[112] PERFORMANCE-BASED PREVENTION/REHABILITATION OF FALLS IN ELDERLY VETERANS
Kevin M. Means, MD; Daniel E. Rodell, PhD; Patricia S.
O'Sullivan, EdD
Physical Medicine and Rehabilitation Service and Falls
and Mobility Disorders Program, VA Medical Center, North
Little Rock, AR 72114; Research, Social Work Service, John L.
McClellan Memorial VA Medical Center, Little Rock, Arkansas
72205; College of Nursing Research Center, University of
Arkansas for Medical Sciences, Little Rock, Arkansas 72205;
email: means.kevin@little-rock.va.gov;
rodell.daniel@little.rock.va.gov;
posullivan@con.uams.edu
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #E827-RA)
PURPOSE--The objective of the study is to further refine a functional obstacle course developed to balance and mobility of elderly community-dwelling persons; to determine the efficacy of a rehabilitation program in reducing frequency and severity of falls and fall-related injuries by improving the balance and mobility of elderly persons who fall, and to determine the efficacy of a rehabilitation program in preventing falls by maintaining/improving balance and mobility among persons with no history of falls.
METHODOLOGY--A retrospective comparison of performance data from the new and old versions of the obstacle course will be made. Baseline obstacle course testing on community-dwelling, ambulatory elderly veterans with falls (fallers) and without (nonfallers) will be completed. One hundred-twenty consecutive fallers will participate in a 6-week falls prevention/balance rehabilitation exercise program lead by a physical therapist. One hundred-twenty nonfallers will be randomized into either an identical 6-week falls prevention/balance rehabilitation exercise program or a nonexercise control group. All persons completing an exercise group will be offered an optional maintenance exercise program. Obstacle course and other clinical testing will be repeated immediately postintervention and 6 and 12 months afterward. Exercise adherence will be monitored, as will the prospective monthly falls and fall-related injuries of all participants for 18 months. Preintervention to postintervention measures will be compared.
PROGRESS--Recruitment has been extended to include the spouses of veterans. This may improve participation and adherence. The originally planned nonexercise control group for nonfallers has been extremely difficult to recruit and retain. A delayed or modified exercise group is planned instead.
PRELIMINARY RESULTS--To date, 158 persons have been screened for eligibility for the study; 126 of them have entered the study and completed their pretest evaluation, and 77 have started or completed their 6-week intervention program and a posttest evaluation. Eighteen persons have completed a 6-month follow-up evaluation. Four have dropped out of the study to date. No analyses have been completed on this incomplete sample.
[113] UPPER BODY MOTION ANALYSIS FOR AMELIORATION OF FALLS IN THE ELDERLY
Eric E. Sabelman, PhD; Carol H. Winograd, MD; Betty
Troy, MS; Deborah Kenney, MS OTR; Sandra Dunn Gabrielli;
David Jaffe, MSEE; John W. Oehlert, MS; Wayne Phillips,
PhD
Rehabilitation R&D Center, VA Palo Alto Health Care
System, Palo Alto, CA 94304; Dept. of Functional
Restoration, Stanford University Medical School, Stanford CA
94305; Center for Research on Disease Prevention, Stanford
University, Stanford CA 94305; email:
sabelman@roses.stanford.edu
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(#E601-2RA)
PURPOSE--The sense of balance declines with age due to combined vestibular, proprioceptive, and visual losses, resulting in impaired mobility and increased risk of injurious falls. A wearable accelerometric instrument has been developed to record movements outside the laboratory, identify motion patterns that accompany loss of balance before a fall occurs, warn the individual of prefall behavior, and if necessary, signal that the wearer has fallen. Clinical use of accelerometric instrumentation is anticipated to occur as a diagnostic tool to quantify hitherto qualitative measures of balance, as a biofeedback device during therapy, and as a fall-prevention aid or a balance orthosis for fall-prone elderly individuals.
METHODOLOGY--The accelerometric motion detection system consists of two small 3-axis sensors attached to both corners of eyeglass frames to measure head motion, and a sensor above each hip on a belt at the waist. Also on the belt is a self-contained data acquisition package that digitally records sensor outputs. An infrared remote control is used to command the wearable unit, so the wearer is unencumbered by cables. In a typical test, subjects perform 65 tasks in 8 categories derived from qualitative balance assessment protocols, including: stand eyes open, then closed (15 s); ascend stairs, turn, then descend; rise from and sit in chair; normal walk 10 m; tandem (toe-to-heel) walk 3 m; walk over obstacles 1 m apart. After testing, data are transferred to a fixed computer for analysis.
