Epidemiology of autism in adults across age groups and ability levels.

BACKGROUND: The epidemiology of autism in adults has relied on untested projections using childhood research. AIMS: To derive representative estimates of the prevalence of autism and key associations in adults of all ages and ability levels. METHOD: Comparable clinical diagnostic assessments of 7274 Adult Psychiatric Morbidity Survey participants combined with a population case-register survey of 290 adults with intellectual disability. RESULTS: The combined prevalence of autism in adults of all ages in England was 11/1000 (95% CI 3-19/1000). It was higher in those with moderate to profound intellectual disability (odds ratio (OR) = 63.5, 95% CI 27.4-147.2). Male gender was a strong predictor of autism only in those with no or mild intellectual disability (adjusted OR = 8.5, 95% CI 2.0-34.9; interaction with gender, P = 0.03). CONCLUSIONS: Few adults with autism have intellectual disability; however, autism is more prevalent in this population. Autism measures may miss more women with autism.

Prevalence and treatment of common mental disorders in the English national population, 1993-2007.

BACKGROUND: The National Psychiatric Morbidity Surveys include English cross-sectional household samples surveyed in 1993, 2000 and 2007. AIMS: To evaluate frequency of common mental disorders (CMDs), service contact and treatment. METHOD: Common mental disorders were identified with the Clinical Interview Schedule - Revised (CIS-R). Service contact and treatment were established in structured interviews. RESULTS: There were 8615, 6126 and 5385 participants aged 16-64. Prevalence of CMDs was consistent (1993: 14.3%; 2000: 16.0%; 2007: 16.0%), as was past-year primary care physician contact for psychological problems (1993: 11.3%; 2000: 12.0%; 2007: 11.7%). Antidepressant receipt in people with CMDs more than doubled between 1993 (5.7%) and 2000 (14.5%), with little further increase by 2007 (15.9%). Psychological treatments increased in successive surveys. Many with CMDs received no treatment. CONCLUSIONS: Reduction in prevalence did not follow increased treatment uptake, and may require universal public health measures together with individual pharmacological, psychological and computer-based interventions.

Prevalence of psychosis in black ethnic minorities in Britain: analysis based on three national surveys.

PURPOSE: A considerable excess of psychosis in black ethnic minorities is apparent from clinical studies, in Britain, as in other developed economies with white majority populations. This excess is not so marked in population surveys. Equitable health service provision should be informed by the best estimates of the excess. We used national survey data to establish the difference in the prevalence of psychosis between black ethnic groups and the white majority in the British general population. METHODS: Analysis of the combined datasets (N = 26,091) from the British national mental health surveys of 1993, 2000 and 2007. Cases of psychosis were determined either by the use of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), or from a combination of screening items. We controlled for sex, age, social class, unemployment, design features and other putative confounders, using a Disease Risk Score. RESULTS: People from black ethnic minorities had an excess prevalence rate of psychosis compared with the white majority population. The OR, weighted for study design and response rate, was 2.72 (95 % CI 1.3-5.6, p = 0.002). This was marginally increased after controlling for potential confounders (OR = 2.90, 95 % CI 1.4-6.2, p = 0.006). CONCLUSIONS: The excess of psychosis in black ethnic minority groups was similar to that in two previous British community surveys, and less than that based on clinical studies. Even so it confirms a considerable need for increased mental health service resources in areas with high proportions of black ethnic minority inhabitants.

Ethnic inequalities in the use of health services for common mental disorders in England.

PURPOSE: The purpose of this study is to investigate whether minority ethnic people were less likely to receive treatment for mental health problems than the white population were, controlling for symptom severity. METHOD: We analysed data from 23,917 participants in the 1993, 2000 and 2007 National Psychiatric Morbidity Surveys. Survey response rates were 79, 69 and 57 %, respectively. The revised Clinical Interview Schedule was used to adjust for symptom severity. RESULTS: Black people were less likely to be taking antidepressants than their white counterparts were (Odds ratio 0.4; 95 % confidence interval 0.2-0.9) after controlling for symptom severity. After controlling for symptom severity and socioeconomic status, people from black (0.7; 0.5-0.97) and South Asian (0.5; 0.3-0.8) ethnic groups were less likely to have contacted a GP about their mental health in the last year. CONCLUSIONS: Interventions to reduce these inequalities are needed to ensure that NHS health care is delivered fairly according to need to all ethnic groups.

