with skilled nursing and congregate apartments. PARTICIPANTS: Four hundred thirty-nine facility residents selected on the basis of completeness of self-report data and physician ratings. PRIMARY MEASURES: Composite measures of illness severity and comorbidity, based on physicians' CIRS ratings; time to death or acute hospitalization after assessment; medication use, drawn from pharmacy records; medical chart data on laboratory tests; self-reported functional disability. RESULTS: CIRS illness severity and comorbidity indices, as well as individual CIRS items, were significantly associated with mortality, acute hospitalization, medication usage, laboratory test results, and functional disability. The CIRS showed good divergent validity vis a vis functional disability in predicting mortality and hospitalization. CONCLUSIONS: The CIRS appears to be a valid indicator of health status among frail older institution residents. The illness severity and comorbidity composites performed equally well in predicting longitudinal outcomes. Item-level analyses suggest that the CIRS may be useful in developing differential illness profiles associated with mortality, hospitalization, and disability.

Psychometric characteristics of the minimum data set II: validity.

OBJECTIVE: To determine the validity of the Minimum Data Set (MDS). DESIGN: MDS domain scores were correlated with a variety of independently obtained measures of basic behavioral and mental health functions of 513 nursing home residents. SETTING: All participants were residents of the Philadelphia Geriatric Center. PARTICIPANTS: One group of residents (n = 260) represented consecutive admissions who were able to respond to formal testing. The other group of residents (n = 253) represented presumably cognitively impaired residents whose data did not depend on self-report. MEASUREMENTS: MDS item-composite scores based on a confirmatory factor analysis were derived for the domains of cognition, activities of daily living (ADL), time use, depression, and problem behaviors. Hypotheses stating how these MDS domains should be related to standard measures of cognitive function, ADL, depression, agitation, social behavior, and irritability were tested. CONCLUSIONS: The majority of the hypotheses were upheld, thus suggesting that the MDS is usable as a source of research data. The sizes of the validity coefficients were modest, however. Depression and problem behavior were less well affirmed than cognition, ADL, and Time Use. There is a clear need for improvement in training and probably in the form of MDS measurement in some areas.

Depression and medical illness in late life: report of a symposium.

The high comorbidity of medical illnesses and late life depression poses both challenges and opportunities. Challenges in assessment techniques, diagnosis, and specific prognosis affect clinical care and research methodology alike. However, investigations that turn this vexing "confound" into research questions may prove fruitful. For clinicians working with older persons, recognizing the prognostic import of comorbid medical illnesses in late-life depression is essential to treatment planning. This comorbidity also poses difficulties in diagnosing depression inasmuch as symptoms of the medical conditions may overlap with those of an affective disorder. Symptom assessments must strike a balance between overly inclusive (e.g., mistakenly treating the psychomotor slowing of Parkinson's disease as depression) and overly exclusive (e.g., erroneously dismissing the patient's mood symptoms as "understandable"). Clinicians also should be sensitive to the broad range of symptomatic presentations with varying severities of both mood and medical disorders, as exemplified by variability across treatment settings. For researchers, similar issues are of relevance in planning investigative strategies. Consideration should be given to the following: 1. Case identification is a crucial first step; the approach to depressive symptoms potentially confounded by medical illnesses must be defined explicitly. Choice of an inclusive approach avoids premature exclusion of relevant phenomena; exploratory analyses can examine the effects of other approaches to the relationships of interest. 2. The use of similar research instruments across sample sites would greatly facilitate comparisons of results. Each subject group offers its own "leverage" for answering particular questions. Psychiatric inpatients will highlight the contributions of severe psychopathology (useful, for example, in identifying biologic markers). Medical inpatients are well suited to studies examining validity of different approaches to case identification, investigating health service utilization, or highlighting the contribution of acute, severe, life-threatening medical disorders to affective illness. Long-term care residents lend themselves to issues that benefit from compression of health processes over time. Medical outpatients have many advantages regarding generalizability and public health significance. Community samples are needed to determine the biases of all the above groups, which are each defined by service utilization. 3. Study of the relationships between depression and medical illness may further understanding of pathogenic mechanisms in late life mood disorders. Research questions might be guided by the biopsychosocial conceptual context described above. On the one hand, this context demands multidimensional study methodology to identify the routes by which medical illness influences depression in particular patient groups. Multivariate models should examine direct and indirect effects of medical illness on depression while, at the same time, considering intervening variables such as functional disability, personality, and social support. Guided multiple regressions or structural equation modeling will allow for determination of strengths of associations. 4. At the same time, and of particular importance if complex multivariate analyses are used, specific theoretic models should help direct focused investigations. The development and testing of such models is a major challenge that should be addressed by current research. Finally, from a societal perspective, the comorbidity of depression and medical illness likely has a tremendous impact on both health and health care delivery for older adults. Further study is needed to identify more specific approaches to treatment. Yet existing data clearly support a policy of routine psychiatric assessment of older people in general medical settings...

