Evaluating the Elderly Patient:
the Case for Assessment Technology
National Institutes of Health
NIH Technology Assessment Conference Summary
June 29-30, 1983
This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong. For reliable, current information on this and other health topics, we recommend consulting the National Institutes of Health's MedlinePlus http://www.nlm.nih.gov/medlineplus/.
This statement was originally published as: Evaluating the elderly patient: The case for assessment technology. Workshop summary; 1983 Jun 29-30. Bethesda (MD): National Institutes of Health, Office of Medical Applications of Research; .For making bibliographic reference to the statement in the electronic form displayed here, it is recommended that the following format be used: Evaluating the elderly patient: The case for assessment technology. NIH Technology Assessment Online Statement 1983 Jun 29-30 [cited day, month, year];(1) :14.
The problems and costs associated with aging and the aged pose a major challenge to the future of society. The elderly portion of our population is constantly expanding--so much so that by the year 2050 some 22 percent of the population will be over 65 years old. The most rapidly growing segment of our population is that 80 years of age and older.
For the great mass of society, no single health issue will demand more attention than aging. The costs alone are staggering. In 1980, $22 billion were spent on nursing-home care. By 1990, nursing home costs are estimated to soar to $75 billion annually. As a society, we are relatively unprepared for this wave of older people and the challenges and opportunities they pose for our health care system.
From a medical point of view, there is a need to adequately assess the elderly patient. Often, the first interaction with such a patient is crucial. Systematic and comprehensive evaluation of the patient's functional capacities and incapacities as well as his/her social support system establishes a rational basis for the development of treatment plans geared to the patient's biomedical, psychological, and social needs.
If this kind of evaluation is not made, correctable problems may be missed or the patient may not receive the specific level and type of care needed. This is especially the case with respect to the need for ongoing care on a long-term basis. Various evaluation instruments, collectively known as assessment technology, have been developed in order to guide comprehensive assessment of elderly patients.
It is against this backdrop that the Office of Medical Applications of Research, the National Institutes of Health, the National Institute on Aging, the American Medical Association, and the National Center for Health Services Research sponsored a joint conference in Bethesda, Maryland, to look into the state of the art of evaluation or assessment technology and how it is employed in clinical, educational, and administrative settings. The conference, attended by 637 health professionals and other persons from across the nation, was held on June 29 and 30, 1983. Key goals of the conference were to heighten the awareness of health professionals to the importance of comprehensive assessment of elderly patients, to identify and describe a sample of assessment instruments which are now available, and to circumscribe the state of current research in the assessment field.
Papers were first presented illustrating the actual experience of assessment in its various clinical, administrative, and educational applications followed by a delineation of key domains of data which are collected. The conference then moved to panel discussions of both practical and outstanding research issues related to the use of assessment technology and concluded with a summary statement and critical review of the proceedings. This Summary focuses on the papers presented at the conference.
Assessment as a Useful Tool
In the overview keynote presentation by Dr. T. Franklin Williams, the rationale for comprehensive assessment was outlined and data presented indicating its importance. For example, in studies dating from 1968 and 1982, from upstate New York, up to 50 percent of persons needing long- term care were not receiving what was judged to be an appropriate type or level of care. It was found that some were receiving more, some less, care than they needed, and in inappropriate care settings. Thus, the implication is that, without adequate assessment, the elderly may be consigned to nursing homes or other long-term care facilities when less-confining living settings or continued living at home with support services might be possible. Conversely, the patient may not receive the intensity of care he or she really needs, with resulting accelerated disability or burnout on the part of family caregivers.
Similarly, in another survey, after a closer assessment of patients who were already on the waiting list for nursing-home admission, it was found that two-thirds could be taken care of in settings other than nursing homes. Incredibly, one-fourth (23 percent) could stay at home, or in supervised boarding houses, with support services.
Among other things, such studies consistently document the value of careful assessment by a multidisciplinary professional team in improving decision-making concerning the appropriateness of long-term care, including more use of home-support service and of institutional settings other than nursing homes. They also help identify those characteristics of the patient or of his psychosocial support system that appear to be most critical in determining the type and level of care needed. Comprehensiveness seems to be a key. The assessment procedure in these studies consisted of a comprehensive clinical workup by a physician, community health nurse, social worker, and necessary consultants, with an emphasis on functional and social competence.
