Function and medical comorbidity in south Texas nursing home residents: variations by ethnic group.

OBJECTIVE: To evaluate differences in functional status and burdens of medical conditions in Mexican American and non-Hispanic white nursing home residents. DESIGN AND SETTING: Cross-sectional survey of 17 nursing homes in south Texas. PARTICIPANTS: A total of 617 older nursing home residents, of whom 366 were Mexican American and 251 were non-Hispanic white. MEASURES: Activities of Daily Living (ADL) status abstracted from standard nurses notes and Burden of Disease abstracted from medical records. RESULTS: Mexican American residents had greater numbers of ADL dependencies and poorer overall ADL scores than non-Hispanic white residents. This poor functioning was not explained by age, gender, or marital or educational status. The average number of medical conditions was greater, and specific conditions, such as cerebrovascular disease, recent acute infections, diabetes, hypertension, and anemia, were more common in Mexican American residents compared with non-Hispanic white residents. In models relating function with medical conditions and ethnic group, ADL scores and dependencies were significantly related to bowel and bladder incontinence, cerebrovascular disease, dementia, recent infections, and skin decubiti, but not to ethnic group. CONCLUSION: Mexican American nursing home residents are more functionally dependent than non-Hispanic white residents. The difference in function is explained by a greater burden of medical conditions in the Mexican American residents.

Classifying change with the Sickness Impact Profile for Nursing Homes (SIP-NH).

The aim of this cohort study was to evaluate the concordance of the Sickness Impact Profile for Nursing Homes (SIP-NH) and Sickness Impact Profile (SIP) in classifying change. Subjects consisted of 194 consecutive long-stay nursing home residents at one academic department of the V.A. and in 8 community proprietary nursing homes in San Antonio, Texas. They were to have more than 3 months residency; to be > or = 61 years; and to be dependent in at least 2 ADLs with an MMSE score of > or = 15. Subjects were administered a 128-item SIP and a reduced 66-item SIP-NH at baseline and 4, 8, and 12-month follow-up. At each follow-up, subjects were classified into 3 mutually exclusive change categories using a change score of > or = 5 points. Concordance of the classification of subjects by the SIP-NH and SIP was evaluated. The misclassification rate as well as its direction was also assessed. Both instruments classified a little over one-quarter of the subjects as better, over a third as being unchanged, and another third as being worse at the four-month follow-up. More subjects were classified as worse by both instruments at 8 and 12 months. All kappas ranged from 0.52 to 0.78, indicating good to excellent agreement. Overall, the SIP-NH characterized persons as changed more often than the SIP with no systematic directional bias. In conclusion, the SIP-NH was concordant with the SIP in classifying change in subjects. However, we cannot say which of the two is better for detecting change. Future research must focus on defining a change score which has clinical meaning, and evaluate responsiveness to change.

Case-finding instruments for depression in primary care settings.

OBJECTIVE: To evaluate the usefulness of case-finding instruments for identifying patients with major depression in primary care settings. DATA SOURCES: A MEDLINE search of the English-language medical literature; bibliographies of selected papers; and experts. STUDY SELECTION: Studies that were done in primary care settings with unselected patients and that compared case-finding instruments with accepted diagnostic criterion standards for major depression were selected. DATA SYNTHESIS: 9 case-finding instruments were assessed in 18 studies. More than 15,000 patients received screening with a case-finding instrument; approximately 5300 of these received criterion standard assessment. Case-finding instruments ranged in length from 2 to 28 questions. Average administration times ranged from less than 2 minutes to 6 minutes. Sensitivities and specificities for detecting major depression ranged from 67% to 99% and from 40% to 95%, respectively. No significant differences between instruments were found. Overall sensitivity was 84% (95% CI, 79% to 89%); overall specificity was 72% (CI, 67% to 77%). If a case-finding instrument were administered to 100 primary care patients with a 5% prevalence of major depression, the clinician could expect that 31 patients would screen positive, that 4 of the 31 would have major depression, and that 1 patient with major depression would not be identified. CONCLUSIONS: Several instruments with reasonable operating characteristics are available to help primary care clinicians identify patients with major depression. Because the operating characteristics of these instruments are similar, selection of a particular instrument should depend on issues such as feasibility, administration and scoring times, and the instruments' ability to serve additional purposes, such as monitoring severity or response to therapy.