PROGRESS--Advances in computer and sensor technology have improved the size, speed, and power consumption of the equipment. Data sampling rates have been increased from 50/s to 200/s. A second-generation device incorporates digital pulse-output acceleration sensors, two semicustom digital signal processing chips, and PCMCIA memory cards. The chips perform time integration, scaling, and transfer of data to the computer for storage, and in addition can detect peaks in any channel's signal. The PCMCIA card is removed from the wearable computer and plugged into a fixed computer, eliminating the present slow serial data transfer process. Subject populations were comprised of acute stroke patients, Parkinson's disease patients, and hip arthroplasty patients, as well as nondisabled subjects induced to stumble in the laboratory. Local collaborators have used the method in a study of therapeutic interventions in fall-prone elderly subjects, and other researchers have studied fatigue in walking by the elderly, frail hospitalized patients, and standing balance in a variety of subjects. Duplicate sets of accelerometry apparatus have been placed with researchers engaged in balance and mobility testing of diverse elderly populations. These include collaborators at the Travelers Center on Aging at the University of Connecticut Health Center, Department of Movement Sciences and Education at Teachers College of Columbia University, and Zablocki VA Medical Center, Madison, WI.
FUTURE PLANS--In addition to its use as a diagnostic and therapeutic tool for balance-impaired elderly individuals, realtime accelerometric pattern analysis and feedback can be applied to prevention of reinjury following occupational rehabilitation, and to athletic training. A collaboration has been established to develop a special-purpose device for identifying and preventing lateral falls likely to result in hip fracture.
[114] EXERCISE PROGRAM DESIGNS FOR OLDER ADULTS
Lisa Boyette, MEd; James E. Boyette, MS
Atlanta VA Medical Center (151-R), Rehabilitation
Research and Development Center, Decatur, GA 30033; email:
boyette.lisa_w@atlanta.va.gov
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #E825-3RA)
PURPOSE--This 2-year study will develop an expert system that creates individualized exercise plans for healthy older adults using factors, or determinants, that affect exercise initiation and adherence. The exercise plans produced by this system can be used by practitioners at VA hospitals and other healthcare facilities during regular physical examinations and routine medical visits of older adults to help them initiate and adhere to exercise programs. The system will focus on personal, environmental, and activity characteristics that act as incentives and barriers to exercise initiation and adherence and will be a model of determinants and recommended strategies that provides the understanding needed to help improve exercise initiation and adherence for healthy older adults, including older veterans.
METHODOLOGY--The knowledge base will be reviewed by local and national experts in the fields of medicine, exercise physiology, health promotion, exercise psychology, psychometry, and gerontology. Using case study analyses, the experts will develop a rule base to define the relationships between the determinants and the recommended strategies. The knowledge base will then be translated into a diagnostic questionnaire and implemented into a computerized expert system. Local and national experts will validate the knowledge base by consensus. Case studies of healthy older adults will be analyzed using this system, with a focus on how the exercise plans created by the system respond to each subject's profile on exercise initiation and adherence determinants. A priority ordering will be assigned to the determinants based on their importance in creating recommended strategies. Discrepancies between recommended strategies in the plan and expert opinion will be cross examined until consensus is reached among the experts concerning the appropriateness of the exercise plan developed for each subject.
PROGRESS--A notebook containing the updated initial knowledge and other pertinent information was sent out to 16 experts, both local and national. Most have critiqued the initial knowledge base for organizational structure, completeness, and importance of the exercise determinants, editing the material by writing comments directly on the printout or by using the software contained in the notebook. They ordered the determinants according to how they affect initiation or adherence, and they have returned their case studies. Currently project staff is updating the knowledge base to reflect their input.
PRELIMINARY RESULTS--Pilot work has been conducted to determine the practical usefulness of the expert system within the Atlanta VA Medical Center as well as creating the initial knowledge base. This base has been updated by the addition of additional references and findings from studies recently conducted at the Atlanta Rehab R&D Center and is being revised based on the experts' review.
FUTURE PLANS--This system will allow customization of exercise plans for healthy older adults that will increase the likelihood that they will initiate and adhere to exercise. It can later be expanded to include recommendations specific to other subpopulations, including those with physical disabilities and chronic illnesses. Several follow-up studies will further validate the system and expand it to include subgroups of frail and disabled elderly individuals.
[115] AGE-RELATED CHANGES IN THE TRICEPS SURAE STRETCH REFLEX AND POSTURAL CONTROL
Steven L. Wolf, PhD
VA Medical Center, Decatur, GA 30033
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #E723-2RA)
No report was received for this issue.
[116] NONINVASIVE RECORDINGS OF BLADDER PRESSURE IN ELDERLY MALES
John S. Wheeler, MD; James S. Walter, PhD; James S.
Griffin, MD; Timothy G. Schuster; Lisa Schlehahn, MSN;
Margot S. Damaser, PhD
Hines VA Medical Center, Rehabilitation Research and
Development Center, Hines, IL 60141; Loyola Medical Center,
Department of Medicine, Maywood, IL 60153
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #B2025-RA)
PURPOSE--Obstructive voiding is best evaluated with urodynamics, including bladder pressure and urine flow rates. Until recently, the recording of bladder pressure required the use of a urethral catheter. We evaluated a noninvasive back-pressure method using an external condom catheter around the outside of the penis to determine bladder pressure. Design criteria for clamping devices, back-pressure condom devices, and recording techniques were investigated.