According to Dr. Williams, a number of other projects in states such as Georgia, Connecticut, and Wisconsin have shown both the value of the multidisciplinary-team approach to assessment, as well as the usefulness of a standardized assessment protocol or instrument. In practice the two have acquitted themselves well, but questions remain.
Among these are the domains or types of information that are essential components of comprehensive assessment. The following appear to be crucial: (1) physical functioning, (2) mental and emotional functioning, (3) family and social supports, (4) environmental characteristics, (5) the need for specific medical or rehabilitative therapies as, for example, with incontinence, and (6) the potential for productive or personally rewarding use of time.
Additional questions relate to the issue of what characteristics there are in common, and what characteristics differ, among the various assessment approaches that have thus far been developed. There are questions as well about how thoroughly they have been tested for reliability, and validity, for comparative usefulness--and for indications for utilizing a specific instrument or instruments.
These questions are at the heart of assessment as an emerging medical technology. And the benefits of answering them carefully are many. A well-designed, properly applied, and regularly used assessment tool could result in an improved overall quality of clinical practice; the identification of high-risk patients and treatable conditions before further functional decline sets in; the serving of important educational, administrative, and health-planning functions; and the identification of knowledge gaps as well as needed research.
The Experience With Employment of Assessment Instruments
Clinical Use: The Geriatric Assessment Unit (Dr. Laurence Rubenstein)
The first reports on geriatric assessment were published in Great Britain. There, Dr. Marjorie Warren, considered one of the founders of modern geriatrics, developed specialized geriatric units (GAU's) during the late 1930's while in charge of a London workhouse infirmary which was filled with bedfast and largely neglected elderly patients who had not received proper medical diagnosis or rehabilitation. High-quality nursing had kept the patients alive, while the lack of diagnostic assessment and rehabilitation kept them disabled. According to Dr. Rubenstein, Dr. Warren systematically evaluated these patients, and was able to get most of the long-bedfast patients out of bed, often walking, and, in some cases, even to the point where they could be discharged home.
Dr. Rubenstein indicated that in the U.S. today, the organization of assessment programs varies considerably, but most include a core team of physician (or physician extender), nurse, and social worker. To this core is added a variety of other specialists who either participate in the initial assessment or are called upon as consultants (e.g., psychologist or psychiatrist, occupational therapist, physical therapist, audiologist, dentist, optometrist or ophthalmologist, dietician, and public-health nurse, among others). The size of the team is influenced by several factors, including program goals, setting, patient load, and costs. As evidence accumulates that these programs can improve the quality of life and reduce overall health-care costs, funding sources are likely to expand.
Most GAU's today complete a multidimensional assessment in which most or all of the areas pertaining to medical problems, functional capacities and disabilities, psychological status, and social network and other needs are covered. In some programs, individual team members complete separate assessment instruments, while in others a single individual--a nurse practitioner or researcher, for example--completes the entire form. Some programs take special efforts to ensure reliability and validity of their instruments in their own settings, while others simply use forms validated elsewhere.
The use of easy-to-administer, well-validated assessment instruments makes the process of assessment considerably easier to perform and teach, and more reliable as well. In addition, such instruments facilitate the transmission of understandable clinical information between health providers, promoting communication between them. The result is more teamwork, useful and valid data, and a way of measuring the effectiveness of therapeutic interventions over time.
A recent book by R.L. Kane and R.A. Kane (Assessing the Elderly: A Practical Guide to Management, Lexington, MA.: D.C. Heath, 1981) provides a thorough analysis of geriatric assessment instruments and describes in detail which appear appropriate for particular settings and patient populations.
According to Dr. Rubenstein, most geriatricians are convinced of the effectiveness of geriatric assessment programs for improving both the process and outcome of geriatric care, even though well-designed studies are still relatively few in number. Published reports on GAU's show clear associations between the programs and major improvements in care, including improved diagnostic accuracy, appropriateness of placements, functional status, and use of medications.
