Teleassessment of Gait and Gait Aids: Validity and Interrater Reliability.

BACKGROUND: Gait and mobility aid assessments are important components of rehabilitation. Given the increasing use of telehealth to meet rehabilitation needs, it is important to examine the feasibility of such assessments within the constraints of telerehabilitation. OBJECTIVE: The objective of this study was to examine the reliability and validity of the Tinetti Performance-Oriented Mobility Assessment gait scale (POMA-G) and cane height assessment under various video and transmission settings to demonstrate the feasibility of teleassessment. DESIGN: This repeated-measures study compared the test performances of in-person, slow motion (SM) review, and normal-speed (NS) video ratings at various fixed frame rates (8, 15, and 30 frames per second) and bandwidth (128, 384, and 768 kB/s) configurations. METHODS: Overall bias, validity, and interrater reliability were assessed for in-person, SM video, and NS video ratings, with SM video rating as the gold standard, as well as for different frame rate and bandwidth configurations within NS videos. RESULTS: There was moderate to good interrater reliability for the POMA-G (intraclass correlation coefficient [ICC] = 0.66-0.77 across all configurations) and moderate validity for in-person (ß = 0.62; 95% confidence interval [CI] = 0.37-0.87) and NS video (ß = 0.74; 95% CI = 0.67-0.80) ratings compared with the SM video rating. For cane height, interrater reliability was good (ICC = 0.66-0.77), although it was significantly lower at the lowest frame rate (8 frames per second) (ICC = 0.66; 95% CI = 0.54-0.76) and bandwidth (128 kB/s) (ICC = 0.69; 95% CI = 0.57-0.78) configurations. Validity for cane height was good for both in-person (ß = 0.80; 95% CI = 0.62-0.98) and NS video (ß = 0.86; 95% CI = 0.81-0.90) ratings compared with SM video rating. LIMITATIONS: Some lower frame rate and bandwidth configurations may limit the reliability of remote cane height assessments. CONCLUSIONS: Teleassessment for POMA-G and cane height using typically available internet and video quality is feasible, valid, and reliable.

Tele-Assessment of the Berg Balance Scale: Effects of Transmission Characteristics.

OBJECTIVE: To compare Berg Balance Scale (BBS) rating using videos with differing transmission characteristics with direct in-person rating. DESIGN: Repeated-measures study for the assessment of the BBS in 8 configurations: in person, high-definition video with slow motion review, standard-definition videos with varying bandwidths and frame rates (768 kilobytes per second [kbps] videos at 8, 15, and 30 frames per second [fps], 30 fps videos at 128, 384, and 768 kbps). SETTING: Medical center. PARTICIPANTS: Patients with limitations (N=45) in ≥1 of 3 specific aspects of motor function: fine motor coordination, gross motor coordination, and gait and balance. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Ability to rate the BBS in person and using videos with differing bandwidths and frame rates in frontal and lateral views. RESULTS: Compared with in-person rating (7%), 18% (P=.29) of high-definition videos and 37% (P=.03) of standard-definition videos could not be rated. Interrater reliability for the high-definition videos was .96 (95% confidence interval, .94-.97). Rating failure proportions increased from 20% in videos with the highest bandwidth to 60% (P<.001) in videos with the lowest bandwidth, with no significant differences in proportions across frame rate categories. Both frontal and lateral views were critical for successful rating using videos, with 60% to 70% (P<.001) of videos unable to be rated on a single view. CONCLUSIONS: Although there is some loss of information when using videos to rate the BBS compared to in-person ratings, it is feasible to reliably rate the BBS remotely in standard clinical spaces. However, optimal video rating requires frontal and lateral views for each assessment, high-definition video with high bandwidth, and the ability to carry out slow motion review.

Trends in decayed teeth among middle-aged and older adults in the United States: socioeconomic disparities persist over time.

OBJECTIVES: While trends in tooth loss among older adults have been well documented and show a decline over the last few decades, little is known about trends in tooth decay which may lead to tooth loss. The study aim was to examine trends in tooth decay among adults ages 50 years and older in the United States and determine whether these trends were consistent across demographic and socioeconomic subgroups of middle-aged and older adults. METHODS: Secondary analysis of data collected through detailed oral health examinations in the National Health and Nutrition Examination (NHANES) surveys 1988-1994 and 1999-2004. Tooth decay was measured as active caries. Multivariable associations were estimated using negative binomial regression models. RESULTS: Averaged over time, the mean number of decayed teeth was 0.54. Rates of decay remained stable over time. Males, non-Hispanic Blacks, Mexican-Americans, and those of other race/ethnicity as well as those with fewer years of education and lower levels of income had more decayed teeth. The increased number of decayed teeth for Mexican-Americans and those of other race/ethnicity was due in part to differing levels of education and income. Trends over time did not vary by any of these demographic and socioeconomic characteristics. Trends in the number of decayed teeth did not meaningfully change when the numbers of missing and filled teeth were controlled. CONCLUSIONS: Although studies have shown the number of middle-aged and older Americans experiencing tooth loss has decreased over time, trends in tooth decay have remained relatively stable, with socioeconomic disparities persisting over time.