METHODOLOGY--Back-pressure recording was conducted with a modified commercial condom catheter. An outlet tube was inserted into the side of the condom for pressure recording while clamping the exit tube. Silastic cement was also placed around the condom to prevent ballooning and reduce compliance during back-pressure procedures.
Four subjects with voiding complaints underwent testing in our urodynamic clinic. In the standing position and at peak urinary flow rate, the outlet tube of the external condom was clamped for 1-3 s and the back-pressure measurement was repeated once or twice while the patient voided to completion. The condom catheter was then removed and the urethra catheterized for cystometry and pressure/flow studies. Rectal pressure was also recorded. Filling of the bladder was conducted with sterile water at 30-60 ml/min.
PRELIMINARY RESULTS--This study shows that back-pressure results were similar to pressure/flow results using a urethral catheter into the bladder. Results for the four subjects showed no statistically significant differences (p=0.836) when comparing pressure results between back-pressure procedures and standard pressure/flow procedures. This study also indicated that the clamping procedures on the outlet tube caused a back flow of urine which facilitated the back-pressure recordings. Compliance of the catheter and longer clamping times may be issues that will continue to merit study.
FUTURE PLANS--We propose to study simultaneous back-pressure recording with bladder pressure recording via a urethral catheter. Additional parameters for back-pressure recording are being determined, including clamping procedures and condom catheter design.
[117] EFFECT OF CHAIR DESIGN ON CHAIR RISE PERFORMANCE IN DISABLED OLDER ADULTS
Neil B. Alexander, MD; Andrzej Galecki, PhD; Linda
Nyquist, PhD; Mark Hofmeyer, BS; Martina Grenier, BA; Julie
Grunawalt RN MS; Donna Fry-Welch, MS PT; Jodi Buck,
BS
Geriatrics Center, University of Michigan, Ann Arbor, MI
48109-0010; GRECC Department of Veterans Affairs Medical
Center, Ann Arbor MI, 48105; email:
nalexand@medmail.med.umich.edu
Sponsor: Department of Veterans Affairs, VA Rehabilitation Research and Development Service, Washington, DC 20420 (Project #E760-RA); National Institute on Aging, Claude Pepper Older Adults Independence Centers, Bethesda, MD 20892
PURPOSE--Difficulty in rising from a chair and a bed is a significant problem for many older veterans. Few have empirically studied how to reduce rise difficulty. General training techniques often used in disabled older adults include task-specific training, (i.e., learning the task through practice of the components of the task) and progressive resistance (strength) training. Our goal was to improve chair and bed rise ability in frail older adults by combining task-specific and progressive resistance training. We hypothesized that task-specific resistance training can improve the ability of frail older adults to rise from a bed and a chair.
METHODOLOGY--Congregate housing resident volunteers were randomized into a training group or a control group for a 12-week controlled trial. Residents were eligible if they reported difficulty in least one of four mobility-related areas: transferring, bathing, toileting, walking. The training group performed a series of bed and chair rise-related tasks with vest, belt, and ankle weights, while controls performed seated flexibility exercises. Testing at baseline, and at 6 and 12 weeks, was performed on bed and chair rise tasks of graded difficulty (e.g., alter head of bed elevation and seat height, alter hand use). The main outcomes were whether the subject was able to successfully rise, and if successful, the time taken to rise.
PROGRESS--Thirty-eight volunteers have been allocated, 19 to each group (mean age 84 both groups). Due mainly to intercurrent medical illness, 10 subjects dropped out before completing 12-week testing, 4 in the control group and 6 in the intervention group, for a drop out rate of 26 percent.
RESULTS--Results are taken from data at the first site (n=17 total participants). The majority of training and control group subjects (11 of the 17) successfully completed more tasks (usual range 1-2) from baseline to 12-week test. Chair and bed rise task performance time was analyzed using a linear model covarying for baseline performance. The mean group difference in task performance time when adjusted for baseline values, varied from 0 to 17 s and more often favored the training group for bed rise tasks. For example, for some tasks when the head of the bed was at 45° elevation, (i.e., sit-up in bed, no hands) and supine to sit at edge (hands used), the mean group difference was 0.4-0.5 s in favor of the training group (p values 0.08 and 0.05 respectively). For sit-up in bed (no hands used) at 30° head of bed elevation, the mean group difference was 1 s (p=0.05) in favor of the training group. Mean performance time differences for the chair rise tasks favored either training or control groups, depending on the task.
IMPLICATIONS--We have demonstrated that subject recruitment, allocation to study groups, participation in training, and compliance to participation is feasible in frail older adult congregate housing residents. While there are improvements in rise ability in both control and training groups, there are suggestions of timed performance improvement in the training versus control groups. The incremental benefit of training over control interventions, especially in regard to the factors contributing to intervention outcome, must await further training and testing in additional sites.
[118] LONG-TERM EVALUATION OF MAXILLARY SINUS BONE GRAFTS WITH DENTAL IMPLANTS
Jon Tom McAnear, DDS; Michele Saunders, DMD; Christopher
Smith, DDS; Carol Venus, PhD; Suzanne Neil, DDS; John I.