Age and birth cohort differences in the prevalence of common mental disorder in England: National Psychiatric Morbidity Surveys 1993-2007.

BACKGROUND: There are concerns that the prevalence of mental disorder is increasing. AIMS: To determine whether the prevalence of common adult mental disorders has increased over time, using age-period-cohort analysis. METHOD: The study consisted of a pseudocohort analysis of a sequence of three cross-sectional surveys of the English household population. The main outcome was common mental disorder, indicated by a score of 12 or above on the Revised Clinical Interview Schedule (CIS-R). Secondary outcomes were neurotic symptoms likely to require treatment, indicated by a CIS-R score of 18 or over, and individual subscale scores for fatigue, sleep problems, irritability and worry. RESULTS: There were 8670 participants in the 1993 survey, 6977 in the 2000 survey and 6815 in the 2007 survey. In men a significant increase in common mental disorder occurred between the cohort born in 1943-9 and that born in 1950-6 (odds ratio 1.4, 95% CI 1.1-1.9) but prevalence in subsequent cohorts remained largely stable. More extended increases in prevalence of sleep problems and mental disorders were observed in women, but not consistently across cohorts or measures. CONCLUSIONS: We found little evidence that the prevalence of common mental disorder is increasing.

The nature and impact of urinary incontinence experienced by patients receiving community nursing services: a cross-sectional cohort study.

BACKGROUND: Nurses have played a pivotal role in the delivery of continence services yet little is known about the nature or impact of urinary symptoms experienced by patients in receipt of such care. AIM: To define the nature and impact of urinary symptoms experienced by patients in receipt of community nursing services. METHOD: The Leicestershire Urinary Symptoms Questionnaire was administered to 1078 patients with incontinence identified from 176 community nurses' caseloads in 157 general practices in England. Information included type and severity of urinary symptoms, impact on quality of life, help with coping, use of continence products and health service resources. RESULTS: Nine hundred and ninety nine (92.7%) patients (median age 79.0 years) returned completed questionnaires. Most patients had incontinence between 1 and 5 years duration, women were more likely than men to have had long standing ( > 5 years) symptoms and more than half the sample reported severe leakage. Women were more likely than men to report symptoms of stress incontinence (71.7% and 46.8%, respectively, p < 0.001) and urge incontinence UI (86.3% vs. 74.8%, respectively, p < 0.01). Half of the men and most women also experienced leakage as a result of difficulty getting to, on or off, a toilet/commode. Men were more likely than women to report getting up three or more times a night to pass urine (53.6% vs. 37.0%, respectively, p < 0.05). Most patients reported that their symptoms had a significant impact on many aspects of quality of life, and 45.7% would be very dissatisfied to continue "the way they are now". Professional help appeared principally one of containment. CONCLUSION: Many people with incontinence receiving community nursing services experience two or more urinary symptoms which, in the majority, have a significant impact on quality of life. Many older patients were not satisfied to "put up" with their urinary symptoms. Current service provision appears to be failing those who are most in need of such care.

Cohort differences in disease and disability in the young-old: findings from the MRC Cognitive Function and Ageing Study (MRC-CFAS).

BACKGROUND: Projections of health and social care need are highly sensitive to assumptions about cohort trends in health and disability. We use a repeated population-based cross-sectional study from the Cambridgeshire centre of the UK Medical Research Council Cognitive Function and Ageing Study to investigate trends in the health of the young-old UK population METHODS: Non-overlapping cohorts of men and women aged 65-69 years in 1991/2 (n = 689) and 1996/7 (n = 687) were compared on: self-reported diseases and conditions; self-rated health; mobility limitation; disability by logistic regression and four-year survival by Cox Proportional Hazards Regression models, with adjustments for differences in socio-economic and lifestyle factors. RESULTS: Survival was similar between cohorts (HR: 0.91, 95% CI: 0.62 to 1.32). There was a significant increase in the number of conditions reported between cohorts, with more participants reporting 3 or more conditions in the new cohort (14.2% vs. 10.1%). When individual conditions were considered, there was a 10% increase in the reporting of arthritis and a significant increase in the reporting of chronic airways obstruction (OR: 1.36, 95% CI: 1.04 to 1.78). CONCLUSION: This study provides evidence of rising levels of ill-health, as measured by the prevalence of self-reported chronic conditions, in the newer cohorts of the young-old. Though changes in diagnosis or reporting of disease cannot, as yet, be excluded, to better understand whether our findings reflect real increases in ill-health, investment should be made into improved population-based databases, linking self-report and objective measures of health and function, and including those in long-term care.

