The Life-Long Mortality Risks Of World War II Experiences.

OBJECTIVE: This longitudinal study of American veterans investigated the mortality risks of five World War II military experiences (i.e., combat exposure) and their variation among veterans in the post-war years. METHODS: The male subjects (N=854) are members of the Stanford-Terman study, and 38 percent served in World War II. Cox models (proportional hazards regressions) compared the relative mortality risk associated with each military experience. RESULTS: Overseas duty, service in the Pacific and exposure to combat significantly increased the mortality risks of veterans in the study. Individual differences in education, mental health in 1950, and age at entry into the military, as well as personality factors made no difference in these results. CONCLUSIONS: A gradient is observable such that active duty on the home front, followed by overseas duty, service in the Pacific, and combat exposure markedly increased the risk of relatively early mortality. Potential linking mechanisms include heavy drinking.

Community-based service use by elders with dementia and their caregivers: a latent class analysis.

BACKGROUND: With the increase in the number of older adults with dementia, research efforts have focused on increasing community-based support service (CBSS) use to improve older adult and caregiver outcomes. However, the research on factors that may explain CBSS use has been focused on individual characteristics, and how the care recipient and caregiver as a pair influence CBSS use has not been accounted for. OBJECTIVE: To classify care recipients with dementia and their caregivers who shared similar patterns of CBSS use and to identify predictors of class membership. METHODS: Participants were 1,813 elders with dementia and their caregivers from the National Longitudinal Caregiver Study, a cross-sectional dataset from 1998. A latent class analysis was used to identify classes of CBSS users by examining use of caregiver support group, home aide, home health, adult day care, and respite care. Multinomial logistic regression analysis was used to examine relationships between predisposing, enabling, and need variables and class membership. RESULTS: Three classes, that is, Low Users, Adult Day Users, and Home-Based Users, comprised 80%, 10%, and 10% of the sample, respectively. Adult Day Users reported significantly more enabling resources and greater service need. Predictors of home-based use included care recipient age, activities of daily living limitations, number of skilled nursing facilities in the local county, and the extent of caregiver physical limitations from comorbid conditions. DISCUSSION: Using latent class analysis allows identification of specific subtypes of CBSS users, prevalence of user subtype, and risk factors for underutilization. Determining the long-term outcomes of class membership may identify specific groups at risk, which could inform the design of interventions to improve assessment for and delivery of CBSS.

Effect of physical activity guidelines on physical function in older adults.

OBJECTIVES: To determine whether elderly people who meet national guidelines have higher physical function (PF) scores than those who do not and the effect on functional trajectory when physical activity (PA) levels change from above to below this threshold, or vice versa. DESIGN: Pooled data. SETTING: Two 6-month randomized controlled trials aimed at increasing PA in adults. PARTICIPANTS: Adults aged 65 to 94 (N=357). INTERVENTION: PA counseling over the telephone and through mailed materials. MEASUREMENTS: Self-reported PA dichotomized at 150 minutes/week and PF using the Medical Outcomes Study 36-item Short Form Questionnaire PF subscale. RESULTS: At baseline, individuals reporting 150 minutes or more of moderate PA/week had mean PF scores that were 20.3 points higher than those who did not (P<.001). Change in PA minutes from above threshold to below threshold or from below threshold to above threshold from baseline to 6 months resulted in an average change in PF of -11.18 (P<.001) and +5.10 (P=.05), respectively. CONCLUSION: These findings suggest that PA is an important predictor of functional status. Older sedentary adults can improve PF by meeting recommended PA levels. Conversely, dropping below recommended PA levels has a deleterious effect on PF. Given the importance of PF in maintenance of independence and quality of life in older adults, adherence to recommended PA guidelines should be endorsed.

Differences in health-related quality of life between older nursing home residents without cognitive impairment and the general population of Norway.