The structure of depression among elderly institution residents: affective and somatic correlates of physical frailty.

BACKGROUND: Confounding of depression with somatic illness and anxiety, a problem in any age group, may be especially troublesome in frail older persons. This paper examined this problem in a factor analytic study of the structure of depressive symptomatology, identifying affective and somatic symptom clusters and relating those clusters to health and functional variables cross-sectionally and prospectively over a 1-year interval. METHODS: The factor structure of a DSM-IV symptom checklist was examined among 1,245 elderly long-term care residents. Regression analyses examined the association of resulting factors with cognition, functional disability, self- and physician-rated health, and pain at baseline and a year later. One-year mortality was also examined. RESULTS: Factor analysis revealed three unique symptom clusters: depressed mood, somatic symptoms, and psychic anxiety. Depressed mood and somatic symptoms were associated cross-sectionally with all functional health variables, but psychic anxiety was associated only with pain. Longitudinally, depressed mood was the only independent predictor of decline in cognition, functional ability, physician-rated health, and mortality; the last effect, however, did not withstand control for baseline health and functioning. Somatic symptoms at baseline predicted decrement in self-rated health a year later. Effects varied as a function of cognitive status. CONCLUSIONS: These data suggest that concerns about the confounding role of somatic symptoms in the association of depression with physical health are unfounded. Although somatic symptoms of depression and anxiety were associated with health and functional status cross-sectionally, depressed mood was by far the stronger predictor of health declines over time.

Residential environment and self-directedness among older people.

Research on the environmental psychology of later life has produced data and theoretical advances that have been incorporated into the design of nursing homes and housing, neighborhood planning, housing policy, and housing-related services for older people. The applications of knowledge have been particularly useful in compensating for behaviors impaired by the physical illnesses that become more prevalent with aging. Some research has also documented environmental transactions made with the intent of choosing, creating, or shaping environments that increase need fulfillment. These two directions of the transactions between the older person and the environment have been characterized as environmental docility and environmental proactivity. The need for more research on promoting opportunities for proactivity in an attempt to raise environmental quality is discussed.

Failure to thrive in the elderly: exploration of the concept and delineation of psychiatric components.

Findings from an exploratory study of the relationships between routine clinical laboratory tests and the clinical status of elderly patients living in a nursing home or congregate housing facility demonstrate that low albumin and anemia are associated with decreased survival and with self-care deficits, cognitive impairment, depression, and summary measures of the severity of medical illness. The interrelationships observed among these variables support the usefulness of the concept of failure to thrive. Although albumin can serve as a nutritional marker, findings on its relationship with sedimentation rate, triiodothyronine uptake, fasting plasma amino acids, and retinol-binding protein levels suggest that the low albumin related to failure to thrive is not a simple reflection of steady-state deficits in protein-calorie nutrition; it appears to be sensitive to more direct effects of disease and inflammation or to the interactions between nutrition and illness.

Affect and age: cross-sectional comparisons of Structure and prevalence.