Hudson, DDS; Michael C. Duggan, DDS
Audie L. Murphy VA Medical Center (160A), San Antonio,
TX 78284-0001
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project A649-3RA); Nobelpharma, USA, Inc.; Dentsplay,
Inc.
PURPOSE--Dental implants can greatly improve oral function. However, many candidates for implants have resorbed too much bone to support maxillary implants. This study was designed to demonstrate that autologous cortico/cancellous bone grafts from the ilium to the maxillary sinuses will mature (consolidate) and support titanium cylindrical implants, which, in turn, will support a fixed prosthesis that will withstand the masticatory forces of a similar prosthesis in the mandible. It is expected that subjects' biting force, mastication, deglutition, dietary intake, nutritional knowledge/attitudes, and reported self-esteem will improve subsequent to implant therapy and nutritional education, while speech articulation and acceptability will remain unaffected. The current patient population of the VA can benefit greatly from these procedures.
METHODOLOGY--After pretherapy evaluation of bite force, speech, deglutition, mastication, dietary intake, nutritional knowledge/attitudes, and reported self-esteem, subjects undergo the following: 1) bone transplant from the ilium to the maxillary sinus, and placement of five titanium cylindrical implants into the anterior mandible; 2) a soft tissue procedure on the mandible 2 months following bone augmentation and implant placement, if necessary; 3) 2 months later, placement of abutments through the soft tissue and attachment to the mandibular implants; 4) construction and placement of a fixed bridge to the mandibular implants and construction of a new maxillary conventional denture; 5) 5 1/2 months after bone grafting, placement of 6-8 implants in the bony maxilla, 4 of which are in the bone grafts; 6) 6 months later, placement of abutments through the maxillary soft tissue and attachment of abutments to implants; and 7) implant-supported maxillary fixed bridge construction. Computerized axial radiographs, as well as periapical radiographs and clinical examination, are used to determine the status of osseointegration. Post-testing is performed 1 month and 1 year after step 7.
PROGRESS--All 20 subjects have finished all surgical and prosthetics procedures.
RESULTS--All subjects have completed the treatment protocol and have undergone post-testing at 1 month. Fourteen of the 20 subjects have undergone post-testing at 1 year. A repeated measures ANOVA on the bite force measurement at baseline, 1 month, and 12 months revealed significant increases in peak force and average force at all sites (front, right and left). All tests were significant at the p<0.01 level. Peak and average bite force of 1-month and 12-month values are significantly higher than the pretreatment measurements at all sites. Subjects, on the average, show a 3 to 4-fold increase in peak and average bite force across all sites at the 1 month assessment. These differences are maintained at the 12-month assessment. At least one subject increased by a factor of 10. Subjects also show a significant 3 to 4-fold increase in masticatory efficiency and effectiveness at 1 month that is maintained at the 12-month assessment.
FUTURE PLANS--We will finish the required measurements, start the evaluation of the data obtained and present for publication. We shall follow these implant subjects for an additional 3-year period to assess the dimensions and densities of the bone grafts in the sinuses with computed tomography and the endosseous implants with standardized intraoral radiography. This is in an effort to comply with the recommendations of the 1988 NIH/NIDR Consensus Conference on Dental Implants, which recommended a 5-year follow up on all dental implants.
[119] ADJUSTMENT AFTER SPINAL CORD INJURY: THE 20-YEAR MINNESOTA LONGITUDINAL STUDY
J. Stuart Krause, PhD
Shepherd Center, Atlanta, GA 30309
Sponsor: National Center for Medical Rehabilitation Research, National Institute of Health, Bethesda, MD 20892; American Association of Spinal Cord Injury Psychologists and Social Workers; Minnesota Medical Foundation; National Institute for Handicapped Research
PURPOSE--The purpose of this project is to identify how aging impacts multiple aspects of life adjustment after spinal cord injury (SCI). Three separate parameters have been studied in relation to aging: (1) chronologic age, (2) time since injury, and (3) environmental change.
METHODOLOGY--Participants. Four study samples have participated over the 20-year period, the first three of whom were identified through two large midwestern rehabilitation hospitals. The inclusion criteria were traumatic onset SCI of at least 2 years duration and a minimum of 18 years of age at the time of the study. The first sample consisted of 256 individuals in the preliminary stage of the study in 1974. An additional sample of 193 was added in 1985 during the second stage of this study. Although no new participants were added during the third study stage in 1989, a third sample of 201 was added for the fourth stage in 1994. A fourth sample from the Southeastern United States was also added to the 1994 data collection (n = 607). Unlike the midwestern samples, the southeastern included significant minority representation (178 males, 67 females).
Instruments. The Life Situation Questionnaire (LSQ) was the primary outcome measure used during each of the four stages. It was developed in 1974 to measure information on multiple aspects of life adjustment. The LSQ was revised during each subsequent stage with core items maintained to allow for direct longitudinal comparisons over time. The most significant revisions were implemented during the 1985 stage.