Relationship between physical performance and self-perceived physical function.

OBJECTIVE: The objective of this study was to compare two methods of measuring physical function in subjects with a broad range of abilities and to evaluate the effects of cognitive, social, educational, and age factors on the relationship between the two methods. DESIGN: Multiple regression analysis was used to compare self-perceived (dependent variables) with performance measures (independent variables). Covariates included age, gender, Mini-Mental State Exam score, education, living status, and depression score. SETTING: Five community-dwelling and two nursing home sites. PARTICIPANTS: 417 community-dwelling subjects and 200 nursing home residents aged 62-98 years. MEASUREMENTS: Self-perceived physical function was assessed with the physical dimension summary score of the Sickness Impact Profile, which comprises three subscales: ambulation, mobility, and body care and movement. Physical performance was evaluated by self-selected gait speed, chair-stand time, maximal grip strength, and a balance score. RESULTS: Nursing home residents and community-dwellers were significantly different (P < .0001) in all variables except age and gender. Self-perceived and performance-based measures were moderately correlated, with a range from r = -.194 to r = -.625 (P < .05). Gait speed was the strongest independent predictor of self-perceived physical function in both groups. Symptoms of depression were also an independent predictor of self-perceived function in nursing home residents; subjects who had such symptoms report more self-perceived dysfunction than would be predicted based on performance tests. CONCLUSIONS: Self-selected gait speed is a global indicator of self-perceived physical function over a broad range of abilities. External determinants (depressive symptoms, cognitive function, marital status, etc.) affect self-perceived function in both groups, but gait speed is the greatest single predictor of self-perceived function. In nursing home residents depressive symptomatology is related to self-perceived.

Health care reform from the view of a geriatrician.

In an ideal world, all citizens would receive high-quality health care, all services which are appropriate and necessary, in the setting that can best meet the patients' needs and preferences. The frail, dependent, chronically ill person has been considered an outlier by third party payment systems, including Medicare, the health care system designed for the elderly. Physician payment systems have penalized those who care for the frail, resulting in an inadequate medical workforce to care for the elderly. Medicare and state-financed long-term care systems, by attempting to limit expenditures of public funds on long-term care, have become biased toward institutional care. Although the frail and disabled represent a minority (approximately 12%) of those aged 65 or older, their numbers are large and growing. The health care system of today and the system proposed for tomorrow by the Clinton Administration is not prepared to care for large numbers of people with chronic, disabling illness. Only when the health care system or new health alliances share responsibility for all care provided to every citizen will the looming problems of large numbers of persons with chronic illness and functional dependency be faced. Care must be driven by patient needs and preferences, not by reimbursement regulations and financial incentives. The Clinton plan institutionalizes the segregation of chronic long-term care from hospital and outpatient care. Responsibility for these services is relegated to states. This political compromise, as disappointing as it may be to geriatricians, may offer opportunity for experimentation. Fifty new state-regulated systems may serve as health services experiments.(ABSTRACT TRUNCATED AT 250 WORDS)

Performance of case-finding tools for depression in the nursing home: influence of clinical and functional characteristics and selection of optimal threshold scores.

OBJECTIVE: To compare case-finding tools for depression in the nursing home setting and to evaluate effects of subject function, cognition, and disease number on test performance. DESIGN: Cross-sectional survey. SETTING: One academic and four community homes. SUBJECTS: One hundred thirty-four randomly selected, mildly cognitively impaired, functionally dependent residents. METHODS AND MEASURES: The Geriatric Depression Scale (GDS), Short Geriatric Depression Scale (SGDS), Center for Epidemiologic Studies Depression Scale (CES-D), and Brief Carrol Depression Rating Scale (BCDRS) were administered. The Structured Clinical Interview for DSM-III-R diagnoses was administered independently,. Operating characteristics and the effects of subject characteristics on test performance were evaluated using McNemar's test and logistic regression. Selection of "optimal" threshold scores was guided by Kraemer's quality indices and clinical judgment. RESULTS: Thirty-five subjects (26%) had major depression. No differences were found among the instruments in sensitivity (range 0.74-0.89), specificity (range 0.62-0.77), or area under the receiver operating curve (ROC) (range 0.85-0.91). Resident characteristics did not affect test performance. Quality indices showed the GDS and BCDRS met criteria for moderate to substantial agreement with the criterion standard, whereas the SGDS and the CES-D achieved only fair agreement. No change in threshold scores was warranted. CONCLUSIONS: The GDS and BCDRS performed well in the nursing home. As the GDS can serve as a both a case-finding and severity instrument, it is preferred. Use of brief, interviewer-administered tools may improve detection of depression in the nursing home.

