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Biomedical subjects

C D Mulrow

Publications and source records attributed to C D Mulrow.

At least 19 recordsLinked to original sources
PubMed1995

Case-finding instruments for depression in primary care settings.

OBJECTIVE: To evaluate the usefulness of case-finding instruments for identifying patients with major depression in primary care settings. DATA SOURCES: A MEDLINE search of the English-language medical literature; bibliographies of selected papers; and experts. STUDY SELECTION: Studies that were done in primary care settings with unselected patients and that compared case-finding instruments with accepted diagnostic criterion standards for major depression were selected. DATA SYNTHESIS: 9 case-finding instruments were assessed in 18 studies. More than 15,000 patients received screening with a case-finding instrument; approximately 5300 of these received criterion standard assessment. Case-finding instruments ranged in length from 2 to 28 questions. Average administration times ranged from less than 2 minutes to 6 minutes. Sensitivities and specificities for detecting major depression ranged from 67% to 99% and from 40% to 95%, respectively. No significant differences between instruments were found. Overall sensitivity was 84% (95% CI, 79% to 89%); overall specificity was 72% (CI, 67% to 77%). If a case-finding instrument were administered to 100 primary care patients with a 5% prevalence of major depression, the clinician could expect that 31 patients would screen positive, that 4 of the 31 would have major depression, and that 1 patient with major depression would not be identified. CONCLUSIONS: Several instruments with reasonable operating characteristics are available to help primary care clinicians identify patients with major depression. Because the operating characteristics of these instruments are similar, selection of a particular instrument should depend on issues such as feasibility, administration and scoring times, and the instruments' ability to serve additional purposes, such as monitoring severity or response to therapy.

Depression↗
PubMed1995

The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques.

OBJECTIVE: To determine if short-term exercise reduces falls and fall-related injuries in the elderly. DESIGN: A preplanned meta-analysis of the seven Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)--independent, randomized, controlled clinical trials that assessed intervention efficacy in reducing falls and frailty in elderly patients. All included an exercise component for 10 to 36 weeks. Fall and injury follow-up was obtained for up to 2 to 4 years. SETTING: Two nursing home and five community-dwelling (three health maintenance organizations) sites. Six were group and center based; one was conducted at home. PARTICIPANTS: Numbers of participants ranged from 100 to 1323 per study. Subjects were mostly ambulatory and cognitively intact, with minimum ages of 60 to 75 years, although some studies required additional deficits, such as functionally dependent in two or more activities of daily living, balance deficits or lower extremity weakness, or high risk of falling. INTERVENTIONS: Exercise components varied across studies in character, duration, frequency, and intensity. Training was performed in one area or more of endurance, flexibility, balance platform, Tai Chi (dynamic balance), and resistance. Several treatment arms included additional nonexercise components, such as behavioral components, medication changes, education, functional activity, or nutritional supplements. MAIN OUTCOME MEASURES: Time to each fall (fall-related injury) by self-report and/or medical records. RESULTS: Using the Andersen-Gill extension of the Cox model that allows multiple fall outcomes per patient, the adjusted fall incidence ratio for treatment arms including general exercise was 0.90 (95% confidence limits [CL], 0.81, 0.99) and for those including balance was 0.83 (95% CL, 0.70, 0.98). No exercise component was significant for injurious falls, but power was low to detect this outcome. CONCLUSIONS: Treatments including exercise for elderly adults reduce the risk of falls.

Accidental Falls↗
PubMed1995

Depressive disorders in primary care: prevalence, functional disability, and identification.

