Deborah T. Gold

Association of osteoporotic vertebral compression fractures with impaired functional status

PURPOSE To determine if vertebral compression fractures in elderly women were associated with impairments in physical, functional, and psychosocial performance. SUBJECTS AND METHODS Ten white women with confirmed vertebral compression fractures were age- and race-matched with 10 control subjects without fractures in a case-control design. All subjects invited to participate in this study were patients of the Geriatrics Division of the Department of Medicine at Duke University Medical Center. All study participants lived either in the community or in the independent-living sections of local retirement communities in and around Durham, NC. Subjects with fractures (mean age = 81.9 years, SD = 5.9 years) had two or more vertebral compression fractures in their medical records, whereas control subjects (mean age = 79.6 years, SD = 6.5 years) had no history of vertebral fractures. Spinal radiographs of all women confirmed group assignment. Physical, functional, and psychosocial performances were evaluated. Physical performance was assessed by measurements of maximal trunk extension torque and thoracic and lumbar spinal motion in the sagittal plane, functional reach, mobility skills, 10-ft timed walk, and 6-minute walk test. Thoracic and lumbar spinal configurations were also determined. Functional performance was assessed using the Functional Status Index. Psychosocial performance was assessed with the following scales: Hopkins Symptom Checklist 90 Revised, Rosenberg Self-Esteem Scale, West Haven-Yale Pain Inventory, Beck Depression Inventory, and single-item health-belief questions. RESULTS Control subjects were not significantly different from patients with fractures in age, weight, number of current illnesses, number of prescribed medications, number of pain medications, ratings of lumbar spine degenerative disc disease, or lumbar spine facet joint arthritis. Activity levels and exercise participation were similar in both groups. Control subjects had no vertebral fractures, whereas fracture subjects had 4.2 +/- 2.6 fractures (range: 2 to 10). Thoracic kyphosis was increased and lumbar lordosis was reduced in fracture subjects. Fracture subjects had reduced maximal trunk extension torque, thoracic and lumbar spine sagittal plane motion, functional reach, mobility skills, and 6-minute walk test. The Functional Status Index showed reduced levels of functional performance in fracture subjects compared with controls with increased levels of assistance, pain with activity, and difficulty in activities. Psychosocial performance was limited in fracture subjects with increased psychiatric symptoms, increased pain, and greater perception of problems caused by health. CONCLUSION Vertebral compression fractures are associated with significant performance impairments in physical, functional, and psychosocial domains in older women.

The Clinical Impact of Vertebral Fractures: Quality of Life in Women With Osteoporosis

Osteoporosis has obvious physical and functional consequences such as kyphosis, restricted range of motion, and pain. What are not so obvious are the psychosocial sequelae that result from this metabolic bone disease. Many patients in the initial phases of the disease express substantial anxiety, especially about the possibility of future fractures and physical deformity. As the disease progresses, depression can become profound for those who experience hip or multiple vertebral fractures. The effects of the chronicity of osteoporosis, its disabling and disfiguring aspects, and the chronic postural pain that develops as time passes challenge even the most stable individuals. In addition, osteoporosis has substantial impact on interpersonal relationships and social roles. The dependency created by this disease affects close relationships, because the patient with osteoporosis cannot reciprocate in social support. Todays older women find the restrictions of the disease socially devastating. These women, unlikely to work in the labor force, took pride in their roles of housekeeper and cook. Unfortunately, severe osteoporosis can force women to relinquish even these social roles, leaving them with no source of self-esteem or accomplishment. In all, osteoporosis is devastating both psychologically and socially.