The relationship between disease and function and perceived health in very frail elders.

OBJECTIVE: To study associations between disease and observed function and self-perceived health in very frail elders. DESIGN AND SETTING: Cross-sectional survey of nine nursing homes in San Antonio, TX. PARTICIPANTS: 194 elderly long-stay nursing home residents dependent in at least two ADLs and without severe cognitive impairment. MEASURES: Burden of disease (BOD) was chart abstracted using a standardized protocol that assessed types and severities of 59 categorizations of chronic and acute medical conditions. Observed function and self-perceived health status were assessed independently by the Katz Activities of Daily Living scale (ADL) and the Sickness Impact Profile (SIP), respectively. RESULTS: Summary BOD scores had a low, but statistically significant, univariate correlation with ADL scores (r = 0.21, P = 0.003) and no significant correlation with SIP scores (R = -0.008). Multiple linear regression analyses, including the 24 most frequent disease categories, showed that disease explained significant amounts of ADL (r2 = 0.25, P = 0.001) and borderline significant amounts of SIP (r2 = 0.16, P = 0.11). Models including both disease and sociodemographic, cognitive, and affective variables showed disease added significant incremental explantation beyond the other factors to ADL (incremental r2 = 0.14, P = 0.04), but not to SIP (incremental r2 = 0.08, P > 0.10). CONCLUSIONS: Disease, observed function, and self-perceived health status are separate, but interrelated entities, with disease having a stronger relationship to observed function than self-perceived health. Comprehensive assessment of frail elders may need to include all three areas, and studies that focus on one area should take into account the other two as potential important covariates.

Functional status of Mexican American nursing home residents.

OBJECTIVE: To compare sociodemographic characteristics, physical function, and cognition of Mexican American and non-Hispanic white nursing home residents. DESIGN AND SETTING: Cross-sectional survey of residents in eight proprietary nursing homes and one Veterans Affairs nursing home in San Antonio, Texas. SUBJECTS: Residents with lengths of stay greater than or equal to 90 days. MEASUREMENTS: Sociodemographic characteristics, residence prior to admission, and dependency in activities of daily living (ADL) were abstracted from the medical record. The Folstein Mini-Mental State Examination (MMSE) was administered in the resident's self-selected language to a subset of residents. MAIN RESULTS: There were 1160 participants, 261 Mexican American (23%) and 899 non-Hispanic white residents (77%). Mexican Americans were younger (77.1 vs 80.7 years), more often men (44% vs 30%), less educated (6.2 vs 10.8 years), and more often dependent on Medicaid funding (66% vs 40%) than non-Hispanic whites. Mexican Americans were less independent in feeding (34% vs 49%), transfers (18% vs 30%), toileting (19% vs 29%), and dressing (12% vs 19%). Mean MMSE scores were different in Mexican Americans and non-Hispanic whites (8.93 vs 11.85), and this difference remained significant after adjustment for age and education (P = 0.04). ADL function was strongly associated with MMSE (P = 0.0001) and less strongly associated with ethnicity (P = 0.056) in multiple regression analysis. CONCLUSIONS: This study provides the strongest evidence to date that Mexican American nursing home residents are more cognitively and functionally impaired than non-Hispanic white residents. Further studies should explore whether medical conditions, selection and referral patterns or cultural factors explain functional differences between Mexican American and non-Hispanic white nursing home residents.

A randomized trial of physical rehabilitation for very frail nursing home residents.

