Marion A. Becker

A new patient focused index for measuring quality of life in persons with severe and persistent mental illness

The quality of life in persons with severe and persistent mental illness is often poor. Most treatment programmes have the goal of increasing quality of life. Unfortunately, existing methods to assess qualtiy of life are cumbersome and oriented towards research rather than clinical settings. This study describes preliminary steps in the development, testing and application of a new patient focused index for measuring quality of life in persons with severe mental illness. The Quality of Life Index for Mental Health (QLI-MH) differs from existing instruments in that it is based on an easy to use, self-administered questionnaire that assesses nine separate domains that together encompass quality of life. Each domain can be individually weighted depending on its relative importance to the patient. Different parts of the instrument solicit information from the patient, the primary clinician and, when available, the family. The instrument and its scoring system address limitations of previous approaches to quality of life measurement.

Risk Indicators for Malnutrition are Associated Inversely with Quality of Life for Participants in Meal Programs for Older Adults

OBJECTIVE To evaluate the nature and strength of associations between quality of life and factors commonly linked with malnutrition in participants in a meal program for the elderly. DESIGN A questionnaire that assessed quality of life, nutritional risk, quality of health, depression, social satisfaction, functional status, food security, and food enjoyment was administered. SUBJECTS/SETTING All persons aged 60 years and older enrolled in the Title III-C meal program in Pepin County, Wisconsin, during a 1-month period were asked to participate. Of 180 eligible subjects, data were available for 155; 108 received meals at congregate sites and 47 received home-delivered meals. STATISTICAL ANALYSES PERFORMED Descriptive statistics were used to characterize the population. Independent-samples t tests and chi 2 analysis were used to test for differences between the congregate-meal group and home-delivered-meal group. Spearman correlation coefficients were used to determine the direction and magnitude of associations between scale variables and quality of life. RESULTS Quality of life and quality of health were positively correlated (r = .83, P < .0001). Nutritional risk, food insecurity, decreased enjoyment of food, depression, and impaired functional status were all negatively associated with quality of life. This research offers evidence that there are measurable associations between nutritional factors and quality of life. APPLICATIONS Our finding could be helpful to dietitians in justifying, planning, and evaluating nutrition programs and interventions. Quality of life in older adults may be further enhanced by programs that include social and psychological components in addition to elements oriented to reduce nutritional risk.

Attitudes towards mental health care in younger and older adults: Similarities and differences

It is commonly assumed that older and younger adults have very different attitudes about seeking mental health services and that this is a major factor in reducing the use of mental health services by the elderly. However, little evidence exists to illustrate how elders actually perceive mental health care. Responses from a survey of 474 older adults age 65 and over were compared with data from a national survey of 1001 persons age 21-65. Results indicate similarities in many attitudes including likelihood of seeking treatment for severe mental disorders, importance of mental health care, and concerns about cost and coverage as barriers to care. Differences included use of services, perceptions about less severe disorders, referral sources, and preferred providers. Clinical, policy and public education implications are discussed.

Assessing Alzheimer severity with a global clinical scale.

Diagnosis of dementia needs to be complemented by precise determination of disease severity across the broad spectrum of disease progression. The Mini-Mental State Exam (MMS), the Activities-of-Daily-Living assessment (ADL) and the Clinical Dementia Rating scale (CDR) were modified for direct comparability and administered to 112 outpatients and 45 nursing home residents with a range of dementia severity from mild to profound. The scales showed the highest correlations for the probable Alzheimers disease patient group (62) (Global Assessment of Dementia; GAD vs. ADL: r = 0.91; Extended Mini-Mental Assessment; EMA vs. GAD: r = 0.91; ADL vs. EMA: r = 0.86). For these patients, scores on the individual scales tended to be similar. Disparity among the three scores for individual cases was associated with the presence of comorbidities. The high correlations and correspondence among these scales demonstrate their reliability, validity, and utility in the assessment of dementia severity. The use of an average of these measures, with their increased precision, may give a more accurate indication of dementia severity over a broader range of impairment.

Physical health burdens of women with trauma histories and co-occurring substance abuse and mental disorders

This article documents the physical health burdens of participants in a large, federally funded cross-site study of specialized services for women with histories of trauma (physical or sexual abuse) and co-occurring substance abuse and mental health disorders. Nearly half of the 2729 women in the study (48%) reported serious physical illnesses that frequently limited their daily life activities or required them to use special equipment. Nearly half (46%) rated their health status as only fair or poor. Given the prevalence of physical illnesses in this population, behavioral service providers should discuss with clients their overall health and how it might hinder their participation in treatment for trauma, substance abuse, and mental illness, and policymakers should consider this need when designing behavioral health requirements, setting reimbursement rates, and allocating funds.