Impairment of physical and psychosocial function in recurrent syncope

Physical and psychosocial function have rarely been assessed in syncope. We used two valid and reliable measures of health status, the Sickness Impact Profile (SIP) and the Symptom Checklist 90 (SCL-90-R), to assess functional impairment in 62 patients with recurrent syncope seen in a syncope specialty clinic. Mean total SIP scores were markedly elevated at 17 (SD = 14), indicating a level of impairment similar to severe rheumatoid arthritis and chronic low back pain. SIP psychosocial scores were significantly greater than SIP physical scores (20 vs 11, p less than 0.0001). SCL-90-R scores were also high, comparable to those of psychiatric inpatients. Somatization, anxiety and depression dimensions of the SCL-90-R were particularly elevated. SCL-90-R subscale scores were highly correlated with SIP psychosocial scores (all r greater than 0.4, and p less than 0.001). Neither age nor number of comorbid diseases correlated with measures of psychosocial function, suggesting that syncope itself causes psychosocial impairment. Although this was a referral population, these data suggest that function can be seriously impaired by syncope, that the degree of impairment is similar to that reported in other chronic diseases, and that syncope leads to significantly greater psychosocial than physical impairment.

Disability as a Function of Social Networks and Support in Elderly African Americans and Whites The Duke EPESE 1986–1992

Objectives. We examined the association of structural and functional aspects of social relationships with change in disability, and the degree to which race modifies these associations. Methods. Data are from a population-based sample of 4,136 African Americans and Whites aged ^ 65 living in North Carolina. Disability data were collected during seven consecutive yearly interviews and summarized in two outcome measures. Measures of social relationships included five measures representing network size, extent of social interaction, and specific type of relationships, as well as instrumental and emotional support. Weighted proportional odds models were fitted to model disability as a function of baseline social network and support variables, and the interaction of each variable with follow-up time. Results. Network size and social interaction showed significant negative associations with disability risks, which did not vary by race, or as a function of time. Social interaction with friends was associated with a reduced risk for disability, but social interaction with children or relatives was not related to disability. Instrumental support was associated with a significantly increased disability risk, with a greater adverse effect among Whites than African Americans. Emotional support was not associated with disability, but a protective effect for ADL disability was found after controlling for its intercorrelation with instrumental support. Discussion. The findings provide further evidence for the role of social relationships in the disablement process, although not all types of social relationships may be equally beneficial. Furthermore, these associations may be more complex than simple causal effects. There were few racial differences in the association of social relationships with disability, with the possible exception of instrumental support, which may allude to possible sociocultural differences in the experience of instrumental support exchanges.OBJECTIVES We examined the association of structural and functional aspects of social relationships with change in disability, and the degree to which race modifies these associations. METHODS Data are from a population-based sample of 4,136 African Americans and Whites aged > or = 65 living in North CAROLINA: Disability data were collected during seven consecutive yearly interviews and summarized in two outcome measures. Measures of social relationships included five measures representing network size, extent of social interaction, and specific type of relationships, as well as instrumental and emotional support. Weighted proportional odds models were fitted to model disability as a function of baseline social network and support variables, and the interaction of each variable with follow-up time. RESULTS Network size and social interaction showed significant negative associations with disability risks, which did not vary by race, or as a function of time. Social interaction with friends was associated with a reduced risk for disability, but social interaction with children or relatives was not related to disability. Instrumental support was associated with a significantly increased disability risk, with a greater adverse effect among Whites than African AMERICANS: Emotional support was not associated with disability, but a protective effect for ADL disability was found after controlling for its intercorrelation with instrumental support. DISCUSSION The findings provide further evidence for the role of social relationships in the disablement process, although not all types of social relationships may be equally beneficial. Furthermore, these associations may be more complex than simple causal effects. There were few racial differences in the association of social relationships with disability, with the possible exception of instrumental support, which may allude to possible sociocultural differences in the experience of instrumental support exchanges.

The Nonskeletal Consequences of Osteoporotic Fractures: Psychologic and Social Outcomes