Several reports have examined patient functional status before and after treatment on those GAU's which include rehabilitation along with the assessment. These reports usually have used a validated measure of functional status, such as the Katz index of Activities of Daily Living (ADL), to document change over time. They uniformly show that many if not most patients improve during their stays at the GAU's.
Another major area of GAU impact is the improvement in diagnostic accuracy, usually shown by the discovery of new, treatable problems. Depending on the particular study, new diagnoses were found in frequencies varying from 0.76 per patient to almost 4 per patient.
In a Cleveland study, 50 consecutive patients age 70 and over discharged from a GAU were compared with 50 control patients discharged from other medical wards in the same hospital. They were matched for age, sex, and primary diagnosis. Mean length of stay for the two groups was comparable and fairly long (68.0 and 70.7 days, respectively), and reflected the extensive rehabilitation being performed along with the assessment. Discharge location was significantly different in the case of the GAU group compared to the controls (80 percent vs. 62 percent went home, and 20 percent vs. 38 percent to nursing homes, respectively). GAU patients were more likely than control patients to show improvement in measures of their functional status (Katz's Activities of Daily Living [ADL], independent ambulation, and continence) in the hospital. Later, several months after discharge, significantly more GAU than control patients were still at home.
The Sepulveda VA/UCLA GAU reported on by Dr. Rubenstein has been conducting a prospective randomized experiment, comparing inpatient candidates randomly assigned to enter the GAU or to continue receiving care on their acute hospital wards. Though the study is still in progress, preliminary data indicate fewer deaths (1-year mortality), fewer institutional admissions in the year after treatment, less cost per patient, and lower costs per day survived. In fact, the savings in direct medical care costs for the GAU group appear to be substantial and more than enough to pay for the program.
One important goal of assessment should be to identify which subgroups of patients can be expected to benefit from the specific programs in order to make the most of scarce resources. While it might be argued that the majority of elderly could benefit from careful assessment, most older persons are generally healthy and therefore the relative yield of assessment tends to be lower for those who are healthy than for those who are frail or ill. In general, according to Dr. Rubenstein, the elderly who are most likely to benefit from assessment are those who are on the verge of needing institutionalization, who have multiple medical problems or less social support, who have had inadequate primary care, and who are poor.
The Administrative Value of Assessment (Angela Falcone)
Ms. Falcone outlined the administrative benefits that follow from comprehensive functional assessment. She asserted that it is difficult to imagine a long-term care administrative or policy issue that is not related, at least indirectly, to the need for functional assessment. Level-of-care determinations, program eligibility, referral, discharge and care planning, quality of care, and quality assurance all impinge on administrative concerns: physical plant, volume and kinds of services, staffing, costs, data processing, medical recordkeeping, and quality control are among the administrative duties that could be improved by the use of assessment instruments. Until such tools are further developed and validated, however, these data will be relatively unavailable and thus unable to help improve overall health-care operations.
The Educational Value of Assessment (Dr. Richard Besdine)
The intrinsic worth of comprehensive functional assessment to educational activities cannot be overestimated. According to Dr. Besdine, this importance results from the special nature of functional impairment in old age. Essentially, functional impairment is seen as the decreased ability to meet one's own needs, including mobility, cognition, eating, toileting, dressing, hygiene, shopping, cooking, and managing money. Unlike young persons, when elderly individuals become ill, the first sign of chronic disease is rarely a single, specific, symptomatic complaint which helps localize the organ system or tissue in which the disease occurs. Rather, older patients usually express the presence of active illness with one or more nonspecific disabilities that rapidly result in functional impairment. These functional expressions of disease include:
- cessation or reduction in eating or drinking
- urinary incontinence
- acute confusion
- new onset or worsening of previously mild dementias
- weight loss
- failure to thrive
Any of these problems may quickly induce dependency in the previously independent older person without signifying a specific root cause.
According to Dr. Besdine, the crucial implication of health-care and quality of life maintenance in old age is that deterioration of functional independence is a reliable signal or marker of active, usually inadequately managed or unrecognized disease. Since diseases producing functional impairment in older people often are treatable and even at times reversible, detection is essential. Periodic formal assessment with rapid diagnostic and therapeutic attention to new decline in independence is a central principle of geriatric care, and is, or should be, crucial in the basic, postgraduate, and continuing education of geriatric health-care providers.