Trajectories of depressive symptoms and oral health outcomes in a community sample of older adults.

OBJECTIVE: Adverse outcomes associated with chronic depressive symptoms are of clinical importance. The objective was to identify subgroups of older adults based on their trajectories of depressive symptoms over a 10-year period and determine if these subgroups predicted oral health outcomes. METHODS: The sample was 944 adults aged 65+ who participated in the oral health module of the the Health and Retirement Survey in 2008. Depressive symptoms were measured with a modified version of the Center for Epidemiologic Studies-Depression (CES-D) scale. Latent class trajectory analysis was used to identify distinct subgroups of elders based on their CES-D scores from 1998-2008. Group membership was used to predict self-rated oral health, overall mouth condition (problems with bleeding gums, gum sensitivity, and food avoidance), and edentulism in 2008. RESULTS: Three distinct subgroups were identified using zero-inflated Poisson regression models: (i) minimal depressive symptoms over the study period (43%), (ii) low but generally stable level of depressive symptoms (41%), and (iii) moderate symptoms and higher CES-D scores than the other groups over the 10 years (16%). Controlling for demographic and health variables and edentulism status, having a trajectory of moderate symptoms was associated with poorer mouth condition (p < 0.0001) and poorer self-rated oral health (p = 0.0003) compared with those with minimal symptoms. Having low levels of depressive symptoms was not significantly associated with these two outcomes. Group membership was not significantly associated with the probability of edentulism. CONCLUSIONS: Chronic moderate depressive symptoms are associated with poorer oral health in older adults.

Chronic kidney disease and recurrent falls in nursing home residents: a retrospective cohort study.

This study examined whether chronic kidney disease (CKD) is associated with recurrent falls in older adults in nursing homes (NHs). We used data abstracted over a six month period from 510 NH residents with a history of falls. Thirty-five percent of the NH residents had CKD. In adjusted analyses, the incidence of recurrent falls was similar in those with and without CKD [fall rate ratio (FRR) 1.00, 95% confidence interval (CI) 0.97-1.02]. Orthostatic hypotension (FRR 1.52, 95% CI 1.12-2.05), history of falls during the prior six month period (FRR 1.25, 95% CI 1.05-1.49), cane or walker use (FRR 1.64, 95% CI 1.16-2.33), and ambulatory dysfunction (FRR 1.47, 95% CI 1.23-1.75) were independently associated with increased fall rate. CKD was not an important predictor of falls in this cohort of nursing home residents with prior falls. Instead, traditional fall risk factors were much more strongly associated with recurrent falls.

One size does not fit all-mobility device type affects speed, collisions, fatigue, and pain.

OBJECTIVE: To determine whether differences could be detected in mobility outcomes during community mobility and home mobility tasks according to type of mobility assistive device. DESIGN: Randomized, repeated measures. SETTING: Community mobility task: traversing 341.4m between the rehabilitation clinic and hospital entrance; home mobility task: traversing 39m into and out of a patient training bathroom and bedroom. PARTICIPANTS: Community-dwelling, cognitively intact ambulatory veterans (N=59) who used a mobility device within the 14 days prior to the study. INTERVENTIONS: Participants tested 3 types of mobility assistive devices with wheels: 4-wheeled walker (WW), manual wheelchair (MWC), and powered wheelchair (PWC). The first and last devices used by each participant were randomly assigned as either MWC or WW. The PWC was always the second device. MAIN OUTCOMES MEASURES: Speed (m/s), collisions (total), fatigue (0-10 Likert scale), and pain (0-10 Likert scale, diagram). RESULTS: The community mobility task was performed with all 3 devices by 52 (88%) veterans, and the home mobility task was performed with all 3 devices by 53 (90%) participants. In each task, 28 participants used the WW and 28 participants used the MWC as the final device. In the community mobility task, statistically significant differences (P<.05) were seen with ≥1 device comparison for all studied outcomes (eg, standardized mean difference for the MWC compared with the PWC showed -.67 fewer collisions for the MWC). In the home mobility task, speed, collisions, and fatigue showed statistically significant (P<.05) device-related differences (eg, standardized mean difference for the WW compared with the MWC showed -.88 fewer collisions for the WW). CONCLUSIONS: We found statistically significant and substantively different effects from 3 commonly used mobility assistive devices with wheels on diverse mobility outcomes when used in typical community mobility and home mobility tasks, providing proof of concept support for a research methodology applicable to comparative outcome studies of diverse mobility aids.