OBJECTIVES: To assess the relative prevalence of subsyndromal depression (SubD) and major depression (MDD) in primary care patients and describe their associated functional impairments, and to define the operating characteristics of a short depression screen (SDS). SETTING: Three primary care clinics: a university-affiliated Veterans Affairs clinic, a county general internal medicine clinic, and a community health center. SUBJECTS: Randomly selected adult patients (n = 221), aged > or = 30 years, with no history of psychiatric comorbidity, current substance abuse, major depressive disorder, chronic pain disorder, or dementia. MEASUREMENTS: The SDS and the Medical Outcomes Study Short Form 36 (SF-36) were interviewer-administered by an experienced bilingual research assistant to all subjects in the language of their choice. A physician administered independently the Structured Clinical Interview for DSM-III diagnosis (SCID) and the Hamilton Depression Rating Scale (HDRS) to all patients who exceeded a minimum threshold on the SDS and to a randomly selected sample of patients who had subthreshold scores. MDD was defined by DSM-III criteria and SubD was defined as two to four DSM-III criteria, of which one had to be depressed mood or anhedonia. RESULTS: Demographic and clinical characteristics of the patients were: Mexican American 53%, non-Hispanic white 38%, and African American 9%; men 68%; mean age 60 +/- 12.7 years; mean level of education 9.5 +/- 4.4 years; and hypertension 57%, diabetes mellitus 51%, and arthritis 45%. The prevalences of MDD and SubD (adjusted for sampling strategy) were 4% and 16%, respectively. For the patients who had MDD, the median HDRS score was 17 (interquartile range, 10-18), and for those who had SubD, the median HDRS score was 9 (interquartile range, 8-14). Compared with the patients who did not have depressive symptoms, those who had either MDD or SubD were significantly impaired in multiple domains of self-reported function. The sensitivity and specificity of the SDS for MDD were 100% (95% CI 57-100) and 72% (95% CI 63-81), respectively. For depressive disorders (MDD or SubD), the sensitivity was 66% (95% CI 49-83) and the specificity was 79% (95% CI 69-89). CONCLUSIONS: SubD was more prevalent than MDD in these primary care settings. Both MDD and SubD were associated with significant functional impairment. The sensitivity of the SDS was lower for identifying depressive disorders (MDD or SubD) than it was for identifying MD.

Adult↗
PubMed1995

Up for review.

Explore the source record for details and available documents.

Humans↗
PubMed1995

Accuracy and reliability of apical S3 gallop detection.

This study assessed physician performance in detecting the apical S3 gallop using a cardiology patient simulator. Six physicians (two cardiology fellows, two medicine residents, and two attending physicians) performed two sets of 24 cardiac examinations that included the presence or absence of an apical S3 gallop. All the examiners were able to significantly alter the prior odds of an apical S3 gallop's being present, but the cardiology fellows had higher sensitivities. Sensitivity was lower for detecting soft S3 gallops, and specificity was lower when a diastolic murmur was also present. Physician performance in detecting apical S3 gallops is variable, but can be excellent.

Heart Murmurs↗
PubMed1995

Relationship between physical performance and self-perceived physical function.

OBJECTIVE: The objective of this study was to compare two methods of measuring physical function in subjects with a broad range of abilities and to evaluate the effects of cognitive, social, educational, and age factors on the relationship between the two methods. DESIGN: Multiple regression analysis was used to compare self-perceived (dependent variables) with performance measures (independent variables). Covariates included age, gender, Mini-Mental State Exam score, education, living status, and depression score. SETTING: Five community-dwelling and two nursing home sites. PARTICIPANTS: 417 community-dwelling subjects and 200 nursing home residents aged 62-98 years. MEASUREMENTS: Self-perceived physical function was assessed with the physical dimension summary score of the Sickness Impact Profile, which comprises three subscales: ambulation, mobility, and body care and movement. Physical performance was evaluated by self-selected gait speed, chair-stand time, maximal grip strength, and a balance score. RESULTS: Nursing home residents and community-dwellers were significantly different (P < .0001) in all variables except age and gender. Self-perceived and performance-based measures were moderately correlated, with a range from r = -.194 to r = -.625 (P < .05). Gait speed was the strongest independent predictor of self-perceived physical function in both groups. Symptoms of depression were also an independent predictor of self-perceived function in nursing home residents; subjects who had such symptoms report more self-perceived dysfunction than would be predicted based on performance tests. CONCLUSIONS: Self-selected gait speed is a global indicator of self-perceived physical function over a broad range of abilities. External determinants (depressive symptoms, cognitive function, marital status, etc.) affect self-perceived function in both groups, but gait speed is the greatest single predictor of self-perceived function. In nursing home residents depressive symptomatology is related to self-perceived.

Activities of Daily Living↗
PubMed1994

Hypertension in the elderly. Implications and generalizability of randomized trials.