Another principle of geriatric medicine illustrated by assessment is the lack of correlation between functional impairment and disease burden. Because prevalence of disease and functional loss increase with age, most health professionals assume that the number of conditions identified on the problem list of an elderly individual determines the severity of functional loss. But accumulation of numerous problems or diseases by a single person does not necessarily produce severe functional impairment. To the contrary, many independent old people have long and impressive problem lists.
Dr. Besdine noted that there exists in medicine a general set of assumptions that a specific type of functional loss is determined by the locus of disease, so that, for example, problems with mobility originate in arthritis or stroke, problems of confusion originate in brain disease, problems with incontinence in bladder or kidney disease, and weight loss in gastrointestinal pathology, etc. He asserted that this principle of medicine, generally valid in young and middle-aged persons, is not valid in the elderly. Rather, certain organ systems responsible for crucial functions that permit independence are most vulnerable to disease effects in the frail, very old but compensated individual.
Additionally, the severity of disease as measured by objective laboratory tests does not necessarily determine the presence or severity of functional impairment. For example, asymptomatic complete heart block may be discovered on a routine electrocardiogram or a startling but asymptomatic elevation of blood urea nitrogen on multiphasic screening may be identified in an independent elderly person. Thus, in situations of impressive laboratory abnormalities with minimal or no obvious functional impairment in an old person, comprehensive assessment can provide the basis for judgments to withhold interventions for the asymptomatic aberration, especially if the treatment, such as a pacemaker or dialysis, carries with it substantial risk, discomfort, or expense. The educational mandate is clear: to equip health-care professionals with both the skill and the motivation to perform functional assessment to permit maximum continuing independence and prompt detection of decline.
Therapeutic goals for the elderly individual can be reached by the measurement and then reduction of the burden of functional decrements. The listing of all functional impairments, contrasted side by side with the problem list, will allow a careful comparison of diagnosis with lost function. Using the list of functional losses and their severity, items on the problem list can be identified as the most likely sources of the most troublesome functional impairments.
According to Dr. Besdine, for geriatric health care to be truly multidisciplinary, and thus best able to meet the needs of the elderly individuals who are to be saved, a common language of functional assessment must be shared by the professionals providing care. As each provider discipline becomes freer of its own jargon, communication and coordination of care can be more fully achieved. Comprehensive functional assessment can provide the common language facilitating multi- and interdisciplinary evaluation and therapeutic intervention. The educational value of assessment in the multidisciplinary, team care setting is that by using functional data, each discipline can see and discuss problems of the older person as they affect life and independence.
At that point, teaching several disciplines simultaneously becomes possible and simple. Freed from the language and thought constraints of medical, nursing, dental, physical therapy, or other discipline-specific diagnoses by use of shared data, professionals can learn what each discipline has to offer in solving or managing the needs of functionally impaired elders. Evaluation, treatment planning, therapeutic interventions, and follow-up then all become easier as well as measurable.
The Science Base of Assessment Technology
Assessment of Self-Maintenance (Dr. Sidney Katz)
The aging of the population and a concern for the well-being of older people have hastened the emergence of measures of functional health. Among them, measures of self-maintaining function--expressed in terms of basic Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and mobility--have been particularly useful and are now widely employed. Many are expressed in reasonably similar terms and are incorporated within available comprehensive assessment instruments. Although continuing studies of reliability and validity are needed (especially of predictive validity), there is evidence that sufficient reliability can be achieved for the clinical use of these measures, as well as for their application in program evaluation and planning. Current evidence also indicates that patient evaluation by means of these measures helps to identify problems that require treatment or care, and produces useful information for prognosis and for monitoring health status.
The measures of an elderly patient's ADL, IADL, and mobility have evolved over the last few decades under the sponsorship of the National Institute on Aging, the Administration on Aging, and the National Center for Health Services Research, among others.