Diseases and impairments as risk factors for onset of disability in the older population in England and Wales: findings from the Medical Research Council Cognitive Function and Ageing Study.

BACKGROUND: This paper reports the association between self-reported diseases and impairments and 2-year onset of disability in a prospective study of people aged 65 years or older in five urban and rural centers in England and Wales (Medical Research Council Cognitive Function and Ageing Study; MRC-CFAS). METHODS: We initially reviewed risk factors for onset of disability in 35 prospective studies of functional decline in older people published in 1998-2001. In the present study, disability was defined as requiring help from another person at least several times a week and was assessed by dependency in activities of daily living. Polytomous and bivariate logistic regression models were fitted for onset of disability and mortality among those nondisabled at baseline (n=7913), adjusting for age, sex, and sociodemography. RESULTS: Among prevalent conditions, arthritis (population-attributable risk 11.4%) and cognitive impairment indicated by a Mini-Mental State Examination score of

Socioeconomic factors associated with the onset of disability in older age: a longitudinal study of people aged 75 years and over.

Although the association between socioeconomic status and mortality is well documented, there is less work focusing on the association with morbidity in older people. This is partly due to the difficulties of measuring socioeconomic status at older ages. The work that does exist tends to use cross-sectional data and objective measures of socioeconomic status such as education, social class or income. However, these standard measures may be less relevant for older people. In this study, we explore the association between socioeconomic status and disability in older people using a range of individual, household and area level indicators of socioeconomic status, including a subjective measure of adequacy of income. We use cross-sectional data of 1470 participants aged 75 years or over on 31/12/1987 and registered with a UK primary care practice. Of these 719 participants with no disability at baseline were followed up until 2003 with measurements at up to seven time points to determine onset of disability. Disability was defined as difficulty with any one of five activities of daily living. In cross-sectional multivariate analysis, age, housing tenure, living status and a subjective measure of income adequacy were associated with prevalence of disability. In longitudinal analyses, self-perceived adequacy of income showed the strongest association with onset of disability; with those reporting difficulties managing having a median age of onset 80.5 years, 7 years younger than those who felt their income was adequate (median age 87.8 years). The prospective association between self-perceived adequacy of income and onset of disability decreased with age. This subjective measure of income adequacy may signify difficulties in budgeting, but could also capture differences in objective indicators of status not recorded in this study, such as wealth. Further work is needed to explore what causes older people to experience difficulty in managing their money and to understand the mechanisms behind its impact on their physical health.

The role of sensory and cognitive function in the onset of activity restriction in older people.

BACKGROUND: Extending healthy active life expectancy is a priority if we are to achieve gains in both the quality and quantity of life lived at older ages. We investigated the role of sensory (vision and hearing) and cognitive function on the onset of activity restriction in older people. METHODS: A survey of a total population (N = 1579) of people aged 75 years and older, registered with a large general population in Melton Mowbray, Leicestershire, England, was undertaken in 1988 and linked with subsequent routine health assessments (up to a maximum of five) over 10 years. Activity restriction was defined as having difficulty performing on their own, requiring help or aids or not doing any one of seven Activities of Daily Living (ADLs). The study population comprised the 643 persons who were not restricted at baseline. Cox proportional hazard regression models were fitted to time of onset of activity restriction with those dying before activity restriction was reported being censored at time of death. RESULTS: After adjustment for confounding factors (socio-demographic and psychosocial factors, physical health and physical functional limitations), difficulty with both vision and hearing conferred a doubling of risk of activity restriction (RR = 2.36, 95% CI 1.31 to 4.28). A unit decrease in the Information/Orientation subtest was associated with a 10% increase in risk (RR = 1.10, 95% CI 1.02 to 1.19), even after adjustment for vision and hearing as well as other confounding factors, though baseline Mini-Mental State Examination score was not indicative of increased risk (RR= 1.02, 95% CI 0.98 to 1.06). CONCLUSION: Differentiating whether disability is a result of physical, sensory or cognitive functional limitations, is necessary to identify need and the direction in which efforts should be targeted to improve active life expectancy in older people.

Standard of living in the retirement survey: a predictor of six-year functional limitation onset and mortality in women, but not in men from ages 55 - 69 years.