Vascular lesions and functional limitations among older adults: does depression make a difference?

ABSTRACT Background: The association between disability and depression is complex, with disability well established as a correlate and consequence of late life depression. Studies in community samples report that greater volumes of cerebral white matter hyperintensities (WMHs) seen on brain imaging are linked with functional impairment. These vascular changes are also associated with late life depression, but it is not known if depression is a modifier in the relationship between cerebrovascular changes and functional impairment. Methods: The study sample was 237 older adults diagnosed with major depression and 140 never depressed comparison adults, with both groups assessed at study enrollment. The dependent variable was the number of limitations in basic activities of daily living (ADL), instrumental ADLs, and mobility tasks. The independent variable was the total volume of cerebral white matter lesions or hyperintensities assessed though magnetic resonance imaging. Results: In analyses controlling for age, sex, race, high blood pressure, and cognitive status, a greater volume of WMH was positively associated with the total number of functional limitations as well as the number of mobility limitations among those older adults with late life depression but not among those never depressed, suggesting the association between WMH volume and functional status differs in the presence of late life depression. Conclusions: These findings suggest older patients with both depression and vascular risk factors may be at an increased risk for functional decline, and may benefit from management of both cerebrovascular risk factors and depression.

Using the past to predict the future: latent class analysis of patterns of health service use of older adults in the emergency department.

OBJECTIVES: To classify older adults in the emergency department (ED) according to healthcare use and to examine associations between group membership and future ED visits and hospital admissions. DESIGN: Secondary analysis. SETTING: Medicare Current Beneficiary Survey. PARTICIPANTS: Adults aged 65 and older with at least one treat-and-release ED visit between January 1, 2000, and September 30, 2007 (N = 4,964). MEASUREMENTS: Measures of health service use included primary care visits, treat-and-release ED visits, and hospital days in the 12 months preceding the index ED visit. RESULTS: Five groups of individuals in the ED with distinct patterns of health service use were identified. "Primary Carederly" (39%) had low rates of ED and hospital use and a high mean number of primary care visits. "Wellderly" (34%) had fewer visits of all types than other groups. "Chronically Illderly" (14%) had the highest mean number of primary care visits and hospital days. "Acute Carederly" (9.8%) had lowest mean number of primary care visits but higher ED visits and hospital days than all other groups except the "Sickest Elderly." Sickest Elderly (3.2%) had the highest number of ED visits; mean number of hospital days was more than four times that of any other group. Primary Carederly and Wellderly had a lower risk of hospital admission within 30 days of the index ED visit than the other groups. CONCLUSION: In older adults released from an ED, group membership was associated with future health services use. Classification of individuals using readily available previous visit data may improve targeting of interventions to improve outcomes.

Participation in decision making as a property of complex adaptive systems: developing and testing a measure.

Objectives. To (1) describe participation in decision-making as a systems-level property of complex adaptive systems and (2) present empirical evidence of reliability and validity of a corresponding measure. Method. Study 1 was a mail survey of a single respondent (administrators or directors of nursing) in each of 197 nursing homes. Study 2 was a field study using random, proportionally stratified sampling procedure that included 195 organizations with 3,968 respondents. Analysis. In Study 1, we analyzed the data to reduce the number of scale items and establish initial reliability and validity. In Study 2, we strengthened the psychometric test using a large sample. Results. Results demonstrated validity and reliability of the participation in decision-making instrument (PDMI) while measuring participation of workers in two distinct job categories (RNs and CNAs). We established reliability at the organizational level aggregated items scores. We established validity of the multidimensional properties using convergent and discriminant validity and confirmatory factor analysis. Conclusions. Participation in decision making, when modeled as a systems-level property of organization, has multiple dimensions and is more complex than is being traditionally measured. Managers can use this model to form decision teams that maximize the depth and breadth of expertise needed and to foster connection among them.

Interactive behaviors of American Indian mothers and their premature infants.