AIM: To advance the understanding of health-related quality of life among older nursing home residents by assessing their health-related quality of life and comparing this with norms from the general population. METHODS: The study used a two-group cross-sectional comparative design. The samples comprised 227 nursing home residents aged 65-102 years with at least six months' residence and a representative population sample of 1137 Norwegian citizens aged 65-102 years. All nursing home residents had a Clinical Dementia Rating Scale score > or =0.5 and were capable of conversing. The respondents provided demographic information and were surveyed using the SF-36 Health Survey. We used univariate and multivariate linear models to identify possible differences in health-related quality of life between the nursing home residents and the general population, controlled for age, sex, marital status and education. RESULTS: After adjustment for age, group, sex, marital status and education, the nursing home residents scored significantly higher on bodily pain and on physical and emotional role limitation and significantly lower on the other SF-36 subscales, except social functioning, with the largest differences for physical functioning (mean nursing home 23.2 and mean general population 62.9). The general population scores on all subscales generally increased with increasing education but not among the nursing home residents. CONCLUSIONS: The mean SF-36 scale scores differed markedly between the nursing home residents and the general population, with the nursing home residents generally scoring lower. The association with background variables known to be related to health-related quality of life differed between the groups. Healthcare professionals should increase attention to health-related quality of life among nursing home residents, periodically assess health-related quality of life and consider interventions that may improve health-related quality of life in older institutionalised populations. RELEVANCE TO CLINICAL PRACTICE: This study highlights the role of nurses and other health professionals in ensuring that nursing home residents have opportunities to improve their health-related quality of life.

Post-traumatic stress outcomes in non-Hodgkin's lymphoma survivors.

PURPOSE: A large body of evidence suggests that being diagnosed with and treated for cancer adversely affects functioning and quality of life, yet less is known about longer term outcomes. Therefore, this study aims to estimate the prevalence of post-traumatic stress disorder (PTSD) symptoms in survivors of adult non-Hodgkin's lymphoma (NHL) who are at least 2 years postdiagnosis and identify the risk factors associated with PTSD symptoms, with a focus on those that are amenable for screening and modifiable. PATIENTS AND METHODS: A total of 886 NHL survivors identified from the cancer registries of two hospitals in North Carolina participated, ranging in age from 25 to 92 years old and ranging from 2 to 44 years postdiagnosis. Survivors were mailed a survey that assessed PTSD symptoms and quality of life. RESULTS: Participants averaged 10.2 years postdiagnosis, and most (61%) reported no PTSD symptoms. The adjusted prevalence for full PTSD was 7.9%, with an additional 9.1% meeting criteria for partial PTSD. Modifiable risk factors that were independently associated with PTSD in multiple linear regression included less social support, negative appraisals of life threat and treatment intensity, and more employment and insurance issues. Additionally, several demographic characteristics (nonwhite race, less education, and younger age) and clinical or health-related factors (active disease, more recent diagnosis, and more comorbidity) were independently associated with PTSD. CONCLUSION: Although only 8% of survivors met PTSD diagnostic criteria, the impact of a cancer diagnosis and treatment persists for many survivors, as evidenced in 39% of this sample. Early identification of those at risk could enable treatment to minimize PTSD symptomatology.

Identification of dementia: agreement among national survey data, medicare claims, and death certificates.

OBJECTIVE: To estimate the proportion of seniors with dementia from three independent data sources and their agreement. DATA SOURCES: The longitudinal Asset and Health Dynamics among the Oldest Old (AHEAD) study (n=7,974), Medicare claims, and death certificate data. STUDY DESIGN: Estimates of the proportion of individuals with dementia from: (1) self- or proxy-reported cognitive status measures from surveys, (2) Medicare claims, and (3) death certificates. Agreement using Cohen's kappa; multivariate logistic regression. PRINCIPAL FINDINGS: The proportion varied substantially among the data sources. Agreement was poor (kappa: 0.14-0.46 depending upon comparison assessed); the individuals identified had relatively modest overlap. CONCLUSIONS: Estimates of dementia occurrence based on cognitive status measures from three independent data sources were not interchangeable. Further validation of these sources is needed. Caution should be used if policy is based on only one data source.

Childhood cancer survivors' perceived barriers to improving exercise and dietary behaviors.