In the mid-1950's, Katz had shown that basic ADL (the six functions of bathing, dressing, toileting, transfer, continence, and feeding) were related hierarchically and that a combined measure of these could be used to assess change in a patient's functional ability over time. The validity of the measure was affirmed by the observation that certain recovering disabled patients passed through successive stages that paralleled the order of development of these basic functions in children.
Later, as conceived by Lawton, another set of activities of daily living, termed "Instrumental Activities of Daily Living" or IADL, were seen as being on a somewhat more complex level of organized human behavior than the basic ADL functions. IADL functions are concerned with the individual's ability to cope with his or her environment in terms of such adaptive tasks as shopping, cooking, housekeeping, laundry, use of transportation, managing money and medication, and use of a telephone. Others have spoken of these adaptive behaviors as factors of social competency, e.g., in literature about mental retardation which dates back more than 100 years. Mobility, a third measure, constitutes another basic domain and is closely related to IADL.
Thus, the domain of ADL, which lacked clear theoretical framework prior to the 1950's, is now seen to include three self-maintenance components--basic ADL, IADL, and mobility. Several forms of these measures now appear on some comprehensive assessment instruments. Examples include the Functional Life Scale, the Long Range Evaluation Summary, the Functional Limitation Scale, the Burke Stroke Time-Oriented Profile, the Long-Term Care Information System, the Comprehensive Assessment and Referral Evaluation (CARE), the Philadelphia Geriatric Center Multilevel Assessment Instrument (MAI), the OARS Multidimensional Functional Assessment Questionnaire, the Patient Assessment Instrument of the Long-Term Care Facility Improvement Study (PACE), and the Patient Status Instrument (PSI). Examples of separate measures of one or more of the ADL components include the ADL Index, the Rapid Disability Rating Scale, the Barthel Index, the Kenny Self-Care Ratings, the Rosow Functional Health Scale, and the PGC Instrumental Activities of Daily Living.
According to Dr. Katz, given the presence of a large number of instruments and measures, the degree of compatibility among the kinds of information and the definitions of individual items is an important issue. An evaluation of compatibility among 24 such assessment instruments, reported in 1981, showed a high degree of compatibility among measures of basic ADL and mobility, while compatibility among items of IADL, although not as high, was acceptable.
Urinary Incontinence in the Elderly (Dr. Mark Williams)
According to Dr. Williams, although much is already known about the urinary tract, a careful functional evaluation of urinary function complements other health observations, contributes to different levels of data, and frequently uncovers conditions predisposing to urinary incontinence. Generally, the evaluation includes mobility testing, quantifying the time and effort a patient must spend to toilet successfully, and observing the patient's ability to overcome any physical constraints (such as doors or stairs) interfering with toilet use. Complete evaluation of these environmental factors may require a home visit by a health-care provider.
Dr. Williams pointed out that health-care providers caring for incontinent elderly can choose from a variety of diagnostic tests. One simple but important diagnostic maneuver is to have an incontinence chart kept by patients or those providing care. The chart documents the number and time of daily accidents and associated circumstances, and the amount of urine lost. The pattern of incontinence is often relevant. For example, small volume losses connected with a change in posture suggest stress incontinence. Remarkably, some patients recover completely when an incontinence chart is maintained.
According to Dr. Williams, it is also clear that an accurate diagnosis of the urinary pathophysiology greatly increases the likelihood of successful treatment. All medications consumed by the patient should be reviewed, minimized, or discontinued. Coexistent illnesses should be optimally managed and a concentrated effort made to uncover and eliminate iatrogenic causes. Approximately 30 percent of incontinent elderly may experience spontaneous recovery within a few weeks. Most patients can expect significant improvement or cure, especially if ambulatory skills are preserved. Consequently, according to Dr. Williams, the prevailing pessimism about the treatment of incontinence is clearly not justified and it should never be assumed the problem is irremediable unless comprehensive assessment and multiple treatment regimens, supervised by an experienced clinician, prove unsuccessful. Palliative measures such as absorbent pads or indwelling catheters are appropriate only as temporary measures or as last-resort options.