The interactive behaviors of 17 American Indian mothers and their premature infants and selected maternal and infant factors affecting those behaviors were measured using naturalistic observation and the Home Observation for Measurement of the Environment (HOME) Inventory at 3, 6, and 12 months corrected infant age. The frequency of some maternal behaviors changed over the first 12 months. Mothers spent less time holding, looking at, touching, and interacting with their premature infants and more time uninvolved as the infant aged. Maternal education and infant illness severity were associated with mother-infant interactive behaviors and HOME Inventory scores. These findings emphasize the importance of maternal and infant factors affecting the interactions between American Indian premature infants and their mothers.

Latent subtypes of depression in a community sample of older adults: can depression clusters predict future depression trajectories?

Identifying sources of heterogeneity in late life depression remains an important focus of psychiatric investigation. Community samples are particularly informative since many older adults have clinically significant depressive symptoms but fail to meet criteria for major depression and older adults generally do not seek treatment for their depressive symptoms. The primary data used for these analyses were those collected in a community-based survey of over 3000 adults age 65 or older followed for up to ten years. Depressive symptoms were measured by the Center for Epidemiologic Studies-Depression scale (CES-D). Latent class analysis was used to identify clusters of participants based on their symptom profiles at baseline. Mixed models were used to examine trajectories of CES-D scores based on cluster assignment. A model with three unique clusters best fit the data. Cluster 1 (59%) had a low probability of any symptom endorsement. Cluster 2 (31%) endorsed as a group some negative affect and somatic symptoms but their endorsement of low positive affect did not differ from Cluster 1. Participants in Cluster 3 (10%) had a higher probability of endorsement of all symptoms compared to Clusters 1 and 2. The results did not appreciably differ when symptom severity was included. Cluster assignment was a significant predictor of change in CES-D score over the ten-year follow-up period, and the effects over time differed by sex. Depressive symptom profiles predict the longitudinal course of depression in a community sample of older adults, findings that are important especially in primary care settings.

Interactive behaviors of ethnic minority mothers and their premature infants.

OBJECTIVE: To compare the interactive behaviors of American Indian mothers and their premature infants with those of African American mothers and their premature infants. DESIGN: Descriptive, comparative study. SETTING: Three neonatal intensive care units and two pediatric clinics in the southeast. PARTICIPANTS: Seventy-seven mother/infant dyads: 17 American Indian mother/infant dyads and 60 African American mother/infant dyads. METHODS: Videotapes of mother/infant interactions and the Home Observation for Measurement of the Environment (HOME) were used to assess the interactions of the mothers and their premature infants at 6 months corrected age. RESULTS: American Indian mothers looked more, gestured more, and were more often the primary caregivers to their infants than the African American mothers. American Indian infants expressed more positive affect and gestured more to their mothers, whereas African American infants engaged in more non-negative vocalization toward their mothers. African American mothers scored higher on the HOME subscales of provision of appropriate play materials and parental involvement with the infant. American Indian mothers scored higher on the opportunities for variety in daily living subscale. CONCLUSION: Although many of the interactive behaviors of American Indian and African American mother/infant dyads were similar, some differences did occur. Clinicians need to be aware of the cultural differences in mother/infant interactions. To optimize child developmental outcomes, nurses need to support mothers in their continuation or adoption of positive interactive behaviors.

A quality assurance study on the accuracy of measuring physical function under current conditions for use of clinical video telehealth.

OBJECTIVE: To determine whether conditions for use of clinical video telehealth technology might affect the accuracy of measures of physical function. DESIGN: Repeated measures. SETTING: Veterans Administration Medical Center. PARTICIPANTS: Three healthy adult volunteers for a sample size of n=30 independent trials for each of 3 physical function tasks. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Three tasks capturing differing aspects of physical function: fine-motor coordination (number of finger taps in 30s), gross-motor coordination (number of gait deviations in 10ft [3.05m]), and clinical spatial relations (identifying the proper height for a cane randomly preset ±0-2in [5.1cm] from optimal), with performance simultaneously assessed in person and video recorded. Interrater reliability and criterion validity were determined for the measurement of these 3 tasks scored according to 5 methods: (1) in person (community standard), (2) slow motion review of the video recording (criterion standard), and (3-5) full speed review at 3 Internet bandwidths (64kps, 384kps, and 768kps). RESULTS: Fine-motor coordination-Interrater reliability was variable (r=.43-.81) and criterion validity was poor at 64kps and 384kps, but both were acceptable at 768kps (reliability r=.74, validity ß=.81). Gross-motor coordination-Interreliability was variable (range r=.53-.75) and criterion validity was poor at all bandwidths (ß=.28-.47). Motionless spatial relations-Excellent reliability (r=.92-.97) and good criterion validity (ß=.84-.89) at all the tested bandwidths. CONCLUSIONS: Internet bandwidth had differing effects on measurement validity and reliability for the fine-motor task, the gross-motor task, and spatial relations, with results for some tasks at some transmission speeds well below acceptable quality standards and community standards.