PURPOSE/OBJECTIVES: To determine childhood cancer survivors' barriers to increasing exercise and consuming less fat and more fruits and vegetables, whole grains, and calcium-rich foods. DESIGN: Mailed survey. SETTING: Cases from a comprehensive cancer center. SAMPLE: Convenience sample of 144 childhood cancer survivors aged 13-35 years identified through previous research. Surveys were returned by 118 participants (82% response rate). METHODS: Descriptive statistics with chi-square tests were performed between subgroups defined by age (< 18 years and < or = 18 years) and diagnosis (leukemia, lymphoma, and central nervous system cancers). MAIN RESEARCH VARIABLES: Barriers to exercise, consuming less fat, and eating more fruits and vegetables, whole grains, and calcium-rich foods. FINDINGS: Proportionately more childhood cancer survivors reported barriers to exercise and following a low-fat diet than to consuming more fruits and vegetables, whole grains, and calcium-rich foods. Primary barriers to exercise included being too tired (57%), being too busy (53%), and not belonging to a gym (48%), whereas barriers for restricting high-fat foods were commercials that make high-fat foods look so appealing (58%) and having friends who eat a lot of high-fat foods (50%). Difficulty associated with ordering healthy foods when dining out also was a leading barrier to following a low-fat diet (50%), as well as eating more whole grains (31%), fruits and vegetables (30%), and calcium-rich foods (15%). CONCLUSIONS: Childhood cancer survivors report several barriers to exercise and consuming a low-fat diet with more fruits and vegetables, whole grains, and calcium-rich foods. IMPLICATIONS FOR NURSING: This study's findings may be helpful to nurses, health educators, and allied health professionals in developing effective interventions that promote healthful lifestyle change among childhood cancer survivors.

Identifying trajectories of depressive symptoms for women caring for their husbands with dementia.

OBJECTIVES: To use an innovative statistical method, Latent Class Trajectory Analysis (LCTA), to identify and describe subgroups (called trajectories) of caregiver depressive symptoms in a national sample of wives providing informal care for their husbands with dementia. DESIGN: Longitudinal. SETTING: Community. PARTICIPANTS: Respondents to the National Longitudinal Caregiver Survey were wife caregivers of veterans with dementia who were identified through Veterans Affairs hospitals nationally. MEASUREMENTS: Mean number of depressive symptoms as measured using the Center for Epidemiologic Studies Depression scale (CES-D, 20-item scale). RESULTS: Overall mean depressive symptoms of wife caregivers were 6.2 of 20, below the cutpoint (8 or 9/20) associated with clinical depression. Four distinct trajectories of caregiver depressive symptoms were identified. The trajectory with the highest number of symptoms (11.9 of 20), contained one-third of the sample. Another third had mean depressive symptoms virtually identical to the overall sample mean. The final third were divided between two trajectories, low depressive symptoms (mean CES-D, 3.0/20, 22% of sample) and very low (mean CES-D, 0.8/20, 14% of sample). Approximately two-thirds of the sample members were in a depressive symptom trajectory, with substantially higher or lower numbers of symptoms than the overall mean. Two subjective measures asked of wife caregivers (desire for more help, life satisfaction) were significantly associated with membership in the highest depressive symptom trajectory. CONCLUSION: LCTA identified important depressive symptom subgroups of wife caregivers. A population-averaging method identified a mean effect that was similar to the effect in one-third of the cases but substantially different from that in two-thirds of the cases.

Understanding the role of cancer worry in creating a "teachable moment" for multiple risk factor reduction.

The manuscript examines the influence of contextual factors on whether and for whom a colon polyp diagnosis might be a teachable moment, as indicated by engagement with a proactively delivered intervention. Baseline and 8-month follow-up data were analyzed from a two-site behavioral intervention trial with patients in Massachusetts and North Carolina, USA who had recently undergone polypectomy for pre-cancerous colon polyps and were randomized to a behavior change intervention condition (N=591). Intervention "buy-in" was used as an indicator of response consistent with the polyp identification serving as a teachable moment. Cancer worry, personal risk, health-related self-identity and other sociodemographic factors were tested to predict intervention buy-in. As predicted, those who were most worried about colon cancer were most likely to engage in the intervention. One indicator of personal risk, number of risk behaviors, was significantly and negatively associated with buy-in. Predictors of intervention buy-in and cancer worry were not consistent. We recommend that expanded measures of affect and health-related self-identity should be considered in future research to understand the motivational potential of health events for increasing engagement in effective behavior change interventions.

Measuring the quality of dying in long-term care.