Behavioral treatments have been found most useful, especially when they are based on a knowledge of the incontinence pattern. Regular checks performed every two hours and recorded on charts can help define the pattern. The daily schedule can then be altered to allow toilet use at a time when the bladder is most likely to be full. Bladder retraining requires establishing a micturition schedule and then increasing the voiding interval by having the patient consciously delay urinating. Several studies have reported improvement or cure in 50 to 70 percent of women using this technique.
Ultimately, the motivation to improve our knowledge of this subject is related to an awareness of the personal impact of urinary incontinence. The degree to which health-care providers can assist incontinent elderly may reflect a deeper understanding of human discomfort and an increased sensitivity to personal distress. Dr. Williams indicated that it should be considered unacceptable that over one-half of the incontinent elderly choose to hide their problem; or that, despite important advances, we still have not defined a fundamental sequence of diagnostic evaluations for this problem. Moreover, some elderly choose incontinence over the side effects of present treatment. Finally, it is unacceptable that many providers prefer palliative measures such as plastic pants and catheters to comprehensive evaluation that could cure the majority of their patients.
Until these basic issues are explored and resolved, urinary incontinence will continue to compromise the freedom and quality of life of the elderly, and will continue to drain precious health resources for its management.
Behavioral and Psychological Components of Assessment (Dr. Samuel Granick)
According to Dr. Granick, there is probably no greater endorsement for a wide-ranging, multidimensional assessment of the elderly than that prompted by a consideration of incontinence problems. Here it is clear that, if the medical decisions about these patients depended solely on information from the field of urology, many cases of incontinence would go unsolved. Similarly, the patient with circulatory problems or diabetes should be treated in relation to both the psychological stresses generated by his lifestyle and environmental circumstances, and the degree of compliance with a medical evaluation regimen on the basis of such factors as personality, cooperativeness vs. resistance, nutritional habits, and the ability of family members to adapt to new circumstances.
Likewise, according to Dr. Granick, the patient's psychological functioning may be understood and interpreted in relation to the conditions uncovered by the medical exam. Illness may have severe emotional consequences affecting self-image, attitudes toward and expectations from others, sense of security, and emotional control. It may also lead to disturbed cognitive reactions, depression, excessive dependency, and poor cooperation. Such psychological regression may, in turn, have a deleterious effect on the patient's ability to benefit from the medical treatment.
Dr. Granick pointed out that, until the early 1950's, virtually no systematic attempt was made to develop psychological tests specifically for the aged. Tests were used to evaluate cognitive, perceptual, social, and personality functioning of the elderly, but these had actually been standardized on younger age groups, with no norms being available on people 65 and older. Even the Wechsler Adult Intelligence Scale had normative data based on a population below age 65, and it was not until 1981, when the test was restandardized, that norms were developed for an older range (to age 75).
Today, according to Dr. Granick, a fairly sophisticated level of assessment technology is being used in conjunction with existing psychological instruments, as well as in the development of new measurement procedures specifically for the aged.
For those that are used, however, a number of practical considerations are suggested:
- Test length should be adjusted for fatigue. This is important when testing aged patients who may be expected to have attention or energy limitations. The test should either be made shorter or be arranged so that it is possible to be completed in more than on session.
- Test content should be of significant stimulus value to the aged.
- Test directions and materials should be adapted to the visual and auditory limitations of the aged.
- Directions for administration should be specific and include information on the testing environment, materials required, and acceptable adaptations that can be made in the procedures.
- The test manual should state the rationale and purpose of the test along with other information on its development and ways of being used.
- The origin and rationale of the test items selected should be described as well as the results of item analyses and other research findings.
- The qualifications and training for proper administration of the test should be stated.
Dr. Granick indicates that gerontologists have recently begun to develop a multidimensional assessment procedure that combines within a single instrument all the major domains of a comprehensive psychological evaluation. Goals for this approach include developing a testing instrument that is easy to administer, is nonthreatening and nontiring for the subject, and gathers enough information to make a realistic classification of the patient and his/her needs.
Three such instruments are currently available and were designed with the aged in mind. The Multidimensional Functional Assessment Questionnaire (called OARS) contains a 10-item test of mental status; 5 questions on the extent of worrying, satisfaction, interest in life, quality of the current mental status, and change in mental status in the past 5 years; and a 15-item Short Psychiatric Evaluation Schedule. Administration is relatively easy to carry out without much stress for the subject, and takes only 10 to 15 minutes.