OBJECTIVE: To estimate morbidity and mortality benefits of drug therapy for hypertensive elderly subjects, compare these benefits with effects in younger subjects, and provide a framework for generalizing results derived from trials to actual patients. DATA SOURCES: A literature search using MEDLINE from 1966 to 1993, references from reviews and trial articles, and experts. STUDY SELECTION: Randomized trials lasting at least 1 year that evaluated effects of drug treatment on morbidity and mortality outcomes in hypertensive persons. DATA EXTRACTION: Four independent reviewers appraised protocol characteristics and quality of selected trials. DATA SYNTHESIS: There were 13 trials involving 16,564 elderly persons (age 60 years and older). The prevalence of cardiovascular risk factors, cardiovascular disease, and competing comorbid diseases was lower among trial participants than the general population of hypertensive elderly persons. When the six large high-quality trials were combined, trial results showed 43 subjects (95% confidence interval [CI], 31 to 69) and 61 subjects (95% CI, 39 to 141) needed to be treated for 5 years to prevent one cerebrovascular event and one coronary heart disease event, respectively. Including the other seven trials did not change the results significantly. Only 18 subjects (95% CI, 14 to 25) needed to be treated to prevent one cardiovascular event (cerebrovascular or cardiac). Twelve trials in primarily younger and middle-aged adults involved approximately 33,000 persons. For all outcomes except cardiac mortality, two to four times as many of the younger subjects as the older subjects needed to be treated for 5 years to prevent morbid and mortal events. No significant effect on cardiac mortality was seen among younger subjects, while 78 older subjects (95% CI, 50 to 180) needed to be treated to prevent a fatal cardiac event. CONCLUSIONS: Randomized trials demonstrate that treating healthy older persons with hypertension is highly efficacious. Five-year morbidity and mortality benefits derived from trials are greater for older than younger subjects. Extrapolating benefits from trials to individual patients is difficult, but should take into account multiple issues including the patient's risk factors, preexisting cardiovascular disease, and competing comorbid illnesses.

Age Factors↗
PubMed1994

Rationale for systematic reviews.

Systematic literature reviews including meta-analyses are invaluable scientific activities. The rationale for such reviews is well established. Health care providers, researchers, and policy makers are inundated with unmanageable amounts of information; they need systematic reviews to efficiently integrate existing information and provide data for rational decision making. Systematic reviews establish whether scientific findings are consistent and can be generalised across populations, settings, and treatment variations, or whether findings vary significantly by particular subsets. Meta-analyses in particular can increase power and precision of estimates of treatment effects and exposure risks. Finally, explicit methods used in systematic reviews limit bias and, hopefully, will improve reliability and accuracy of conclusions.

Meta-Analysis as Topic↗
PubMed1994

Functional status of Mexican American nursing home residents.

OBJECTIVE: To compare sociodemographic characteristics, physical function, and cognition of Mexican American and non-Hispanic white nursing home residents. DESIGN AND SETTING: Cross-sectional survey of residents in eight proprietary nursing homes and one Veterans Affairs nursing home in San Antonio, Texas. SUBJECTS: Residents with lengths of stay greater than or equal to 90 days. MEASUREMENTS: Sociodemographic characteristics, residence prior to admission, and dependency in activities of daily living (ADL) were abstracted from the medical record. The Folstein Mini-Mental State Examination (MMSE) was administered in the resident's self-selected language to a subset of residents. MAIN RESULTS: There were 1160 participants, 261 Mexican American (23%) and 899 non-Hispanic white residents (77%). Mexican Americans were younger (77.1 vs 80.7 years), more often men (44% vs 30%), less educated (6.2 vs 10.8 years), and more often dependent on Medicaid funding (66% vs 40%) than non-Hispanic whites. Mexican Americans were less independent in feeding (34% vs 49%), transfers (18% vs 30%), toileting (19% vs 29%), and dressing (12% vs 19%). Mean MMSE scores were different in Mexican Americans and non-Hispanic whites (8.93 vs 11.85), and this difference remained significant after adjustment for age and education (P = 0.04). ADL function was strongly associated with MMSE (P = 0.0001) and less strongly associated with ethnicity (P = 0.056) in multiple regression analysis. CONCLUSIONS: This study provides the strongest evidence to date that Mexican American nursing home residents are more cognitively and functionally impaired than non-Hispanic white residents. Further studies should explore whether medical conditions, selection and referral patterns or cultural factors explain functional differences between Mexican American and non-Hispanic white nursing home residents.