PURPOSE: To investigate the predictive validity for health decline of a standard of living, a measure that combines basic necessities and consumer durables. METHOD: A nationally representative sample of those aged 55-69 years was interviewed at home in the Great Britain Retirement and Retirement Plans Survey, (1988; n=3,541). In 1994, 2,247 were re-interviewed, response rate being 70% of survivors. Relationships between socioeconomic status and health decline were investigated using polytomous logistic regression modelling. The outcomes were onset of functional limitation and mortality. RESULTS: Standard of living was an independent predictor of 6-year functional limitation onset (Odds Ratio compared to good standard of living 2.2; 95% Confidence Interval 1.3-3.8) and mortality (OR=4.6; 95% CI 2.3-8.9) in women, with age, household type, educational qualifications and social class taken into account. However, in men, weaker associations were largely accounted for by differences in education and social class (adjusted OR for functional limitation onset 1.0; 95% CI 0.5-1.9; adjusted OR for mortality 1.4; 95% CI 0.6-2.9). A combined indicator of housing tenure and property value was also an independent predictor of functional limitation onset in women. CONCLUSIONS: Poor standard of living identifies women but not men at risk of health decline who are missed by social class and educational level. Measures of current home-based material resources are a useful addition to minimum datasets for monitoring health inequalities.

Are gender differences in the relationship between self-rated health and mortality enduring? Results from three birth cohorts in Melton Mowbray, United Kingdom.

PURPOSE: The purpose of this study was to assess whether there is an enduring gender difference in the ability of self-rated health to predict mortality and investigate whether self-reported physical health problems account for this difference. DESIGN AND METHODS: Cox models for 4-year survival were fitted to data from successive cohorts aged 75-81 years registered with a primary care practice in the U.K. Midlands surveyed in 1981, 1988, and 1993-1995. RESULTS: Self-rated health was consistently a stronger predictor in men (hazard ratio [HR] = 2.7; 95% confidence interval [CI] = 2.1-3.5) than it was in women (HR = 1.9; 95% CI = 1.5-2.4). Women surveyed in 1993-1995 were more likely than men to report problems that were disabling but not life-threatening, whereas men were more likely to report potentially life-threatening problems. However, these differences did not explain the association of self-rated health with mortality. More than half of those who reported a potentially life-threatening problem said that their health was good. IMPLICATIONS: Self-rated health is more strongly associated with mortality in men, but this is unlikely to be explained by differences in the nature of their physical health problems.

Increased prevalence of insomnia and changes in hypnotics use in England over 15 years: analysis of the 1993, 2000, and 2007 National Psychiatric Morbidity Surveys.

STUDY OBJECTIVES: To investigate changes over 15 years in the prevalence of insomnia and its association with demographic characteristics and hypnotic medication use. DESIGN: Analysis of 3 cross-sectional national mental health surveys carried out in 1993, 2000, and 2007, which used comparable sampling methods and identical insomnia assessments. SETTING: Adults living in private households in England. PATIENTS OR PARTICIPANTS: 20,503 people aged 16-64 years. MEASUREMENTS AND RESULTS: Insomnia was defined according to 4 different criteria, using relevant questions from the revised Clinical Interview Schedule. Modest increases in insomnia prevalence were found over the survey periods (any symptoms increasing from 35.0% in 1993 to 38.6% in 2007; insomnia diagnosis from 3.1% to 5.8%, respectively). In all 3 surveys, similar strengths of association in relation to all criteria were found, with female gender, increased age, lower educational attainment, depression, unemployment, economic inactivity, and widowed, divorced, or separated status. Prevalence of hypnotic use was double in 2000 (0.8%) compared to 1993 (0.4%); from limited information on selected medications, there was no such increase between 2000 and 2007. The reasons reported for any sleep disturbance over the last month were generally similar across surveys, the most marked change being illness/discomfort increasing as an explanation from 14.3% to 17.4% to 19.0%. CONCLUSIONS: In the English general population, insomnia (by any definition) showed a modest but steady increase in prevalence over a 15-year period. Strengths of associations with demographic factors and self-reported reasons for sleep disturbance remained reasonably stable over this period.

Carer-held records for dementia: a controlled trial.