The Comprehensive Assessment and Referral Evaluation (CARE) is administered by trained interviewers who require an average of 90 minutes to complete the three sections of the instrument (medical, psychiatric, and social). Scores represent a variety of global judgments and semi-structured ratings related to the subject's responses to various questions. Memory and orientation are measured with 21 items, and 48 items are used to study anxiety, depression, and other aspects of mental-health functioning.
In 1982, the Philadelphia Geriatric Center's Multilevel Assessment Instrument (MAI) was introduced. This procedure was also designed with the aged in mind, with the manual being quite specific in its instructions to the examiner as to how best to deal with the special problems aged persons may experience in being tested or interviewed. A conception of the "good life" for the aged guided the developers of the instrument and led to the inclusion of test items or questions for four major areas of functioning: behavioral competence, psychological well- being, perceived quality of life, and objective environment. These four areas, in turn, are made up of seven domains: physical health, cognition, activities of daily living (ADL), time use, social interaction, personal adjustment, and perceived environment. The total procedure contains 216 items and takes less than an hour to administer.
The MAI can provide an extensive and rich array of information on the geriatric patient's competence to deal with daily life, along with indications of the level and quality of his or her psychological well- being. The instrument's design also enables one to obtain valid results with the use of a short form of the interview, so it can be used as a screening device.
The Role of Social Networks for the Elderly (Dr. Lisa Berkman)
According to Dr. Berkman, it appears that the web of social relationships that surrounds us is increasingly being implicated in the etiology of disease.
In looking for people at increased risk to a variety of diseases, researchers have identified certain groups who appear to be particularly vulnerable. Widows, people living in socially disorganized environments, and people who are very mobile either occupationally or geographically are often thought to be at increased risk.
One element common to all these groups, suggests Dr. Berkman, is that they have few social and community ties and resources. In one way or another, they have become detached from intimate or community contacts.
Social isolation has often been proposed as a critical aspect of the aging process itself and it is commonly held that the elderly are isolated. Widowhood, retirement, and grown children leaving home may bring about an irreversible loss of social attachments and community ties. But if the relationship between social isolation and poor health is a causally strong one, we would expect this to profoundly affect the elderly, for whom such losses are common.
In fact, however, the evidence is quite surprising according to Dr. Beckman. While there is some evidence to suggest that social networks play a role in disease etiology, there is less-convincing evidence regarding increasing social isolation as an age-linked phenomenon, and even less evidence supporting the notion that the relationship between social networks and health status may be unique to, or different for, the elderly. Old people may in fact be somewhat less vulnerable to certain stresses.
As far as social relationships are concerned, it is important to remember that one is dealing with statistical associations. Just as some smokers do not get lung cancer, some isolated people do well. In either case, but particularly with regard to social networks, it may not be within a person's control to make friends, for example. In some cases, social isolation may be part of the social fabric--the result of a move, housing conditions, etc. In the long run, though, we need to consider societal and environmental changes that will promote strong bonds between people instead of weakening them.
Further, according to Dr. Berkman, there is a difference between social networks and social support. At this time, researchers have very little information on which networks are supportive. For example, are daughters more helpful than sons? Are neighbors more helpful than relatives? All self-reports are colored by social response patterns, and feelings about support are certainly molded by psychological factors. Accurate answers to these questions about which social support networks are best must await information from new studies.
Finally, while social relationships are important, as yet we do not have answers to three key questions that clinicians can use to predict disease risks related to then. First, it is not at all clear that living alone, being single, or not having a family necessarily implies social isolation. In fact, the data produced thus far argue for more complex measures. Most people--even old people, stated Dr. Berkman--on the whole seem amazingly resilient and flexible, and able to make new relationships, suitable trade-offs, and substitutions. In fact, only in the absence of all contact do sizeable increases in risk appear.
All of this leads to the conclusion that social relationships and connections are probably very important to the health and well-being of older people--just as they are for young people.