The prevalence of osteoporosis is rising as the population of the United States and other developed countries ages. These increasing numbers of people have motivated pharmaceutical companies to develop and market several antiresorptive medications that can slow down the bone loss associated with osteoporosis. Although these are not cures for this disease, they are an important first step in a vital ongoing public health effort to prevent osteoporosis in the future and to manage osteoporosis now. We cannot expect to remediate the problems caused by this disease if we attend only to its skeletal implications. Like any other chronic disease, osteoporosis has significant psychologic and social consequences. From anxiety and depression to social withdrawal and isolation, if these problems are left unresolved, they can have a significant negative impact not only on health issues but also on overall quality of life. No quick fixes exist for the numerous ways in which osteoporosis can transform an autonomous person into a dependent and hopeless patient. In part, responsibility for helping this patient rests with the medical community. Referrals to appropriate providers can improve a patients physical and emotional well-being. Physician specialists can help the patient manage comorbid conditions. Physical and occupational therapists can teach exercises, home safety, and safe movement. Social workers can provide a framework for coping that enables individuals to improve their interpersonal interactions and minimize stress in their lives. Nutritionists, pharmacists, nurses, and other health care professionals can make major contributions to the quality of life of people with osteoporosis and should be encouraged to do so. Unfortunately, managed care has set policies that deprive patients with osteoporosis of the kinds of care that would be most useful to them. As we have advocated for the last 15 years, a multidisciplinary approach offers patients the most positive overall way to manage osteoporosis. Therefore, new alternatives need to be examined, alternatives that provide both low-cost and high-quality care. In the long run, patients who practice self-management, that is, those who take responsibility for their own calcium and vitamin D intake, are compliant with medications, exercise, and practice home safety, and who have a healthy outlook, can control their osteoporosis. The most effective intervention for the future may be to teach individuals how to use self-management strategies so that they can take charge of their osteoporosis and positively influence their quality of life.

Memory Complaint as a Predictor of Cognitive Decline A Comparison of African American and White Elders

Of a representative, racially mixed community sample of older adults in North Carolina, 59% of Whites and 49% of African Americans reported worsening memory. The complaint about memory was positively correlated with age, depressive symptomatology, and physical function but not with level of cognitive function as measured by the Short Portable Mental Status Questionnaire (SPMSQ) at baseline. In a controlled analysis of longitudinal data, initial SPMSQ score, age, African American race, lower education, depressive symptomatology, and physical deficits at baseline, but not memory complaint, predicted a decline in cognitive function as measured by the SPMSQ 3 years later. Whereas African Americans were less likely to complain of deterioration in memory, actual decline as measured by the SPMSQ was greater for African Americans than for Whites.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior.

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Recurrent syncope as a chronic disease: preliminary validation of a disease-specific measure of functional impairment.

Background: A disease-specific measure of functional health in syncope would provide an important outcome measure for use either in clinical trials or in the clinical management of patients with recurrent syncope.Methods arid Measurements: In a previous study the authors used formal functional status measures to determine physical and psycho-social impairment in recurrent syncope. This study provides a preliminary assessment of a disease-specific measure of function. The measure was pilot tested on 84 subjects, and validated in a separate cohort of 49 patients. The measure consists of 1) an 11-question matrix of yes/no questions, assessing the ways that syncope interferes with a patient’s life (the result is expressed as a proportion of the total number of ways that syncope might interfere and is called the Impairment Score), and 2) three Likert-scale questions that assess the patient’s fear and worry about syncope. Correlations were obtained between scores on the disease-specific measure and other measures of functional health.Results: Among the 49 patients in the test cohort, final scores on the disease-specific measure correlated with both physical and psycho-social dimension scores on a measure of functional status, the Sickness Impact Profile (r=0.35–0.36, p=0.01), and with five of ten subscale scores on a measure of psychological distress, the Symptom Checklist 90-R (r=0.30–0.43, p=0.004–0.02).Conclusions: This new disease-specific quality-of-life measure in syncope measures both physical and psychosocial components of impairment and could be a valuable adjunct in measuring outcomes in syncope patients.

Expenditures in caring for patients with dementia who live at home.

OBJECTIVES Given the national interest in progressive dementia, we estimated expenditures incurred in caring for dementia patients who live at home. METHODS Primary caregivers of 264 patients from a university-based memory disorders clinic were interviewed at baseline and asked to keep service use diaries for 6 months; 141 caregivers who returned the diaries are the focus of this report. We examined both formal and informal services (distinguished by whether money was exchanged) and associated expenditures. RESULTS Neither caregivers returning diaries nor their patients differed at baseline from those not returning diaries and their patients. Expenditures incurred over 6 months were extensive for both formal (

Health Professional's Guide to Rehabilitation of the Patient with Osteoporosis

6986) and informal (