Activities of Daily Living↗
PubMed1994

Performance of case-finding tools for depression in the nursing home: influence of clinical and functional characteristics and selection of optimal threshold scores.

OBJECTIVE: To compare case-finding tools for depression in the nursing home setting and to evaluate effects of subject function, cognition, and disease number on test performance. DESIGN: Cross-sectional survey. SETTING: One academic and four community homes. SUBJECTS: One hundred thirty-four randomly selected, mildly cognitively impaired, functionally dependent residents. METHODS AND MEASURES: The Geriatric Depression Scale (GDS), Short Geriatric Depression Scale (SGDS), Center for Epidemiologic Studies Depression Scale (CES-D), and Brief Carrol Depression Rating Scale (BCDRS) were administered. The Structured Clinical Interview for DSM-III-R diagnoses was administered independently,. Operating characteristics and the effects of subject characteristics on test performance were evaluated using McNemar's test and logistic regression. Selection of "optimal" threshold scores was guided by Kraemer's quality indices and clinical judgment. RESULTS: Thirty-five subjects (26%) had major depression. No differences were found among the instruments in sensitivity (range 0.74-0.89), specificity (range 0.62-0.77), or area under the receiver operating curve (ROC) (range 0.85-0.91). Resident characteristics did not affect test performance. Quality indices showed the GDS and BCDRS met criteria for moderate to substantial agreement with the criterion standard, whereas the SGDS and the CES-D achieved only fair agreement. No change in threshold scores was warranted. CONCLUSIONS: The GDS and BCDRS performed well in the nursing home. As the GDS can serve as a both a case-finding and severity instrument, it is preferred. Use of brief, interviewer-administered tools may improve detection of depression in the nursing home.

Aged↗
PubMed1994

The relationship between disease and function and perceived health in very frail elders.

OBJECTIVE: To study associations between disease and observed function and self-perceived health in very frail elders. DESIGN AND SETTING: Cross-sectional survey of nine nursing homes in San Antonio, TX. PARTICIPANTS: 194 elderly long-stay nursing home residents dependent in at least two ADLs and without severe cognitive impairment. MEASURES: Burden of disease (BOD) was chart abstracted using a standardized protocol that assessed types and severities of 59 categorizations of chronic and acute medical conditions. Observed function and self-perceived health status were assessed independently by the Katz Activities of Daily Living scale (ADL) and the Sickness Impact Profile (SIP), respectively. RESULTS: Summary BOD scores had a low, but statistically significant, univariate correlation with ADL scores (r = 0.21, P = 0.003) and no significant correlation with SIP scores (R = -0.008). Multiple linear regression analyses, including the 24 most frequent disease categories, showed that disease explained significant amounts of ADL (r2 = 0.25, P = 0.001) and borderline significant amounts of SIP (r2 = 0.16, P = 0.11). Models including both disease and sociodemographic, cognitive, and affective variables showed disease added significant incremental explantation beyond the other factors to ADL (incremental r2 = 0.14, P = 0.04), but not to SIP (incremental r2 = 0.08, P > 0.10). CONCLUSIONS: Disease, observed function, and self-perceived health status are separate, but interrelated entities, with disease having a stronger relationship to observed function than self-perceived health. Comprehensive assessment of frail elders may need to include all three areas, and studies that focus on one area should take into account the other two as potential important covariates.

Activities of Daily Living↗
PubMed1992

Sustained benefits of hearing aids.

This study was designed to evaluate long-term benefits of hearing aids in elderly individuals with hearing loss. A primary care cohort of 192 elderly, hearing-impaired veterans (mean age 72 +/- 6, 97% White, 94% retired) were assessed at baseline and at 4, 8, and 12 months after hearing aid fitting. Drop-out rates at 4, 8, and 12 months were 5%, 13%, and 16%, respectively. Outcome assessments included several quality-of-life scales: Hearing Handicap Inventory in the Elderly (HHIE), Quantified Denver Scale of Communication Function (QDS), Geriatric Depression Scale (GDS), and the Short Portable Mental Status Questionnaire (SPMSQ). All quality-of-life areas improved significantly from baseline to 4-month post-hearing aid fittings (p < 0.05). Social and emotional (HHIE), communication (QDS), and depression (GDS) benefits were sustained at 8 and 12 months, whereas cognitive changes (SPMSQ) reverted to baseline at 12 months. We conclude that hearing aids provide sustained benefits for at least a year in these elderly individuals with hearing impairment.