The self-reports of 207 young-adult (ages 18-30), 231 middle-aged (ages 31-59), and 828 older-adult (age 60 and over) Ss were used to study the structure of affect. Affects were represented by terms included in various circumplex arrays of emotions as presented by previous investigators. A set of 46 affects was subjected to exploratory analysis, and a final set of 38 affects was subjected to confirmatory factor analysis. The goodness of fit of each group's factor loadings to the hypothesized factors of positive affect, depression, anxiety-guilt, contentment, hostility, and shyness was not up to the desired .90 level, and some significant differences in factor structure were observed for each age-group comparison. There were few age differences in levels of positive affect. Depression was most frequent among younger Ss and least frequent among older Ss. Younger Ss were most often anxious and shy. Older Ss were most often content and least often hostile.

Relationship of events and affect in the daily life of an elderly population.

The relationship between positive and negative events and emotional well-being for depressed and nondepressed residents of a nursing home and congregate housing care facility was examined. For 30 consecutive working days, each of 79 participants was presented with the Philadelphia Geriatric Center Positive and Negative Affect rating scales. Events during the previous 24 hr were elicited by an open-ended format. Results indicated that variations in daily events (e.g., health, family, self-initiated, and social events) were related to residents' affect, and there was congruence between mood and event valence when the effects of psychopathology and residence were removed. Thus, regardless of diagnosis or residential setting, people's moods showed a relationship to the quality of daily events. Findings also indicated that ratings of residents' affect could be translated into audits for institutional quality.

Dimensions of affective experience in three age groups.

The dimensions by which adults of differing ages experience emotion were studied by self-administering questionnaires administered to older adults (n = 828) recruited from Elderhostel programs, middle-aged (ages 30-59) children of Elderhostel attenders (n = 231), and young adult (ages 18-29) subjects recruited from college classes or through Elderhostel participants (n = 207). Elders were higher in emotional control, mood stability, and emotional maturity through moderation and leveling of positive affect and lower in surgency, psychophysiological responsiveness, and sensation seeking. These findings are consistent with the hypothesized increase in self-regulatory capacity with age. These cross-sectional differences cannot, however, be distinguished from cohort-related explanations; they require considerable replication across different types of subjects and further characterization of the dimensions in terms of their functions for self-regulation.

Depression and cognitive change among institutionalized aged.

Interrelations between depression (Geriatric Depression Scale) and cognitive impairment (Blessed test) were examined among 201 nursing home and congregate apartment residents in a 2-year, 3-wave study. In structural equations models that controlled autocorrelations and within-occasion correlated residuals, introducing paths from depression to subsequent cognitive status significantly reduced unexplained variance, whereas paths from cognitive status to subsequent depression did not. Subsidiary analyses indicated that the relation of depression to subsequent cognitive status was strongest among persons with borderline (vs. impaired or intact) cognitive status, but only for the first time interval. Discussion addresses explanations for obtained results and implications for monitoring and treating depression among elderly long-term care residents.

Research institutes affiliated with nursing homes: strengths and developmental issues.

The United States currently has about 15 research institutes or departments affiliated with nursing homes, and several others are under consideration. This paper summarizes the results of a short survey of these research institutes. The advantages for both the nursing home and the researcher of having a research institute in a nursing home are discussed as well as some of the problems that emerge from this combination.

Two transitions in daughters' caregiving careers.

Daughters and daughters-in-law of presently unmarried elders were studied longitudinally, and the data were analyzed to determine how two transitions in caregiving status affected the women of the younger generation. One transition compared noncaregivers who had become caregivers 1 year later ("caregiving entrants," n = 33) with continuing noncaregivers (n = 56) and with veteran continuing caregivers (n = 78) over the same period. The second transition followed Time 1 new caregivers as they became "new veteran" caregivers (n = 69), comparing them with "old veteran" caregivers (n = 189) over the same year. The transition to caregiving was marked by a decrease in the care receiver's competence and an increase in the amount of care received, but caregiving entrants' quality of life did not change significantly over 1 year, as compared with either continuing noncaregivers or veteran caregivers. Although longitudinal study shows little positive evidence for the wear-and-tear model of caregiving, methodological improvements are needed before discarding the hypothesis that caregiving erodes mental health.