Productive Activities and the Elderly (Dr. Robert Kahn)
It is commonly held that the aged experience a sense of powerlessness and boredom that often comes with retirement.
But is this "nothing to do" concept really valid when one considers normal activities of many elderly persons? Dr. Kahn believes not and argues for a new concept to be used in the assessment of older men and women: productive behavior. The reasons Dr. Kahn advances for using productive behavior as an assessment criterion are several:
- Activity is itself an indicator of health and well-being, and an expression of capacity.
- It is likely that productive activities promote well-being as measured by other criteria. For example, appropriate physical exercise can bring about cardiovascular improvement and the accomplishment of complex cognitive tasks can increase intellectual capacity.
- The productive activities of an individual, in comparison with his or her consumption of goods and services produced by others, indicate the net contribution or demand of the individual on the society. Such measures can be aggregated for age groups, or for other categories of interest.
Despite the promise of the productive behavior concept, a wholly satisfactory definition has yet to be developed, and operational measures are still at an early stage of formulation. Two approaches of promise involve the use of market value (the current cost of hiring a service, if it were not performed voluntarily) and the use of time (hours spent on given activities). In fact, many unpaid activities contribute indirectly to the nation's inventory of goods and services. The care of the ill, the care of a home, gardening, and childcare of grandchildren are important activities that are usually classed as "unproductive."
Five categories of productive behavior have been proposed in the National Plan for Research on Aging, all of which appear amenable to today's assessment instruments. The categories include paid employment, unpaid employment, voluntary organizational activity, mutual help, and self-care (care of person and immediate premises).
Major research tasks to develop productive behavior as a domain of assessment include an improved definition of productive behavior and its activity categories. In addition, ways of measuring these activities need to be developed and validated. Obvious questions suggest themselves: How many hours are worked per week? How many hours are devoted to unpaid work? How many volunteer, church, or civic groups does the person belong to? How much time is spent on individual tasks of self-care (ADL, IADL)?
Beyond such research is the need for field experimentation, designed to increase productive activities of older men and women. The aim is to uncover the full spectrum of the patient's former activities on the assessment, so that those patterns of behavior are disrupted as little as possible by medication, therapeutic rehabilitative interventions, or changed living conditions. Far from being a "burden on society," according to Dr. Kahn, the elderly are more often than not intimately tied into a modest network of productivity for everyone around them.
Afterword (Dr. Isadore Rossman)
There must be a wider awareness that the elderly constitute a growing class of medical patients, but one whose medical problems are profoundly influenced by social, psychological, and environmental factors. We are only now coming to recognize those factors and beginning to develop a science base that will underlie a new generation of assessment instruments.
Much work remains to be done on the reliability, validity, and comprehensiveness of such instruments. In time, this effort could quite possibly result in the identification of a few basic measures that all clinicians could use to quickly assess the status of a new patient. But that day seems not yet at hand.
Until then, it remains the responsibility of health-care practitioners to make the best use of the instruments and technology currently available. Ideally, they should be used with the same sense of care and confidence that an airline pilot exhibits as he scans down his preflight checklist. Both assessment instruments and preflight checklists are mere mechanical exercises, but both require thorough attention to details in order to prevent difficulties and correct identified problems.
About the NIH Technology Assessment Program
NIH Technology Assessment Conferences and Workshops are convened to evaluate available scientific information related to a biomedical technology when topic selection criteria for a Consensus Development Conference are not met. The resultant NIH Technology Assessment Statements are intended to advance understanding of the technology or issue in question and to be useful to health professionals and the public.
Some Technology Assessment Conferences and Workshops adhere to the Consensus Development Conference format because the process is altogether appropriate for evaluating highly controversial, publicized, or politicized issues. Other Conferences and Workshops are organized around unique formats. In this format, NIH Technology Assessment Statements are prepared by a nonadvocate, nonfederal panel of experts, based on: (1) presentations by investigators working in areas relevant to the consensus questions typically during a 1-1/2-day public session; (2) questions and statements from conference attendees during open discussion periods that are part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.
Preparation and distribution of these reports are the responsibility of the Office of Medical Applications of Research, National Institutes of Health, Bldg 31, Room 1B03, Bethesda, MD 20892.