OBJECTIVES: To describe two versions of a new measure, The Quality of Dying in Long-Term Care, for postdeath administration to surrogate respondents (staff and family caregivers) of all decedents (QOD-LTC) and of cognitively intact decedents (QOD-LTC-C) who die in nursing homes (NHs) and residential care or assisted living (RC/AL) facilities. DESIGN: Using two levels of exploratory factor analysis, 15 candidate items for the QOD-LTC and 36 candidate items for the QOD-LTC-C were tested using multiple criteria to determine factor structure and interpretability of the quality of dying in long-term care (LTC). SETTING: One hundred seventeen RC/AL facilities and 31 NHs in FL, MD, NC, and NJ. PARTICIPANTS: Family (n=439) and staff (n=332) caregivers of 633 decedents from a stratified random sample from RC/AL facilities and NHs in four states. MEASUREMENTS: Trained interviewers asked respondents to rate statements describing potentially important aspects of the quality of dying using a 5-point Likert scale. The scale items were analyzed using exploratory factor analysis with communalities set to unity using a Promax rotation. RESULTS: The 11-item QOD-LTC (alpha=0.66), appropriate for surrogate respondents for all decedents, consists of three domains (personhood, closure, preparatory tasks). The 23-item instrument for surrogate respondents of cognitively intact decedents, the QOD-LTC-C (alpha=0.85), consists of five domains (sense of purpose, closure, control, social connection, preparatory tasks). CONCLUSION: The QOD-LTC and QOD-LTC-C are psychometrically acceptable measures of the quality of the dying experience, developed for and tested in LTC settings. Use of these measures can increase understanding of the dying experience in LTC.

The Diet Quality Index-Revised: a tool to promote and evaluate dietary change among older cancer survivors enrolled in a home-based intervention trial.

OBJECTIVE: To utilize the Diet Quality Index-Revised (DQI-R) as a framework for delivering and evaluating an intervention to improve overall diet quality among older cancer survivors. DESIGN: As part of a randomized controlled trial to improve lifestyle behaviors among older cancer survivors, we sought a dietary measure that could serve as both an intervention framework and a means to evaluate global dietary quality. The DQI-R measures overall diet quality by summing 10 subscales that relate to national guidelines. At baseline, DQI-R scores were generated from three multi-pass 24-hour dietary recalls. The 6-month intervention delivered tailored feedback on individual DQI-R subscales. Dietary recalls were repeated at 6 and 12 months. SUBJECTS: Elderly (aged >or=65 years) individuals within 18 months of diagnosis of breast or prostate cancer (n=182) were randomized postbaseline measures to intervention vs attention control arms. RESULTS: Significant differences in overall diet quality were observed between arms at 6 months, with the intervention arm improving (67.6+/-12.2 to 69.8+/-13.9), and controls declining (67.5+/-12.5 to 64.6+/-14.7) (P=0.003). Significant differences were observed between arms over time in dietary diversity subscale scores: baseline and 6-month follow-up means among intervention and control arms were 4.8+/-1.3 to 4.8+/-1.4, and 4.7+/-1.2 to 4.1+/-1.1, respectively (P=0.001). CONCLUSIONS: The DQI-R served as an effective guide and evaluation tool for this diet-related randomized controlled trial. Like many interventions, our effect diminished after the intervention was complete. Future research should consider testing interventions that use the DQI-R, or other global diet-related indexes, as guides and evaluation tools over longer study periods, as well as in other populations.

Main outcomes of the FRESH START trial: a sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors.