BACKGROUND: Past studies suggest multidisciplinary interventions that include physical therapy (PT) can improve function of nursing home residents. This trial specifically evaluates effects of PT for frail long-stay nursing home residents. DESIGN: Randomized, controlled trial. SETTING: One academic nursing home and eight community nursing homes. PATIENTS: A total of 194 elderly nursing home residents dependent in at least two activities of daily living residing in the nursing home for at least 3 months. INTERVENTIONS: Patients were randomized to individually tailored one-on-one PT sessions or friendly visits (FVs) three times a week for 4 months. Physical therapy included range-of-motion, strength, balance, transfer, and mobility exercises. MAIN OUTCOME MEASURES: Performance-based physical function assessed by the Physical Disability Index; self-perceived health status assessed with the Sickness Impact Profile; observer-reported activities of daily living; and falls. RESULTS: Eighty-nine percent and 92% of PT and FV sessions, respectively, were attended; 5% and 9% of subjects dropped out in the PT group and FV group, respectively. Compared with the FV group, the PT group experienced no significant improvements in overall Physical Disability Index, Sickness Impact Profile, or activities of daily living scores. A 15.5% improvement in the mobility subscale of the Physical Disability Index was seen (95% confidence interval [CI], 6.4% to 24.7%); no benefits in range-of-motion, strength, or balance subscales were found. Compared with the FV group, the PT group used assistive devices for bed mobility tasks less often (P = .06) and were less likely to use assistive devices and wheelchairs for locomotion (P < .005). There were 79 falls in the PT group vs 60 falls in the FV group (P = .11). Charge for the 4-month PT program was $1220 per subject (95% CI, $412 to $1832). CONCLUSION: This standardized physical therapy program provided modest mobility benefits for very frail long-stay nursing home residents with physical disability due to multiple comorbid conditions.

The Sickness Impact Profile for nursing homes (SIP-NH)

BACKGROUND: Valid, feasible measures of functional status are needed to evaluate the expanding nursing home population. This study attempts to increase relevance and reduce respondent burden of the Sickness Impact Profile (SIP) for nursing home residents while maintaining internal consistency and validity. METHODS: 231 residents from one academic and four community nursing homes, aged > or = 60 with a Mini-Mental State Exam score > or = 11, were study participants. Nominal group process was used to identify items and/or categories for removal. Candidate items were those that: represented restrictions of the nursing home environment, had weak item-total score correlations, and/or made minimal contribution to category internal consistency. Reduction was constrained by: minimum correlation of r = .90 between SIP and Sickness Impact Profile for Nursing Homes (SIP-NH) scores, coefficients alpha that fell within 95% confidence regions about predicted alpha. Convergent and discriminant validity were evaluated with the Katz Activities of Daily Living, Physical Disability Index, Geriatric Depression Scale, and Folstein Mini-Mental State Exam. RESULTS: The SIP-NH contains 66 items, a 51.5% reduction. Correlations between the SIP-NH and SIP were: total score r = .98, Physical dimension r = .97, and Psychosocial dimension r = .97. Alpha coefficients all fell within the 95% confidence regions. The SIP and the SIP-NH did not differ in correlations with validating instruments. CONCLUSIONS: The SIP-NH reduces respondent burden and has acceptable internal consistency and external validity. Potentially useful for discriminatory and predictive purposes, responsiveness to change will require longitudinal evaluation.

Adverse events related to drugs and drug withdrawal in nursing home residents.

OBJECTIVE: To (1) develop and standardize explicit criteria to link clinical adverse events to drug withdrawal, (2) determine the incidence and severity of Adverse Drug Events (ADEs) and Adverse Drug Withdrawal Events (ADWEs) in a nursing home population, and (3) establish the contribution of demographic, clinical, and functional characteristics to ADEs and ADWEs. DESIGN: Retrospective record review of an admission cohort. SETTING AND SUBJECTS: Consecutive admissions of residents of an academic Veterans Affairs nursing home with available records and lengths of stay > 30 days (n = 175). Subjects were 96% men, aged 70 +/- 12 years, and took 7.0 +/- 3.4 medications. METHODS: We applied standardized algorithms to determine incidence, probability, and severity of ADEs and ADWEs. Multiple regression techniques were used to identify factors associated with frequency and risk of events. RESULTS: Ninety five residents experienced 201 ADEs. Twelve required hospitalization or prolonged hospitalization, and one resident died. Sixty two persons had 94 ADWEs. None were associated with death and one with hospitalization. The four most commonly prescribed drug classes accounted for 72% of ADEs and 80% of ADWEs. Results of multivariate analyses showed common risk factors for both ADEs and ADWEs: number of diagnoses, number of medications, and hospitalization during the nursing home stay. CONCLUSIONS: ADEs and ADWEs were common in nursing home residents in this Veteran's Affairs setting. Explicit criteria developed and applied in this study should be applied prospectively in other settings, both to further define risk of drug discontinuation and to assist in development of specific drug discontinuation guidelines.