Procedures. The LSQ has been sent to participants during each stage. A supplemental measure of personality was added in 1989 only, and a measure of social support was included in 1994. Attrition over time was primarily due to mortality and geographic mobility.
PROGRESS--Longitudinal analyses of the 9-year and 20-year periods have just been completed. Time-sequential analyses, comparing different samples added at different points in time, have also just been completed. Joint analysis of data from the midwestern and southeastern samples is currently underway in an attempt to identify geographic, gender, and race differences in life adjustment. The end result will be a refined LSQ.
RESULTS--Whereas the previous study stages had identified primarily positive changes over time, longitudinal analyses from the current study suggest that there has been a decrease over the last 9 years in subjective well-being, but not objective aspects of community reintegration. Time sequential comparisons, using time-lagged rather than longitudinal data, suggest that environmental and situational factors likely account for the declines in subjective well-being.
IMPLICATIONS--This research has suggested that adjustment is a dynamic process that is influenced by multiple factors. In particular, the aging process appears to be impacted by at least three independent factors, including chronologic age, time since injury, and environmental change. Ultimately, any study of aging and SCI must account for each of these three factors to fully understand the aging process.
FUTURE PLANS--A fifth follow-up study is planned for 1997 to 1999.
[120] THE NATURAL COURSE OF AGING IN SPINAL CORD INJURY: FUNCTIONAL ISSUES
Bryan Kemp, PhD; Margaret Campbell, PhD
Rehabilitation Research and Training Center, Rancho Los
Amigos Medical Center, Downey, CA 90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--The purpose of this study is to assess how aging affects functional capacities such as ADLs, IADLs, Work/Leisure/Social Roles and associations with social support.
METHODOLOGY--The design and sampling frame are grounded in the establishment of a comprehensive database employing a sequential research design. Participants undergo annual history and physicals. Comprehensive examinations including psychological, support, and functional profiles are conducted at 5-year intervals.
PROGRESS--To date, 150 individuals have been assessed.
PRELIMINARY RESULTS--Approximately 27 percent report a change in function. Nearly all report gradual changes. The average duration from onset to time of change is 15.8 years. There does not appear to be a relationship between current age and reports of change or between duration and change, but there may be an interaction between age at onset and number of years before change occurs. Bathing and toileting account for the largest percentages of changes in ADLs. Shopping, chores, and transportation accounted for 86 percent of the IADL changes.
FUTURE PLANS--Our goals are to continue to collect data, to describe more of the functional and social changes occurring and correlate these changes with physiological, psychological, and demographic data.
[121] CHANGES IN PHYSIOLOGIC AND HEALTH STATUS IN INDIVIDUALS AGING WITH SPINAL CORD INJURY
Robert L. Waters, MD; William Bauman, MD; Rodney H.
Adkins, PhD
Rehabilitation Research and Training Center, Rancho Los
Amigos Medical Center, Downey, CA 90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--The purpose of this research is to document and assess physiologic and health status of individuals aging with spinal cord injury (SCI), with a special emphasis on cardiovascular disease and to evaluate the relative effects of current age and time since injury.
METHODOLOGY--The design and sampling frame are grounded in the establishment of a comprehensive database employing a sequential research design. Participants undergo annual history and physicals with serum profiles, including sophisticated lipid profiles conducted and donated by Corning-Metpath Laboratories. Comprehensive examinations including glucose tolerance and insulin resistance, abdominal ultrasound, pulmonary function testing, bone density and body fat assessment by DEXA, psychological support, and functional profiles are conducted at 5-year intervals.
PROGRESS--Annual examinations have been performed on 742 participants aged 18 to 83; durations of injury 1 to 57 years; and age at injury <1 to 65. Annual examinations have been repeated on 144 participants. Comprehensive examinations have been performed on 157 participants.
PRELIMINARY RESULTS--Lipid profiles of SCI individuals indicate higher risk at younger ages than the general population. Levels of HDL cholesterol are significantly related to residual impairment, with complete tetraplegics having the lowest levels and approximately 40 percent having levels below 35 mg/dL. Regression analysis indicates age is a more important factor than duration of injury with regard to most dependent measures. Level of injury, gender, age at injury, and ethnicity are differentially associated with lipid profiles. Cardiovascular risk is associated with personality rather than with depression. Pulmonary function varies with age and level of injury. Bone loss at the knee is rapid and extreme within 18 months of injury and continues as expected with age, resulting in fracture thresholds being reached at earlier ages than the general population. Bone density in the lumbar spine of SCI individuals without other mitigating conditions increases with injury duration.
FUTURE PLANS--Recruitment and follow-up of participants will continue. To adequately assess the effects age and duration of injury in the context of other important variables (e.g., level of injury, age at injury, gender, ethnicity) requires a large and diverse sample. Projects to assess the extent of actual cardiovascular disease in the sample and the associations with risk factors, age, duration, level of injury, gender, and ethnicity have been initiated. Several manuscripts detailing the results summarized above are in process and a number are in press.