BACKGROUND: A carer-held record (CHR) was developed to enable carers to contribute to care plans for their relatives with dementia, alongside other professionals. The aim of this study was to establish whether CHRs provide any measurable benefits for carers, in the areas of health, stress, knowledge of dementia and locus of control. METHODS: This was a controlled parallel-group trial involving 84 carer/patient pairs, drawn from all new referrals to two community mental health teams (CMHTs). Subjects from one CMHT were given CHRs. The control group from the other CMHT were not offered the initiative. Carers in both groups completed instruments measuring knowledge of dementia, carer stress and strain, carer health, and locus of control (internal, external, chance, shared care) at three time points: baseline, 6 months and 1 year. RESULTS: Findings are reported for outcome at 6 months and 1 year on 51 carer/patient pairs. Having a CHR was associated with significantly reduced scores on the Carer Strain Index at 1 year (mean between-group difference: -1.34, 95% CI -2.67 to -0.02). Regarding locus of control, external control scores were significantly lower in the intervention group, by 2.5 points at 6 months (95% CI -4.82 to -0.18) and 3.43 points at 1 year (95% CI -5.57 to -1.29) (p = 0.01). There was a significant group by time interaction in chance control, with the difference in chance control between groups widening between 6 and 12 months. In the shared care dimension of locus of control, there was no difference at 6 months, but a significant group by time interaction, with the intervention group maintaining a higher level of internal control between 6 and 12 months, while the control group reduced. No significant differences were identified in the domains of carer health or knowledge of dementia. CONCLUSIONS: Although not a randomized controlled trial, and limited by smaller sample size than planned, this study indicates that use of CHRs provides some benefits for carers in the domains of carer strain and locus of control.

Factors affecting completion of the SF-36 in older people.

OBJECTIVE: to examine the influence of specific clinical impairments and disabilities on the completion of the SF-36 health status measure among older people. DESIGN: Prospective observational study. SETTING/PARTICIPANTS: An SF-36 was administered to 245 subjects aged 65 years and older. Subjects were chosen by sampling from a variety of inpatient, outpatient and community sources to ensure a range of relevant disabilities. MEASUREMENTS: response rates, overall rates of completion, completion of individual questions and time taken to complete. RESULTS: severe functional impairment (Barthel index < or = 12) was found in 22.4% (51/228), cognitive impairment in 54.1% (132/244), depressed mood in 77.0% (151/196) and visuospatial dysfunction in 71.3% (134/188). The median number of impairments was three (interquartile range 1-4). Specific physical impairments were visual in 13.2% (31/235), hearing in 30.2% (74/245), impaired manual dexterity in 18.0% (44/245) and dysphasia in 23% (55/239). In multivariate analyses, global functional impairment (P = 0.006), cognitive impairment (P = 0.0001) and impaired manual dexterity (P = 0.005) were significantly associated with more dimensions uncompleted, whilst cognitive impairment (P = 0.001), age (P = 0.006) and visuospatial dysfunction (P = 0.0003) were significantly associated with longer completion times. CONCLUSION: the most striking finding of the study was that global rather than specific physical and mental dysfunction was associated with the inability to complete the SF-36 questionnaire. The difficulty appears to lie in the performance of a complex task, rather than with specific aspects of the task which could be overcome by adaptation or aids. Our experience is that this relatively complex questionnaire does not adequately measure functional health status in disabled older people because of non-completion and may therefore overestimate the health of populations.

Cluster randomized controlled trial of the effectiveness of audit and feedback and educational outreach on improving nursing practice and patient outcomes.

BACKGROUND: Current understanding of implementation methods is limited, and research has focused on changing doctors' behaviors. AIM: Our aim was to evaluate the impact of audit and feedback and educational outreach in improving nursing practice and patient outcomes. METHODS: Using a factorial design, cluster randomized controlled trial, we evaluated 194 community nurses in 157 family practices and 1078 patients with diagnosis of urinary incontinence (UI) for nurses compliance with evidence-linked review criteria for the assessment and management of UI and impact on psychologic and social well-being and symptoms. In the outreach arms, nurses' self-reported barriers informed development of tailored strategies. RESULTS: In comparison with educational materials alone, the implementation methods tested did not improve care at 6 months follow-up. Moderate rates of improvement (10-17% of patients) in performance for the assessment of UI and greater rates of improvement (20-30% of patients) for the management of care were found but effects were similar across arms. Improvement in patient outcomes was more consistently positive for educational outreach than for audit and feedback but differences were not significant. Adjustment for caseload size, severity or duration of UI and patients' age did not alter results. CONCLUSIONS: Printed educational materials alone may be as effective as audit and feedback and educational outreach in improving nurses' performance and outcomes of care for people with UI. Greater understanding of the underlying processes in improving performance within multidisciplinary teams through further, theory-driven studies with "no intervention" control groups and longer follow-up are needed.