Medical treatment preferences of nursing home residents: relationship to function and concordance with surrogate decision-makers.

OBJECTIVE: To describe treatment preferences of nursing home residents, concordance with decisions by self-selected proxies and to establish the relationship of sociodemographic and functional measures to decisions. SETTING AND SUBJECTS: 52 patient-proxy pairs at a Veterans Affairs nursing home. METHODS: Treatment preferences were elicited from residents and proxies regarding cardiopulmonary resuscitation, mechanical ventilation, and intensive care unit care. Hospitalization, intravenous antibiotics, intravenous fluid administration, and tube feeding were presented in three separate health scenarios. Concordance was determined for the entire interview and separately for each scenario. Treatment-seeking intensity and decision-making consistency were scored and used to explore associations with sociodemographic variables and function. RESULTS: Subjects were predominantly male (97%) and non-Hispanic white (74%); average age was 70 +/- 12 years, with 4 +/- 2.9 diagnoses. Residents accepted 70% of all treatments. The proportion of subjects accepting interventions declined parallel to health status in each scenario. Only 7/52 (13%) subjects made inconsistent decisions. Resident treatment acceptance was inversely associated with GDS scores but not associated with any other sociodemographic or functional measure. Concordance with proxies was no greater than chance. Proxies' decisions were not systematically biased against resident preferences or influenced by patient characteristics. CONCLUSIONS: Veterans desired most treatments, but adjusted preferences according to health status and were not inconsistent. Depressive symptoms should be addressed prior to advance directive selection. The patient remains the best source of information, but proxies' decisions exhibit no bias and are not affected by patient status.

A negative trial of inpatient geriatric consultation. Lessons learned and recommendations for future research.

PURPOSE: To determine the effectiveness of inpatient interdisciplinary geriatric consultation provided during hospitalization to frail, elderly subjects. SUBJECTS AND SITE: Admission cohort of 197 men admitted from 1985 through 1989, aged 65 years or more, meeting proxy criteria for frailty, living within follow-up area, without terminal illness, and without prolonged nursing home residence. METHODS AND MEASURES: Randomized controlled trial of inpatient geriatric consultation at a tertiary care Veterans Affairs hospital. Differences were determined between groups in the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living, Mini-Mental State Examination, Morale Scale, and nursing home and health care utilization. RESULTS: No differences were seen between groups in any measure after the intervention or during 1 year of follow-up. Intervention implementation may have been incomplete due to compliance and resource availability. CONCLUSIONS: This trial is not definitive in determining whether geriatric consultation is effective or ineffective. Lessons learned from this research indicate that future studies should target frail subjects, include intervention-specific measures, and be conducted with direct control of comprehensive resources.

Falls: an examination of three reporting methods in nursing homes.

OBJECTIVE: To examine the concordance of various fall reporting methods and to use the results to recommend a preferred method of ascertaining fall frequency for residents of nursing homes, both for research and in the collection of federally mandated nursing home data. DESIGN: A cohort study followed for 858 patient months, with a mean individual follow-up of 6.6 months. MEASUREMENTS: Falls were independently ascertained monthly by three methods: review of administrative incident reports, nursing home chart abstraction, and structured interview of subjects. Concordance of events was assessed using measures of simple agreement and Kendall's Tau-b. Simple correlation and multiple regression were used to evaluate the relation of age, sex, gender, depression, mental status, and functional status with degree of concordance between self-reported falls and chart-recorded falls. SETTING: One academic and six community nursing homes in San Antonio, Texas. PARTICIPANTS: 131 long-stay nursing home residents, greater than 60 years of age, dependent in at least two activities of daily living, and mildly cognitively impaired. RESULTS: Falls were ascertained in 74 of the 131 individuals; 53 subjects fell 124 times by incident report, 58 had 140 falls according to chart review, and 66 subjects self-reported 232 falls. Greatest agreement between reporting methods was shown for incident report and chart review, with a Kendall's Tau-b of 0.88; self-report and chart-review agreement was 0.56; and self-report and incident agreement was 0.53. Estimated total fall events were more often (P = 0.001) identified by chart review (92%) than incident report (82%). Although concordance was higher for non-fallers, no significant relationships were observed between concordance and age, sex, race, depression, mental status, and functional status. Also, there was no systematic relationship between length of follow-up and degree of concordance. CONCLUSIONS: Fall frequency varies by ascertainment method, with chart review reflecting a greater number of fall events than the traditionally counted incident reports.