[122] POLICY BARRIERS TO ACCESSING TECHNOLOGY SERVICES FOR PEOPLE AGING WITH SCI
Phoebe Liebig, PhD
Rehabilitation Research and Training Center, Rancho Los
Amigos Medical Center, Downey, CA 90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--We shall examine the scope of current policies and financing mechanisms for access to rehabilitation services, independent living services, and assistive technology (AT) to maintain persons aging with SCI in employment and community-based living, seeking to identify barriers to responsiveness to the dynamic and changing needs of those persons in the matter of upgrades, modifications, or access to additional ATs. We shall attempt to identify alternative strategies for providing appropriate ATs, and we shall recommend alternative methods of financing and organizing these services.
METHODOLOGY--Policy review and survey.
PROGRESS--We have conducted a nationwide survey of state legislative analysts about a variety of state policies affecting AT, and we have made a follow-up study of 10 State Units on Aging (SUAs) with a high level of effort in home modifications and their interactions with their state-level rehabilitation agencies.
We have analyzed RESNA consumer data by two age groups; 40-60 and 61+ to determine particular problem areas, unmet needs, types of problems encountered (lack of knowledgeable professionals and getting letters or calls returned), and receipt of AT information and referral services. We have also analyzed the raw data from an unpublished AT study conducted by the American Society on Aging of SUAs and State Tech Act Projects.
PRELIMINARY RESULTS--We are writing a report on policies affecting AT for persons aging with SCI and other disabilities. It covers three models of disability policy and their effects on the availability of, and access to, AT. It includes an historical overview of AT-related policies, summaries and analyses of major reports on federal and state policies and programs, consumer research relevant to policy issues, conclusions and recommendations for additional research and analysis, and tentative policy recommendations (e.g., the need to create policies sensitive to changing disability status over the lifespan).
FUTURE PLANS--We continue to analyze data: the above report should be completed by mid-1997.
[123] USE OF TECHNOLOGY SERVICES TO MAINTAIN EMPLOYMENT AMONG PEOPLE AGING WITH A SPINAL CORD INJURY
Don McNeal, PhD
Rehabilitation Research and Training Center, Rancho Los
Amigos Medical Center, Downey, CA 90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--The purposes of this study are to document the degree and extent of need for job accommodation of people aging with a disability and to develop strategies for providing job accommodation services. Information about accommodation needs will be gathered through structured interviews. Based on these data, strategies for providing job accommodation services will be developed.
METHODOLOGY--We interview and survey individuals and employers, and assess worksites.
PROGRESS--Fifteen individuals have been assessed to date.
PRELIMINARY RESULTS--Thirteen of 15 had at least some college education and were currently working. The total sample had worked an average of 16 years and almost all required accommodations when work resumed following SCI. Seven reported functional decline since SCI.
FUTURE PLANS--The study will continue to add to the sample and beginning worksite assessments.
[124] ASSESSMENT OF RESIDENTIAL CARE FACILITIES AS AN ALTERNATIVE COMMUNITY SERVICE MODEL FOR DISABLED OLDER ADULTS
Judith M. Mitchell, PhD
Rehabilitation, Research and Training Center on Aging,
Rancho Los Amigos Medical Center, Downey, CA 90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 20202
PURPOSE--The purpose of this project is to investigate how Assisted Living (AL) facilities for the elderly operate as a community-based service model for disabled persons no longer able to remain in their homes. The major objective is to explore how well these homes meet the multiple health and psychosocial needs of their clientele with varying levels of functional impairments, thereby enabling them to "age in place," and avoid institutionalization.
METHODOLOGY--This study will combine an environmental assessment of AL facilities with a health and psychosocial needs assessment of residents. Data are collected by self-report from directors of randomly selected facilities, and from interviews with a sample of residents within each facility. Projected sample size will be 80 facilities representing small, medium, and large bed sizes, and 280 residents within these facilities. Facilities are recruited within the Los Angeles and Orange County areas in California. Secondly, data from another study about functional care needs of older adults living in their own homes will be used for comparative purposes to residents living in AL facilities.
PROGRESS--Data have been collected from 13 facilities and 65 residents. Preliminary descriptive data is available at this phase. Characteristics of surveyed facilities were 83 percent for profit, 91 percent had residents receiving Supplemental Security Income, and the average rate of residents with memory problems was 21 percent. A majority of facilities reported adequate environment accommodations, with fewer facilities having personal assistive devices available for resident use as needed.
A preliminary comparison of health care needs among facility residents with a comparative group of disabled older adults living in their own homes found the following: persons living in either arrangement have similar levels of chronic health problems, incontinence problems, and ADL and IADL health care needs. Thus, living in a AL facility did not necessarily indicate greater functional care needs. Differences in health care were found in an increased need for facility residents to use minimum nursing care. Family involvement (when family existed) ranged from moderate to high for both groups of residents; however, a sizeable minority of facility residents had never married and had no family available. Type of family involvement varied between the two groups, with more social visits and money management given to AL residents and additional functional help given to at-home residents.