PURPOSE: Cancer survivors are at increased risk for cardiovascular disease, diabetes, osteoporosis, and second primary tumors. Healthful lifestyle practices may improve the health and well-being of survivors. The FRESH START trial tested the efficacy of sequentially tailored versus standardized mailed materials on improving cancer survivors' diet and exercise behaviors. METHODS: Five hundred forty-three individuals with newly diagnosed locoregional breast or prostate cancer were recruited from 39 states and two provinces within North America. Participants were randomly assigned either to a 10-month program of tailored mailed print materials promoting fruit and vegetable (F&V) consumption, reducing total/saturated fat intake, and/or increasing exercise or to a 10-month program of nontailored mailed materials on diet and exercise available in the public domain. Telephone surveys conducted at baseline and 1 year assessed body mass index (BMI), dietary consumption, physical activity, and other psychosocial/behavioral indices. Clinical assessments were conducted on a 23% subsample; information was used to validate self-reports. RESULTS: Five hundred nineteen participants completed the 1-year follow-up (4.4% attrition; sample characteristics: 57 +/- 10.8 years old, 83% white, 56% female, 64% overweight/obese, and 0% underweight). Although both arms significantly improved their lifestyle behaviors (P < .05), significantly greater gains occurred in the FRESH START intervention versus the control arm (practice of two or more goal behaviors: +34% v +18%, P < .0001; exercise minutes per week: +59.3 v +39.2 minutes, P = .02; F&V per day: +1.1 v +0.6 servings, P = .01; total fat: -4.4% v -2.1%, P < .0001; saturated fat: -1.3% v -0.3%, P < .0001; and BMI: -0.3 v +0.1 kg/m2, respectively, P = .004). CONCLUSION: Mailed material interventions, especially those that are tailored, are effective in promoting healthful lifestyle changes among cancer survivors. Further study is needed to determine sustainability, cost to benefit, and generalizability to other cancer populations.

Congregational health ministries: a national study of pastors' views.

OBJECTIVES: Since the 1980s, there has been a growing, but little studied, movement that organizes church-based health services under the direction of a coordinator, usually a registered nurse. These Congregational Health Ministries (CHMs) emphasize health promotion and disease prevention. We compared the perceptions of pastors with and without organized CHMs and the characteristics of their congregations' health ministries. DESIGN: We used a quantitative, cross-sectional survey design. SAMPLE: We surveyed a national multidenominational sample of 349 pastors representing over 80 Christian denominations. RESULTS: With limited resources, CHMs provide significant health promotion, disease prevention, and support services. Pastors with CHMs were significantly more involved in health promotion and disease prevention activities. Pastors without CHMs perceived a need for congregations to be involved in health-related services and were willing to become involved if they have adequate resources. CONCLUSIONS: Because of long-term trusting relationships that exist between congregants and those who minister to them, religious congregations may be ideally suited to provide cost-effective, community-based health promotion and disease prevention services as well as health-supporting services to community-dwelling elderly and persons with chronic illnesses.

Evaluation of agreement between physicians' notation of 'no evidence of disease' (NED) and patients' report of cancer status.

This study examines extent of agreement between oncologists' and cancer patients' reports of current cancer status. Participants with history of cancer were given a comprehensive geriatric assessment in which they were asked whether they had cancer at the present time. This was compared to cancer status concurrently recorded by their physicians in the chart. 75.5% of patients whose physicians reported 'no evidence of disease' (NED) reported that they currently had cancer. 30% of them were anxious and 27% were depressed. Among patients for whom both the patient and physician reported no cancer, only 12.5% were anxious and 7% depressed. Compared to patients with concordant responses, those who discrepantly reported they had cancer had significantly more comorbid illnesses, medications, and pain, and lower levels of social, emotional, and physical functioning. Moreover, equal levels of distress and dysfunction were found between those who reported cancer but had NED and those who reported cancer and did have active disease by physician notation. Although conclusions about cause and effect are limited due to study design, findings suggest that some patients might suffer unnecessarily from lack of understanding about current disease status. These findings also suggest the need for improved physician-patient communication and symptom recognition/management.

Identifying, recruiting, and retaining seriously-ill patients and their caregivers in longitudinal research.

BACKGROUND: In order to improve the state of science in palliative care, we must increase our ability to document the real-time experience of patients and families as they traverse the end of life. Yet, frequently, prospective measurement is impeded by difficulty with patient identification, recruitment, enrollment, and retention. The palliative care literature is replete with descriptions of studies unable to meet enrollment goals, and that as a result, do not have adequate power to test hypotheses or draw conclusions. OBJECTIVES: To review the literature describing difficulties associated with ascertainment, enrollment, and attrition. To outline the successful recruitment methods of a new longitudinal study of patients and their caregivers. DESIGN: A two-year longitudinal study of 240 patients with Stage IV cancer (breast, prostate, colorectal, lung), advanced congestive heart failure (CHF) LVEFB < 40 or advanced chronic obstructive pulmonary disease (COPD) pCO(2) > 46, and their caregivers, interviewed monthly for up to two years. Patients were identified using clinical and administrative databases from one geographic region. RESULTS: Representative and successful ascertainment was associated with use of clinical criteria and medical record review versus physician or other provider prognostication, use of recruitment letters from personal physician, recruitment letter content, brochure content, small monetary incentives, refined phone scripts, use of matched ethnicity interviewers, in-home and phone interview strategies, measure selection, patient and caregiver rapport, and on-going staff support (including grief and bereavement). CONCLUSIONS: Recruitment to prospective longitudinal studies at the end of life is difficult, but possible. The lessons learned from this study are applicable to future investigators conducting prospective research.