The psychosocial preferences of older adults: a pilot examination of content and structure.

Individualizing care for older persons depends on knowing about a care recipient's psychosocial preferences. Currently, however, no comprehensive, empirically derived instruments exist to assess these preferences. As part of an effort to develop such an instrument, this pilot study examined the content and structure of psychosocial preferences in older adults using the statistical technique known as concept mapping. Results suggest two underlying dimensions to psychosocial preferences (Enrichment-Self-Maintenance and Extrapersonal-Intrapersonal) and six distinct content domains (Social Contact, Growth Activities, Leisure Activities, Self-Dominion, Support Aids, and Caregivers and Care). Both the dimensions and the content domains provide valuable information for the construction of psychosocial preference instruments. They also might assist formal and informal caregivers in tailoring their interventions to provide individualized care that enhances quality of life for older adults.

A controlled study of respite service for caregivers of Alzheimer's patients.

After a baseline interview of 642 caregivers of aged Alzheimer's disease victims, half were offered formal respite care. Over 12 months, families with respite care maintained their impaired relative significantly longer in the community (22 days). Although respite was ineffective for caregiver burden and mental health, satisfaction was very high. Although not a strong intervention, respite care can increase caregivers' quality of life.

Health, valuation of life, and the wish to live.

This research investigated the relationship of an affective-cognitive schema, valuation of life (VOL), to older people's responses to a set of health utility (years of desired life) questions. Six hundred healthy and chronically ill elders aged 70 and older were interviewed to measure quality of life (QOL), mental health, and VOL. Valuation of life was significantly correlated with longer Years of Desired Life under 8 of 10 health conditions when background, health, QOL, and mental health states were controlled. We concluded that VOL is an internal representation of the many positive and negative features of the person and her everyday life that is necessary to comprehend how people may cling to life or welcome its end.

Observed affect in nursing home residents with Alzheimer's disease.

A method for assessing affect states among older people with Alzheimer's disease was developed for use in a study designed to evaluate a special care unit for such residents of a nursing home. The 6-item Philadelphia Geriatric Center Affect Rating Scale was designed for the use of research and other staff in assessing positive affect (pleasure, interest, contentment) and negative affect (sadness, worry/anxiety, and anger) by direct observation of facial expression, body movement, and other cues that do not depend on self-report, among 253 demented and 43 nondemented residents. Each affect scale was highly reliable, expressed in estimated portions of a 10-minute observation period when the affect expression occurred. Validity estimates were affirmative in showing discriminant correlations between the positive states and various independent measures of social and other outwardly engaged behavior and between negative states and other measures of depression, anger, anxiety, and withdrawal. Limited support for the two-factor dimensionality of the affect ratings was obtained, although positive and negative affect were correlated, rather than independent. Some hope is offered that the preference and aversions of Alzheimer patients may be better understood by observations of their emotional behaviors and that such methods may lead to a better ability to judge institutional quality.

Affective states in normal and depressed older people.

Ratings on a 10-item affect checklist yielding composite positive affect and negative affect scores were made daily for 30 days by older people in residential care: 19 were diagnosed as having major depression, 21 had minor depression, and 37 were without psychiatric diagnosis ("normal"). Mean levels of positive affect were highest in normal people and least in those with major depression; negative affect was lowest in normal ones and highest in those with a major depression. Variability was least among those with major depression in positive affect and among normal people in negative affect, while residents with minor depression showed some tendency, although inconsistent, toward greater day-to-day variability in positive affect. Patterns of invariance were such that those with major depression tended to be consistently lacking in positive affect but were variable in negative affect; normal people showed variability in positive affect but a relatively unvarying lack of negative affect. Clinical major depression was thus characterized less by "pervasive" depressive affect than by anhedonia.