Caloric restriction alters the metabolic response to a mixed-meal: results from a randomized, controlled trial.

OBJECTIVES: To determine if caloric restriction (CR) would cause changes in plasma metabolic intermediates in response to a mixed meal, suggestive of changes in the capacity to adapt fuel oxidation to fuel availability or metabolic flexibility, and to determine how any such changes relate to insulin sensitivity (S(I)). METHODS: Forty-six volunteers were randomized to a weight maintenance diet (Control), 25% CR, or 12.5% CR plus 12.5% energy deficit from structured aerobic exercise (CR+EX), or a liquid calorie diet (890 kcal/d until 15% reduction in body weight)for six months. Fasting and postprandial plasma samples were obtained at baseline, three, and six months. A targeted mass spectrometry-based platform was used to measure concentrations of individual free fatty acids (FFA), amino acids (AA), and acylcarnitines (AC). S(I) was measured with an intravenous glucose tolerance test. RESULTS: Over three and six months, there were significantly larger differences in fasting-to-postprandial (FPP) concentrations of medium and long chain AC (byproducts of FA oxidation) in the CR relative to Control and a tendency for the same in CR+EX (CR-3 month P = 0.02; CR-6 month P = 0.002; CR+EX-3 month P = 0.09; CR+EX-6 month P = 0.08). After three months of CR, there was a trend towards a larger difference in FPP FFA concentrations (P = 0.07; CR-3 month P = 0.08). Time-varying differences in FPP concentrations of AC and AA were independently related to time-varying S(I) (P<0.05 for both). CONCLUSIONS: Based on changes in intermediates of FA oxidation following a food challenge, CR imparted improvements in metabolic flexibility that correlated with improvements in S(I). TRIAL REGISTRATION: ClinicalTrials.gov NCT00099151.

Diffusion of innovations in long-term care measurement battery.

Poor understanding of factors influencing integration of new practices into long-term care (LTC) hinders timely implementation of evidence-based practices (EBPs). Using the Diffusion of Innovations (DOI) framework, a new instrument measuring staff perceptions of an EBP was developed as part of a DOI-LTC measurement battery and tested in a cross-sectional survey of North Carolina LTC nursing personnel. Valid questionnaires were received from 95 licensed nurses and 102 certified nursing assistants (CNAs). Internal consistency reliability for five of seven subscales was acceptable (Cronbach's alpha coefficient = 0.77 to 0.95). Perception of innovation attributes was associated with intention to adopt the new practice (Spearman rho correlation: licensed nurses = 0.41 to 0.68, p < 0.0001; CNAs = 0.26 to 0.54, p = 0.05 to <0.0001). The DOI-LTC measurement battery represents a promising new approach to studying implementation of EBPs in LTC. Future work should examine its responsiveness to interventions that facilitate implementation of EBPs in LTC.

Age differences in symptom expression in patients with major depression.

OBJECTIVE: The aim of the study was to compare symptom expression in primarily middle-aged (<60) and older (60+) patients who were depressed and determine if symptom profiles differed by age. METHODS: Patients diagnosed with major depression (N = 664) were screened using the Center for Epidemiologic Studies--Depression scale and sections of the Diagnostic Interview Schedule. Patients were separated into homogeneous clusters based on symptom endorsement using latent class analysis. RESULTS: Older patients were less likely to endorse crying spells, sadness, feeling fearful, being bothered, or feeling life a failure but were more likely to endorse poor appetite and loss of interest in sex. Older patients were also less likely to report enjoying life, feeling as good as others, feeling worthless, wanting to die, and thinking about suicide. In two latent class models with depressive symptoms as indicators, three-class models best fit the data. Profiles supported heterogeneity in symptom expression. Clusters differed by age when other demographic, clinical, health, and social variables were controlled but did not support age-specific symptom profiles. Overall, older patients had later age of onset, had fewer lifetime spells, were more likely to have ever received electroconvulsive therapy (ECT), and were less likely to have comorbid anxiety. Older patients also had more cognitive impairment, health conditions, and mobility limitations but had higher levels of subjective social support and had experienced fewer stressful life events. CONCLUSIONS: There are age differences in symptom endorsement between younger/middle-aged and older patients with major depression. The data, however, did not identify a symptom profile unique to late-life depression.