[125] MEDICAL COMPLIANCE BY OLDER ADULTS: THE IMPACT OF TREATMENT EXPECTATIONS AND PSYCHOLOGICAL FACTORS OF BOTH FAMILY AND PATIENTS
Judith M. Mitchell, PhD
Rehabilitation, Research and Training Center on Aging
and Disability, Rancho Los Amigos Medical Center, Downey, CA
90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 20202
PURPOSE--The health care needs of elderly adults encompass a multitude of chronic health problems, impairment, and disability. To meet these needs, treatment may be multidisciplinary, leading to several, concurrent treatment recommendations to implement. The purpose of this study was to investigate how psychological factors and treatment expectations of both patient and family members affect medical compliance with concurrent treatments.
METHODOLOGY--Data were collected from 25 older adult patients and a corresponding family member who attended a three-visit multidisciplinary outpatient assessment clinic at Rancho Los Amigos Medical Center. Treatment recommendations were given in the areas of medical, OT, PT, and psychosocial needs. Typical recommendations were referrals to specialists (medical), need for OT equipment (OT), help with mobility (PT), and referrals to counseling or socialization activities (psychosocial).
RESULTS--Patients received an average of three treatment recommendations in 2.3 different modalities. Compliance was noted if the patient met the recommendation within 4 months. Compliance was highest with medical treatment (69 percent) and lowest with psychosocial treatment (52 percent). Overall compliance rate was 58 percent. Medical compliance correlated with positive health locus of control by both family (r=0.63, p<0.05) and patient (r=0.55, p=0.08). Both medical and psychosocial compliance correlated with patient's level of depression (r=0.61, p<0.05; and r=0.55, p<0.05 respectively). OT compliance correlated with increased impairment in ADLs (r=0.65, p<0.01) and IADLs (r=0.45, p=0.10). No measured variables influenced PT compliance.
Data were collected from two medical professionals on their clinical impressions of family member and patient treatment expectations in: a) treatment goals, b) time to achieve goals, and c) efforts to achieve goals. Family had more realistic expectations in these 3 areas (60-72 percent) than patients (36-44 percent). However, findings revealed that high expectations correlated with increased compliance. In those seven cases where family goal expectations were high, overall treatment compliance increased from 50 percent to 75 percent. High treatment expectations among patients were associated with increased total compliance rates of 67 to 87 percent compared to 50 to 59 percent compliance when expectations were realistic or low.
[126] UTILIZATION OF IN-HOME PAID ASSISTANCE BY HISPANIC AND ANGLO OLDER ADULTS, AND MODEL DEVELOPMENT TO ENHANCE UTILIZATION
Judith M. Mitchell, PhD
Rehabilitation, Research & Training Center on Aging and
Disability, Rancho Los Amigos Medical Center, Downey, CA
90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 20202
PURPOSE--The purpose of this research is to investigate the utilization of custodial paid in-home assistance by Hispanic and Anglo disabled older adults, as representing a major long-term community care model that can prevent premature institutionalization. The project has three objectives: Medical: to investigate how well in-home paid assistance meets the functional needs of older disabled adults and document evidence of unmet health care needs; Ethnic: to document ethnic differences in service utilization, family involvement, satisfaction with care received, and evidence of unmet care needs; and Problems and Preferences: to identify the problems older adults experience with paid assistance utilization, their preferences with paid attendant traits, and the gatekeepers utilized by adults to acquire adequate knowledge to successfully use paid in-home assistance
METHODOLOGY--Data collection will be by in-home structured interviews with older adults who use a paid attendant, with a final sample size of 130 (65 per ethnic group). Participants in this study represent both publically and privately paid attendants, and different methods of acquiring paid in-home help (i.e., the independent provider method, use of a home health agency, use of extended programs through Visiting Nurses Associations, use of MSSP sites, and so forth). Participant recruitment has been accomplished through Rancho Los Amigos Medical Center Gerontology Services and local community agencies providing gerontology case management.
PROGRESS--Interviews have been completed with 59 participants, 18 Hispanic and 41 non-Hispanic whites. Preliminary results suggest evidence of mild to serious unmet ADL and IADL care needs among both ethnic groups, (with Hispanic elderly reported more unmet home care needs), difficulties with both current and previous paid attendants, and lack of educational materials to assist disabled older adults and their families with successfully acquiring and maintaining paid in-home help. Positive findings were that elderly preferences of desired paid attendant traits were found among the current paid helpers. For example, those that desired a relative or a woman as a paid helper typically had one. Family involvement existed for both ethnic groups, with slightly more involvement among the Hispanic participants.
[127] USE OF TECHNOLOGY SERVICES TO MAINTAIN EMPLOYMENT AMONG PEOPLE AGING WITH A DISABILITY
Don McNeal, PhD; Nancy Somerville, BS; Dorothy J.