Predictors of Avoidable Hospitalizations Among Assisted Living Residents

OBJECTIVES Hospitalizations for long term care residents, including those from assisted living facilities (ALFs), are very costly, often traumatic, and increase risk for iatrogenic disorders for those involved. Currently, hospital expenditures account for approximately one-third of total national health care spending. Hospitalizations for ambulatory care-sensitive (ACS) conditions are considered potentially avoidable, as these are physical health conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely, adequate treatment at a lower level of care. The goal was to examine risk factors for hospitalization for an ACS condition of Medicaid-enrolled younger and older ALF residents during 2003-2008. DESIGN This is a retrospective cohort study that used 5 years of Medicaid enrollment and fee-for-service claims data. PARTICIPANTS The study sample included 16,208 Medicaid-enrolled ALF residents in Florida, 7991 (49%) of whom were 65 years of age or older. RESULTS In total, study participants had 22,114 hospitalizations, 3759 (17%) of which were for an ACS condition. Sixteen percent of all ALF residents (n = 2587), about 12% of the younger residents and 20% of the older residents, had at least one ACS hospitalization. ACS hospitalizations constitute 13% of all hospitalizations for the younger residents and 22% of all hospitalizations for the older residents. Using Cox proportional hazard regression, we found that for both age groups, increased age, being Hispanic or of other race/ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. For older residents, having a dementia diagnosis and being African American reduced the risk of ACS hospitalization, whereas for younger residents having a major psychotic disorder reduced the risk of ACS hospitalization. CONCLUSION The results highlight the need for increased education, communication, and future research on these predictive factors. The increased frequency of hospitalization for ACS conditions among ALF residents with minority status and older age may well indicate that their more complex health care needs are not being adequately addressed. The role of serious mental illness and dementia in risk for ACS hospitalization also deserves further attention.

Racial and Ethnic Disparities

The primary objective of this chapter is to provide information on economic, psychiatric, and cultural factors that influence service access by racial/ethnic minority women. A secondary objective is to discuss the policy implications of existing research for mental health services that are provided to this population. These objectives draw from the extent and nature of the problems faced by minority women. According to the recent estimates, of the nearly 153 million women living in the USA, more than 31 million (20%) are members of racial/ethnic minorities (U.S. Census Bureau 2007). Their health, therefore, both physical and mental, assumes significance in terms of health services provision and overall social policy.

The effect of cholinesterase inhibitors on risk of nursing home placement among medicaid beneficiaries with dementia.

The purpose of this study was to explore the effect of therapy with cholinesterase inhibitors (ChE-Is) on the risk of nursing home (NH) placement in patients with dementia. Participants were enrolled in the Florida Medicaid program during the fiscal year 1998 to 1999 (N=1188). Of these, 378 had Alzheimer disease as their only dementia diagnosis. About 50% of the sample received ChE-Is. The total follow-up period was 36 months. We used Cox proportional hazard regressions to estimate the risk of NH placement. After adjusting for age, sex, race, and cooccurring diagnoses, we found that dementia patients receiving ChE-Is had reduced risk of NH placement by 28% at 12 months [hazard ratio (HR)=0.72, 95% confidence interval (CI) 0.55-0.94] and 21% at 18 months (HR=0.79, 95% CI 0.62-0.99). The reduction in risk was more pronounced in patients with Alzheimer disease only and was still significant at 24 months after baseline (HR=0.66, 95% CI 0.43-0.99). At 36 months, the association between taking ChE-Is and risk of NH placement was not significant and the proportion of participants placed in a nursing was almost identical. Therapy with ChE-Is may temporarily reduce the risk of NH placement in Medicaid beneficiaries with dementia, thereby improving quality of life and preserving personal and societal resources.

Serious Mental Illness in Florida Nursing Homes: Need for Training

ABSTRACT This study examined how the mental health needs of nursing home (NH) residents with serious mental illness (SMI) are addressed. Data were collected from three sources: interviews with 84 SMI stakeholders; surveys of 206 NH staff members; and focus groups at two psychiatry specialty NHs. Four common themes emerged: placement of older adults with SMI was a significant problem for discharge planners and NH admission coordinators; NH staff reported being uneasy with SMI residents and were concerned over aggressive behavior; staff in NHs with psychiatry specialty units appeared more comfortable serving SMI residents; and SMI training was a consistent recommendation of all SMI stakeholders and NH staff. Implications for training are discussed.

Risk Factors for Early Readmission to Acute Care for Persons with Schizophrenia taking Antipsychotic Medications

OBJECTIVE The study examined risk factors for readmission to acute care among Florida Medicaid enrollees with schizophrenia treated with antipsychotics. METHODS Medicaid and service use data for 2004 to 2008 were used to identify adults with schizophrenia discharged from hospitals and crisis units who were taking antipsychotics. Data were extracted on demographic characteristics, service use before admission, psychopharmacologic treatment after discharge, and readmission to acute behavioral health care. Cox proportional hazards regression estimated readmission risk in the 30 days after discharge and in the period after 30 days for participants not readmitted in the first 30 days. RESULTS The mean±SD age of the 3,563 participants was 43.4±11.1; 61% were male, and 38% were white. Participants had 6,633 inpatient episodes; duration of hospitalization was 10.6±7.0 days. Readmission occurred for 84% of episodes, 23% within 30 days. Variables associated with an increased readmission risk in the first 30 days were shorter hospitalization (hazard ratio [HR]=1.18, 95% confidence interval [CI]=1.10-1.27, p<.001), shorter time on medication before discharge (HR=1.19, CI=1.06-1.35, p=.003), greater prehospitalization use of acute care (HR=2.64, CI=2.29-3.05, p<.001), serious general medical comorbidity (HR=1.21, CI=1.06-1.38, p=.005), and prior substance abuse treatment (HR=1.58, CI=1.37-1.83, p<.001). After 30 days, hospitalization duration and time on medication were not significant risk factors. CONCLUSIONS Short hospital stays for persons with schizophrenia may be associated with risk of early readmission, possibly because the person is insufficiently stabilized. More chronic risk factors include prior acute care, general medical comorbidity, and substance abuse.