Aged↗
PubMed1992

The impact of physical therapy on nursing home patient outcomes.

The objective of this retrospective study was to assess the intensity and outcome of individual components of interdisciplinary care, including physical therapy, in a teaching nursing home. Two independent reviewers abstracted records from 90 consecutive patients admitted to the nursing home. They rated intensity and outcome of each program component using a structured, standardized data-abstraction form. Program components were physical therapy, speech therapy, psychosocial therapy, medication adjustment, and other medical and nursing care. Physical therapy and medication adjustment were the most frequently received therapies. Eighty-eight percent of the patients receiving high-intensity physical therapy and 33% of the patients receiving moderate-intensity physical therapy improved. For medication adjustment, 93% and 72% of the high- and moderate-intensity groups, respectively, improved. In univariate analyses, physical therapy intensity and age were associated with improvement. Baseline function in activities of daily living and cognitive function were not associated with physical therapy outcome. A stepwise multiple logistic regression analysis revealed that only therapy intensity was associated with improved outcome. We conclude that physical therapy was efficacious for patients receiving high-intensity treatment. Advanced age, activities-of-daily-living status, and cognitive impairment were not associated with poor physical therapy outcome.

Aged↗
PubMed1992

Physical therapy assessment and treatment protocol for nursing home residents.

This article describes a standard protocol for assessing physical function in elderly nursing home residents. Major physical dimensions that are measured with the protocol include range of motion, muscle force, muscle reflex activity, sensation, soft tissue status, balance/coordination, and posture. A practical, functionally prioritized treatment model based on the assessment is also presented. The standardized assessment and treatment plan may be useful to the physical therapist in (1) planning and prioritizing treatment, (2) identifying when goals have been met, (3) recognizing when there is a need for treatment plan modification, and (4) educating physical therapy students in applying problem-solving skills in their treatment sessions.

Activities of Daily Living↗
PubMed1992

Correlates of successful hearing aid use in older adults.

OBJECTIVE: To evaluate whether age, education, functional handicap, degree of hearing loss, amount of hearing and speech recognition gain achieved with hearing aid, locus of control, visual acuity, manual dexterity, number of comorbid diseases, and number of medications predict which elderly individuals with hearing loss are likely to benefit from hearing aids. DESIGN: A logistic regression prediction model for hearing aid benefit was developed on a training set of 89 individuals and verified in a test set of 87 individuals. Hearing aid success was assessed 4 mo after hearing aid adminstration. It was defined by assessing hearing aid satisfaction, functional handicap change post-hearing aid, and number of hours of weekly hearing aid use. SETTING: All patients were elderly male veterans from the Audie L. Murphy Memorial Veterans Hospital. There were no differences in demographic or clinical characteristics in training versus test set individuals. RESULTS: Several variables, including baseline perceived functional handicap, education, number of medications, and age correlated with individual success measures. However, no variables consistently correlated with all success measures. The accuracy of prediction rules for success utilizing the variables ranged from 75 to 88% in the training set, and 54 to 84% in the test set. CONCLUSION: Although certain baseline factors were statistically significantly related to individual measures of successful hearing aid use, no factors were good enough to consistently differentiate successful from unsuccessful hearing aid candidates.

Age Factors↗
PubMed1991

Estimating and testing an index of responsiveness and the relationship of the index to power.

Responsiveness has been proposed as a criterion, in addition to reliability and validity, to evaluate instruments that measure quality of life or functional status. The responsiveness index measures the change in a quality of life score due to a treatment relative to the variability of changes in that score within a stable control group. We derive the expected value, variance and distribution of the responsiveness index and give a large sample distribution for comparing the responsiveness of two different instruments. We also give the relationship between the responsiveness index and the power of a test of treatment effect.

Hearing Aids↗