Symptoms, affects, and self-rated health: evidence for a subjective trajectory of health.

OBJECTIVE: Self-rated health (SRH) is known to predict mortality and other health outcomes better than objective ratings, suggesting that patients have important knowledge that physicians do not. The study assessed whether SRH reflects changes in internal states, specifically symptoms and affects. METHOD: In an event-sampling study, 54 elders completed a SRH measure, positive and negative affect scale, a symptom checklist, and a pain scale every evening for 8 weeks. Using lagged (time series) hierarchical regression, the authors modeled associations of SRH with previous symptoms, moods, and changes in symptoms and mood. RESULTS: The SRH was highest when symptoms had decreased from the previous day and lowest when symptoms had increased, suggesting that SRH reflects a sense of change. Symptoms and affects contributed independently to SRH. Self-rated health was more sensitive to positive than negative affect and also sensitive to changes of positive but not negative affect. DISCUSSION: Patients may possess a subjective trajectory of health-an awareness of changes in symptoms and affect. This trajectory may constitute an important component of SRH and help to explain its ability to predict health outcomes.

Preferences for prolonging life: a prospect theory approach.

Kahneman and Tversky's (1979) Prospect theory was tested as a model of preferences for prolonging life under various hypothetical health statuses. A sample of 384 elderly people living in congregate housing (263 healthy, 131 frail) indicated how long (if at all) they would want to live under each of nine hypothetical health conditions (e.g., limited to bed or chair in a nursing home). Prospect theory, a decision model which takes into account the individual's point of reference, would predict that frail people would view prospective poorer health conditions as more tolerable and express preferences to live longer in worse health than would currently healthy people. In separate analyses of covariance, we evaluated preferences for continued life under four conditions of functional ability, four conditions of cognitive impairment, and three pain conditions--each as a function of participant's current health status (frail vs. healthy). The predicted interaction between frailty and declining prospective health status was obtained. Frail participants expressed preferences for longer life under more compromised health conditions than did healthy participants. The results imply that such preferences are malleable, changing as health deteriorates. They also help explain disparities between proxy decision-makers' and patients' own preferences as expressed in advance directives.

Environmental correlates to behavioral health outcomes in Alzheimer's special care units.

PURPOSE: We systematically measured the associations between environmental design features of nursing home special care units and the incidence of aggression, agitation, social withdrawal, depression, and psychotic problems among persons living there who have Alzheimer's disease or a related disorder. DESIGN AND METHODS: We developed and tested a model of critical health-related environmental design features in settings for people with Alzheimer's disease. We used hierarchical linear modeling statistical techniques to assess associations between seven environmental design features and behavioral health measures for 427 residents in 15 special care units. Behavioral health measures included the Cohen-Mansfield physical agitation, verbal agitation, and aggressive behavior scales, the Multidimensional Observation Scale for Elderly Subjects depression and social withdrawal scales, and BEHAVE-AD (psychotic symptom list) misidentification and paranoid delusions scales. Statistical controls were included for the influence of, among others, cognitive status, need for assistance with activities of daily living, prescription drug use, amount of Alzheimer's staff training, and staff-to-resident ratio. Although hierarchical linear modeling minimizes the risk of Type II-false positive-error, this exploratory study also pays special attention to avoiding Type I error-the failure to recognize possible relationships between behavioral health characteristics and independent variables. RESULTS: We found associations between each behavioral health measure and particular environmental design features, as well as between behavioral health measures and both resident and nonenvironmental facility variables. IMPLICATIONS: This research demonstrates the potential that environment has for contributing to the improvement of Alzheimer's symptoms. A balanced combination of pharmacologic, behavioral, and environmental approaches is likely to be most effective in improving the health, behavior, and quality of life of people with Alzheimer's disease.

The Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH): an observational instrument for assessing the physical environment of institutional settings for persons with dementia.

OBJECTIVE: To develop an observational instrument that describes the ability of physical environments of institutional settings to address therapeutic goals for persons with dementia. METHODS: A National Institute on Aging workgroup identified and subsequently revised items that evaluated exit control, maintenance, cleanliness, safety, orientation/cueing, privacy, unit autonomy, outdoor access, lighting, noise, visual/tactile stimulation, space/seating, and familiarity/homelikeness. The final instrument contains 84 discrete items and one global rating. A summary scale, the Special Care Unit Environmental Quality Scale (SCUEQS), consists of 18 items. Lighting items were validated using portable light meters. Concurrent criterion validation compared SCUEQS scores with the Professional Environmental Assessment Protocol (PEAP). RESULTS: Interrater kappa statistics for 74% of items were above.60. For another 10% of items, kappas could not be calculated due to empty cells, but interrater agreement was above 80%. The SCUEQS demonstrated an interrater reliability of.93, a test--retest reliability of.88, and an internal consistency of.81--.83. Light meter ratings correlated significantly with the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) lighting items (r =.29--.38, p =.01--.04), and the SCUEQS correlated significantly with global PEAP ratings (r =.52, p <.01). DISCUSSION: The TESS-NH efficiently assesses discrete elements of the physical environment and has strong reliability and validity. The SCUEQS provides a quantitative measure of environmental quality in institutional settings.

Motivation in later life: personal projects and well-being.

"Personal projects," as defined by B. R. Little (1983), were elicited from 600 community residents aged 70+, representing a broad range of health and illness. Factor analysis revealed 6 types of personal projects: activities of daily living, active recreation, other-oriented activities, intellectual activities, home planning, and spiritual moral activities. Background factors and health were shown to affect the number and type of projects reported. Most indices of personal projects were associated with positive affect and valuation of life. Only 1 was associated with depression. This confirms the differential association of personal projects to positive but not negative affect. Personal projects are seen as part of an open motivational system in which social position, cognitive ability, health, and positive mental health are mutually interacting members.

Anxiety and Its Association With Depression Among Institutionalized Elderly.

The authors assessed anxiety and depression among nursing home and congregate housing residents at yearly intervals. At baseline, modified DSM-III-R criteria yielded a 3.5% prevalence rate for anxiety or panic disorders. Another 13.2% reported milder symptoms not meeting diagnostic criteria. Anxiety was strongly associated with depression and with physical health, functional disability, and cognitive status. Follow-up data yielded an overall incidence rate of 2.3% for possible anxiety disorders; the majority of these cases were among those with mild anxiety at baseline. Change in anxiety was strongly associated with depression and, less consistently, with functional disability and cognitive status. Results are interpreted as indicating the indistinguishability of anxiety from depression in this frail elderly population.