Caregiver psychological distress as a barrier to influenza vaccination among community-dwelling elderly with dementia.

OBJECTIVE: This study examined whether informal caregiver psychologic distress decreases the likelihood of influenza vaccination for community-dwelling elderly with dementia. A secondary aim was to determine whether psychologic distress mediates the relationship between other predisposing, enabling, and medical need variables and vaccination. METHODS: Data were drawn from the 1998 National Longitudinal Caregiver Survey. The final sample consisted of 1406 community-dwelling male veterans with dementia and their coresiding female informal caregivers. Presence of caregiver psychologic distress was measured using the Boston Short Form of the Center for Epidemiologic Studies Depression Scale. Vaccination was identified by examining Veteran Administration Outpatient Data Files for visits indicating influenza vaccine administration during the 1998 influenza vaccine season (September 1 to December 31). Multivariate path analysis with observed variables was used to estimate direct and indirect probit path coefficients between independent variables, caregiver psychologic distress, and veteran vaccination. RESULTS: As hypothesized, caregiver distress was significantly associated with a decreased likelihood of care-recipient vaccination (unstandardized coefficient [b] = -0.023, P < 0.01). Adjusted for other variables, the predicted probability of vaccination was 37.7% for care-recipients with nondistressed caregivers compared with 29.4% for care-recipients with distressed caregivers. Furthermore, a number of factors significantly influenced vaccination via their influence on psychologic distress. CONCLUSION: We conclude that caregiver psychologic distress may interfere with access to influenza vaccination in persons with dementia. Access to vaccination may be improved directly by detecting and treating emotional health problems in caregivers and indirectly by addressing precursors to caregiver distress.

Lifestyle intervention development study to improve physical function in older adults with cancer: outcomes from Project LEAD.

PURPOSE: Declines in physical functioning (PF) among elderly cancer patients threaten quality of life and the ability to maintain independence. Adherence to healthy lifestyle behaviors may prevent functional decline. PATIENTS AND METHODS: Project Leading the Way in Exercise and Diet (LEAD), an intervention development study of the Pepper Older Americans Independence Center, aimed to determine whether breast and prostate cancer survivors (age 65+ years) assigned to a 6-month home-based diet and exercise intervention experienced improvements in PF when compared with an attention control arm receiving general health information. An accrual target was set at 420, and PF (Short Form-36 subscale), physical activity (Community Healthy Activities Models Program for Seniors), and diet quality (index from 3-day recalls) were assessed at baseline and at 6 and 12 months (6 months after intervention). RESULTS: This developmental project did not achieve its accrual target (N = 182); however, PF change scores were in the direction and of the magnitude projected. Baseline to 6-month change scores in the intervention versus the control arms were as follows: PF, +3.1 v -0.5 (P = .23); physical activity energy expenditure, +111 kcal/wk v -400 kcal/wk (P = .13); and diet quality index, +2.2 v -2.9 (P = .003), respectively. Differences between arms diminished during the postintervention period. CONCLUSION: These findings suggest that home-based diet and exercise interventions hold promise in improving lifestyle behaviors among older cancer survivors, changes that trend toward improved PF. Future studies should incorporate larger sample sizes and interventions that sustain long-term effects and also take into account secular trends; these efforts will require adequate planning and resources to overcome the numerous barriers to intervening in this difficult to reach yet vulnerable population.

Caregivers' reasons for nursing home placement: clues for improving discussions with families prior to the transition.