Problems in interpreting cost effectiveness in clinical trials. Experimental versus implementation costs.

OBJECTIVE: To demonstrate the difficulty of estimating cost effectiveness of alternative implementation strategies using clinical trial data. DESIGN: Two examples drawn from a hearing-aid intervention trial and a physical-therapy trial for frail elderly are used to demonstrate how alternative implementation strategies may affect cost effectiveness. Sensitivity analysis is used to document a range of possible economic outcomes for each example and show how assumptions based on trials may bias implementation decisions. MAIN OUTCOME MEASURES: Costs and cost-effectiveness ratios are estimated for alternative implementation strategies and compared with trial results. MAIN RESULTS: Staffing and equipment substitutions, reconfigurations, and economies of scale can reduce the cost of trial interventions substantially. Such resource alterations as well as protocol and target group modifications may also have an impact on effectiveness. In both examples effectiveness can be reduced by as much as 50% and under certain conditions alternative implementation strategies will still be cost effective. CONCLUSIONS: Cost effectiveness of implementations can differ substantially from a trial when different resources or target populations are incorporated. Institutions must conduct preimplementation studies which consider alternative resource configurations before adopting an intervention based on trial results.

Development of the common data base for the FICSIT trials.

The eight FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) sites test different intervention strategies in selected target groups of older adults. To compare the relative potential of these interventions to reduce frailty and fall-related injuries, all sites share certain descriptive (risk-adjustment) measures and outcome measures. This article describes the shared measures, which are referred to as the FICSIT Common Data Base (CDB). The description is divided into four sections according to the four FICSIT committees responsible for the CDB: (1) psychosocial health and demographic measures; (2) physical health measures; (3) fall-related measures; and (4) cost and cost-effectiveness measures. Because the structure of the FICSIT trial is unusual, the CDB should expedite secondary analyses of various research questions dealing with frailty and falls.

Effects of physical therapy on functional status of nursing home residents.

Nursing home residents typically have decreased functional and physical status and high health care utilization and costs. This randomized trial evaluates whether physical therapy is beneficial for frail debilitated long-stay residents of nursing homes. Subjects are recruited from a cohort of academic and community nursing home residents who have resided in the nursing home for greater than 3 months and are over age 60 and dependent in at least two activities of daily living. Subjects randomized to the intervention group receive one-on-one physical therapy sessions three times weekly for 4 months, while control group subjects receive structured social visits three times weekly to control for potential Hawthorne effects. Physical therapy sessions generally last 30 minutes and consist of functional activity and general conditioning exercises; these exercises are individually tailored to the subject's level of physical and functional disability. Prime outcome variables are physical function assessed by an observer-administered, performance-based instrument and self-perceived health status assessed by the Sickness Impact Profile. Health care utilization and associated costs are calculated for the following areas: the nursing home, hospitalizations, outpatient visits and procedures, medications, and the intervention. A cost-effectiveness ratio dividing incremental health care utilization and physical therapy intervention costs by the observed improvement in physical function is calculated. It is expected that results of this study can be used to help determine whether long-stay nursing home residents should be eligible for physical therapy.

Development and validation of a physical performance instrument for the functionally impaired elderly: the Physical Disability Index (PDI).

Article describes development of the Physical Disability Index (PDI), an observer-administered, performance-based instrument measuring physical disability in frail-elderly persons without severe cognitive impairment. Sixty-five items in four subscales encompassing Range of Motion (ROM), Strength (STR), Balance (BAL), and Mobility (MOB) were measured. Subjects were randomly selected frail nursing home residents (N = 103) with a Folstein Mini-Mental State Exam (MMSE) score of > or = 11. Using correlation matrices, cluster analysis, and regression techniques, the scale was reduced to 54 items. All individual item values were standardized and aggregated into subscale and summary PDI scores, each with a range of 0-100. Test-retest and interrater reliability were evaluated. Discriminant and convergent validity were established using MMSE, Physical Self-Maintenance Scale (PSMS), and Sickness Impact Profile-Physical Dimension (SIP-PD). PDI is a performance-based instrument that appears to discriminate among frail individuals with differing levels of physical function. Further testing is warranted in other populations of frail-elderly persons to ascertain its applicability and generalizability.