Disease severity and health-related quality of life across different chronic conditions.

OBJECTIVES: Measurements of health-related quality of life (HRQL) are an essential component in overall assessment of health status, particularly in older patients. Nevertheless, how measures of HRQL relate to measures of disease severity is largely unexplored. This study was carried out to explore the relationship between a measure of HRQL and measures of severity of ischemic stroke, Parkinson's diseases (PD), or chronic coronary heart disease (CHD). DESIGN AND SETTING: Cross-sectional analysis of three groups (54 subjects each) of patients aged > or = 65 years consecutively referred to outpatient clinics for stroke, PD, or CHD, excluding those with cognitive impairment and severe comorbidity. MEASUREMENTS: Severity of stroke, PD, and CHD assessed by Fugl-Meyer Scale (FMS), Webster Rating Scale (WBRS), and total work capacity (TWC, from graded exercise test), respectively. HRQL was determined by the Sickness Impact Profile (SIP). RESULTS: In PD, WBRS correlated linearly with SIP global score, whereas a significant linear relationship between measures of disease severity and SIP score was limited to the least severely diseased stroke (FMS score>160) and the most severely diseased CHD (TWC <700 Kg x m) patients. CONCLUSIONS: In some disease, the relationship between clinical measures of disease severity and HRQL is nonlinear. Thus, depending on initial severity, similar changes in disease severity may have different impacts on HRQL. These findings may help in identifying patients most likely to improve their SIP score substantially, after even small changes in disease severity. However, studies examining the metric properties of SIP across the whole score range are needed to verify whether such improvement really translates into a better HRQL.

Formal education as an effect modifier of the relationship between Mini-Mental State Examination score and IADLs disability in the older population.

The objective of this retrospective, case-series study was to examine the relationship between disability in Instrumental Activities of Daily Living (IADLs) and cognitive impairment measured by the Mini-Mental State Examination (MMSE), and how this relationship was influenced by different levels of formal education. The setting of the study was the Cognitive Disorders Center of the Local Sanitary Unit (USL) No. 4 in Prato (Italy). Independence in IADL was strongly related to MMSE scores. A score of less than 24 at the MMSE was predictive of disability in at least one IADL with 0.82 sensitivity and 0.73 specificity. However, when only people with a very low level of formal education were considered, the best threshold predicting IADL disability was 17 (sensitivity 0.76, specificity 0.75). Thus, scholastic achievement is an effect modifier of the relationship between cognitive status, as measured by the MMSE, and IADL disability. Subjects with low education level and poor performance at the MMSE are often independent in activities making demand on cognitive function, such as IADLs. These results suggest that a lower MMSE cut-off score should be considered when screening for cognitive impairment in these persons.

Functional assessment: a holistic approach to rehabilitation of the geriatric client.

Functional assessment of the elderly client provides a structured approach to the complex and multidimensional issues in rehabilitation. Rehabilitation nurses may be familiar with some of the long-standing functional assessment tools, such as Barthel's index. It is important to have a working knowledge of a variety of tools, as well as an ongoing awareness of newer ones as they are developed (e.g., the Functional Independence Measure). Functional assessment is part of comprehensive geriatric evaluation. After initial assessment by rehabilitation team members, the team considers the patient's strengths and supports and develops a problem list (NIH, 1987). The individualized plan of care is developed with the elderly client to achieve maximum rehabilitation potential. Functional assessment tools assist in measuring rehabilitation progress and in clinical decision making. They also can be used in clinical research in geriatric rehabilitation. The number of elderly persons in this country is growing rapidly. Rehabilitation nurses will need to expand their clinical skills to integrate holistic geriatric assessment.