PURPOSE: This study identifies the relative importance of reasons for institutionalization endorsed by caregivers of patients with dementia; examines the relationship between caregivers' reasons for institutionalization and indicators of caregiver and patient physical and emotional functioning measured in the prior year; and compares, on these indicators, caregivers who institutionalized their care recipients with caregivers who did not. DESIGN AND METHODS: Participants were 2,200 caregivers from the National Longitudinal Caregiver Study, including 580 who institutionalized their care recipient during the 3-year interval. Caregivers' reason(s) for institutionalization were examined and correlated with indicators of caregiver and patient physical and emotional functioning. These indicators were used in a proportional hazards model to determine independent predictors. RESULTS: Caregivers' reasons for placement included (a) the need for more skilled care (65%); (b) the caregivers' health (49%); (c) the patients' dementia-related behaviors (46%); and (d) the need for more assistance (23%). Each of these reasons was significantly associated with indicators in the prior year's survey. This study uniquely demonstrates that caregiving task demand and a single-item measure of caregiver life satisfaction significantly predict placement. IMPLICATIONS: These findings emphasize that caregivers' reasons have valid underpinnings and that institutionalization of dementia patients results from caregiver and patient factors evident in the year prior to placement. In routine office visits, caregivers should be systematically screened; accounts of low life satisfaction, dementia problem behaviors, or high task demand should cue clinicians that discussions of nursing home placement would be timely and appropriate.

"Are you at peace?": one item to probe spiritual concerns at the end of life.

BACKGROUND: Physicians may question their role in probing patients' spiritual distress and the practicality of addressing such issues in the time-limited clinical encounter. Yet, patients' spirituality often influences treatment choices during a course of serious illness. A practical, evidence-based approach to discussing spiritual concerns in a scope suitable to a physician-patient relationship may improve the quality of the clinical encounter. METHODS: Analysis of the construct of being "at peace" using a sample of patients with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease. Descriptive statistics were used to compare response distributions among patient subgroups. Construct validity of the concept of being "at peace" was evaluated by examining Spearman rank correlations between the item and existing spirituality and quality-of-life subscales. RESULTS: Variation in patient responses was not explained by demographic categories or diagnosis, indicating broad applicability across patients. Construct validity showed that feeling at peace was strongly correlated with emotional and spiritual well-being. It was equally correlated with faith and purpose subscales, indicating applicability to traditional and nontraditional definitions of spirituality. CONCLUSIONS: Asking patients about the extent to which they are at peace offers a brief gateway to assessing spiritual concerns. Although these issues may be heightened at the end of life, research suggests they influence medical decision making throughout a lifetime of care.

The association between oral health and general health and quality of life in older male cancer patients.

OBJECTIVES: To describe the long-term effects of oral health problems on quality of life (QoL), functional status, pain, and general health in older male cancer patients. DESIGN: Secondary analysis of a prospective observational study. SETTING: Community dwelling cancer patients served by a Department of Veterans Affairs hospital. PARTICIPANTS: One hundred fifty male cancer patients responded to the question "Do you have tooth or mouth problems making it hard to eat?" The relationship between patients answering "yes" and the following parameters was assessed: demographics, comorbid conditions, habits, activities of daily living, pain, anxiety, depression, social support, spirituality, QoL, and overall health ratings. MEASUREMENTS: Chi-square contingency tables for dichotomous variables, Cochran-Mantel-Haenszel for ordered categorical variables, and t tests for associations with continuous variables. RESULTS: The median age of respondents was 67. Those reporting tooth or mouth problems had had their cancer diagnosed on average 2.9 years before, and 83.3% were found clinically to be cancer free. Patients with these problems had significantly lower global (P=.003) and subscale scores on QoL analysis and higher levels of anxiety (P<.001) and depression (P=.01) than those without tooth or mouth problems; they also had significantly more pain (P<.001) and lower physical functioning (P<.001) and were more impaired in activities of daily living (P<.001). Those with tooth or mouth problems were more likely to describe their overall health as fair or poor (P=.01). Having cancer located in the head and neck region related significantly to having mouth or tooth problems (P=.005), but these problems were not associated with race, education, income, insurance coverage, age, comorbid conditions, alcohol consumption, tobacco or medication usage, type of cancer treatment, tumor stage at diagnosis or follow-up, perceived social support, or spirituality. CONCLUSION: Older male cancer patients with mouth or tooth problems making it hard to eat are more likely to have a lower QoL, poorer emotional health, lower levels of physical functioning, and greater pain than patients without these problems.