Advances in mediation analysis can facilitate nursing research.

BACKGROUND: Two recent advances in the statistical methods for testing hypotheses about mediation effects are important for nursing science. First, bootstrap sampling distributions provide more accurate tests of hypotheses about mediated effects. Second, methods for testing statistical hypotheses about subgroup differences in mediation models (moderated mediation) are now well developed. OBJECTIVE: The aims of this study were to demonstrate the use and relatively simple computation of bootstrap sampling distributions in tests of mediation effects and to demonstrate a recently refined method for testing hypotheses about moderated mediation. METHOD: Using hypothetical data, a step-by-step demonstration was provided of the construction of a bootstrap sampling distribution for a correlation coefficient. Then, tests of mediation and moderated mediation were demonstrated using data from a clinical trial of an intervention for caregivers of patients with Parkinson's disease or Alzheimer's disease. In a model hypothesizing that mutuality between caregiver and care recipient mediates the effect of objective on subjective levels of caregiver burden, the bootstrap sampling distribution was calculated of the mediation effect and, from that, two types of 95% confidence intervals for it. Then the hypothesis was tested that the mediating effect of mutuality was stronger for caregivers of patients with Parkinson's disease than for caregivers of patients with Alzheimer's disease. CONCLUSIONS: Statistical hypothesis testing should never dictate all conclusions. However, the statistical advances in mediation analysis described here will facilitate nursing research as both nurse scientists and methodologists understand their assumptions and logic.

Black-white disparity in disability: the role of medical conditions.

OBJECTIVES: To describe the independent contributions of selected medical conditions to the disparity between black and white people in disability rates, controlling for demographic and socioeconomic factors. DESIGN: Cross-sectional analysis of a community-based cohort. SETTING: Urban and rural counties of central North Carolina. PARTICIPANTS: Two thousand nine hundred sixty-six adults aged 68 and older participating in the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). MEASUREMENTS: Self-reported data on sociodemographic characteristics and medical conditions, Short Portable Mental Status Questionnaire, activities of daily living (ADLs). RESULTS: Fifty-five percent of the cohort was black. Blacks were more likely than whites to report disability (odds ratio=1.39, 95% confidence interval= 1.15-1.68). Controlling for age, sex, marital status, and socioeconomic status, blacks were more likely to be obese and have diabetes mellitus, and less likely to report vision problems, fractures, and heart attacks. The higher prevalence of obesity and diabetes mellitus in blacks, after adjustment for sociodemographic factors, accounted for more than 30% of the black-white difference in disability. Conversely, the black-white disability gap would be approximately 45% wider if whites had a lower prevalence of fractures and vision impairment, similar to their black peers. CONCLUSION: Higher rates of obesity and diabetes mellitus in older black Americans account for a large amount of the racial disparity in disability, even after controlling for socioeconomic differences. Culturally appropriate interventions that lower the prevalence or the functional consequences of obesity and diabetes mellitus in blacks could substantially decrease this racial health disparity.

Correlates of care relationship mutuality among carers of people with Alzheimer's and Parkinson's disease.

AIM: This paper presents findings from secondary analysis of longitudinal data on correlates of care relationship mutuality collected from 91 carers of people with Alzheimer's disease and Parkinson's disease in the control group of a randomized trial of home-care skill training. BACKGROUND: Many family members and other informal carers are reported to suffer multiple adverse social, financial, psychological and physical caregiving outcomes. High levels of mutuality, the perception that the quality of the care relationship is positive, reportedly ameliorate these negative outcomes. METHOD: Multilevel models for change were used to explore whether care recipient functional ability, carer gender, depressive symptoms, kin relation to care recipient (spouse, non-spouse) and years of caregiving experience were related to carers' perceptions of care relationship mutuality over a 12-month period. Data collection took place between 2003 and 2008. RESULTS: Carers who reported lower mutuality: (1) were caring for care recipients with lower functional ability, (2) had less caregiving experience and (3) had more depressive symptoms. CONCLUSION: Informal carers who perceive little mutuality in their relationship with the care recipient may be more likely to terminate care early. Clinicians and researchers should explore the quality of the caregiving relationship as a critical factor in carer and care recipient outcomes. Home-care skill training may need to include relationship-building skills to offset adverse carer outcomes.