Wilson, OTR, FAOTA
Rancho Rehabilitation Engineering Program, Rancho Los
Amigos Medical Center, Downey, CA 90242
Sponsor: National Institute on Disability and Rehabilitation Research, Washington, DC 20202
PURPOSE--Functional changes experienced by individuals as they age with a disability may make performance of job tasks difficult and may jeopardize their employment status. Job accommodations, however, can often compensate for functional decline and may be able to assist workers with disabilities to maintain employment. The purpose of this study is to document the degree and extent of need for job accommodation and how these needs have changed as the workers have aged with their disabilities. This project, under the Rehabilitation Research and Training Center (RRTC) on Aging will focus on individuals who had polio and on those who have rheumatoid arthritis (RA). Individuals with spinal cord injury (SCI) will also be included through an identical study under the RRTC on Aging with SCI.
METHODOLOGY--A questionnaire and structured personal interviews will be used to gather information about job accommodation needs from 150 participants, 50 from each disability category, to be recruited from the RRTC shared databases. Participants will either be currently working or have been unemployed less than 5 years. A worksite evaluation will be offered to each participant who is working to assess current needs and to determine if there are accommodations that will meet their needs. Results of the study will be disseminated as well as any strategies identified for providing job accommodation services.
PROGRESS--Data collection is underway. A total of 56 participants have been interviewed. Of these participants, 39 have a history of polio, 15 have SCI, and 2 have RA. A total of 10 worksite evaluations have been conducted as a follow-up to the interviews of participants who are currently working and agree to the worksite visit. A database for data analysis has been established and the first wave of data has been entered.
FUTURE PLANS--Data collection will continue with a focus on increasing the sample pool through community contacts. Dissemination of information will also be a priority this year.
[128] VARIATIONS IN SECONDARY CONDITIONS, RISK FACTORS, AND HEALTH CARE NEEDS FOR FOUR GROUPS OF PERSONS AGING WITH PHYSICAL DISABILITY
Margaret L. Campbell, PhD; Bryan Kemp, PhD
Rehabilitation Research and Training Center on Aging
with Disability Rancho Los Amigos Medical Center and
University of Southern California Downey, CA 90242; email:
mic@almaak.usc.edu
Sponsor: National Institute on Disability and Rehabilitation Research, U.S. Department of Education, Washington, DC 22202
PURPOSE--This study responds to gaps in our knowledge regarding the new health problems and functional limitations experienced by persons aging with the long-term effects of cerebral palsy (CP), polio, rheumatoid arthritis (RA), and stroke, and the consequences of these secondary conditions for a broad range of quality of life outcomes. These four impairment groups were selected to represent differences in the average age or stage of life when disability occurs, ranging from infancy to mid- to later-life. Specific objectives include: 1) describing variations in the timing, prevalence, type and magnitude of secondary conditions; 2) examining the impact of these health-related changes on productivity, family relations, social participation, psychological well-being, and utilization of and need for services; and 3) identifying the risk and resiliency factors associated with both positive and negative outcomes, focusing on the effects of social support and community integration.
METHODOLOGY--The study incorporates a community-based cross-sectional survey within a group-comparison design based on impairment, and within impairment on gender and race/ethnicity, and it utilizes a cross-sequential framework for sample selection and data analysis. This combination of methods allows us to both identify variations in secondary conditions, risk factors, and needs within and between groups, and to separate age-related changes in health and function associated with aging from those associated with duration of disability.
The study is being conducted in two phases. The first involves the identification and recruitment of subjects from two study populations: a hospital-based population of primarily low-income, ethnic minority patients receiving rehabilitation services from a county facility and a contrasting community-based population recruited from support groups, newspaper solicitation, radio and electronic bulletin board announcements and physician offices. Eligible candidates must meet minimum age and duration of disability criteria which vary by impairment group. The second involves the development and implementation of a comprehensive cross-disability survey instrument. Data collection procedures involve both telephone and face-to-face interviews, the later conducted in respondents' homes.
PROGRESS--Accomplishments include: 1) the formation and operation of a 10 member, cross-disability consumer advisory committee, the members of which participate as decisions-makers in all stages of the research program; 2) development of two versions of the survey instrument, one for polio and RA and the other for CP and stroke; 3) completion of subject identification for the hospital-based subject pool (n=1,602) and ongoing recruitment of volunteers for the community pool (to date: n=500); 4) random selection of 494 candidates, and completion of 266 polio and RA interviews for an overall response rate of 54 percent (data collection for CP and stroke began in November 1996); and 5) ongoing dissemination of preliminary research findings at professional meetings of both aging and disability organizations and to local consumer support groups.
PRELIMINARY RESULTS--With 41 percent of the target sample completed, analyses conducted to date have been limited to quantitative descriptions of subject pool characteristics and qualitative case studies of selected polio and RA participants. Consistent with the life course perspective guiding this investigation, these analyses suggest that timing of acute onset of disability has important consequences for both the health status and life chances of individuals. For example, RA participants with early onset (i.e., age ;le 40) report significantly more secondary health conditions and lower levels of life satisfaction compared to their counterparts whose onset occurred after age 60. Members of both the Polio (n=892) and RA (n=375) hospital subject pool, with ages of onset of 7.4 and 40.1, respectively, were also significantly more likely to have never married compared to stroke patients (n=268) with an average age of onset of 56. Official analysis began in November 1996 once all the data entry screens were completed.
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Last revised Wed 05/26/1999
