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Biomedical subjects

R H Harwood

Publications and source records attributed to R H Harwood.

At least 19 recordsLinked to original sources
PubMed2006

Development of a new measure of health-related quality of life for people with dementia: DEMQOL.

BACKGROUND: We identified the need to develop a scientifically rigorous measure of health-related quality of life (HRQL) in dementia that would be appropriate for use at all stages of dementia severity and would be available in both self- and proxy-report versions. METHOD: We used standard psychometric methods to eliminate items with poor psychometric properties (item-reduction field test) and to assess the acceptability, reliability and validity of the item-reduced instruments (psychometric evaluation field test). We developed and validated two versions of DEMQOL: a 28-item interviewer-administered questionnaire that is self-reported by the person with dementia (DEMQOL) and a 31-item interviewer-administered questionnaire that is proxy-reported by a caregiver (DEMQOL-Proxy). RESULTS: DEMQOL shows high reliability (internal consistency and test-retest) and moderate validity in people with mild/moderate dementia. DEMQOL-Proxy shows good acceptability and internal consistency and moderate evidence of validity in people with mild/moderate and severe dementia. Test-retest reliability and performance in people with severe dementia need further testing. CONCLUSIONS: DEMQOL and DEMQOL-Proxy show psychometric properties that are comparable with the best available dementia-specific measures of HRQL. We recommend that DEMQOL and DEMQOL-Proxy are used together. Reliability and validity need to be confirmed in independent samples and responsiveness needs to be evaluated.

Adult↗
PubMed2006

Quality of life in dementia: more than just cognition. An analysis of associations with quality of life in dementia.

OBJECTIVES: To explore the extent to which commonly used measures of specific outcomes in dementia are an appropriate proxy for quality of life in dementia. METHODS: This was a cross sectional study set in communities in London and Nottingham, comprising 101 people with dementia and their 99 main family caregivers. The main outcome measures were health related quality of life in dementia (measured by the DEMQOL-Proxy), cognition (Mini Mental State Examination), functional impairment (Barthel Index), behavioural and psychological symptoms in dementia (Neuropsychiatric Inventory; NPI), and carer mental health (General Health Questionnaire). RESULTS: On univariate analysis, decreased quality of life was statistically significantly correlated with higher levels of behavioural and psychological disturbance (NPI total score and its agitation, depression, anxiety, disinhibition, and irritability subscales); younger age of the person with dementia; and poorer mental health of the carer. Quality of life was not statistically significantly associated with cognition or carer age. In a multivariate model, psychological and behavioural disturbance and patient age remained statistically significantly associated with quality of life. Carer mental health was no longer statistically significantly associated, and cognition and functional limitation remained statistically insignificant. CONCLUSIONS: These data suggest that quality of life in dementia is complex, and that simple proxy substitutions of discrete measures such as cognition or function are likely to miss important factors.

Activities of Daily Living↗
PubMed2005

Economic analysis of an early discharge rehabilitation service for older people.

OBJECTIVE: to measure the cost-effectiveness of an early discharge and rehabilitation service (EDRS) in Nottingham, UK. DESIGN: data were collected during a randomised controlled trial. METHODS: cost and cost-effectiveness analyses were conducted from the perspective of service providers (health and social services) over a period of 12 months. Resource variables included were the EDRS intervention, the initial acute hospital admission (from randomisation), readmission to hospital, hospital outpatient visits, stays in nursing and residential homes, general practitioner contact, community health services and social services. The effectiveness measure was the EuroQol EQ-5D score, from which quality-adjusted life years (QALY) were calculated. Cost-effectiveness was calculated as cost per QALY gained. RESULTS: at 12 months the mean untransformed total cost for the EDRS was 8,361 pound sterling compared to 10,088 pound sterling for usual care, a saving of 1,727 pound sterling (P = 0.05). Cost-effectiveness acceptability curves showed a high probability that the EDRS was cost effective across a range of monetary values for a QALY. CONCLUSIONS: the Nottingham EDRS was likely to be more cost effective than usual care.

Aged↗
PubMed2005

Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial.

BACKGROUND/AIM: A third of elderly people fall each year. Poor vision is associated with increased risk of falls. The authors aimed to determine if first eye cataract surgery reduces the risk of falling, and to measure associated health gain. METHODS: 306 women aged over 70, with cataract, were randomised to expedited (approximately 4 weeks) or routine (12 months wait) surgery. Falls were ascertained by diary, with follow up every 3 months. Health status was measured after 6 months. RESULTS: Visual function improved in the operated group (corrected binocular acuity improved by 0.25 logMAR units; 8% had acuity worse than 6/12 compared with 37% of controls). Over 12 months of follow up, 76 (49%) operated participants fell at least once, and 28 (18%) fell more than once. 69 (45%) unoperated participants fell at least once, 38 (25%) fell more than once. Rate of falling was reduced by 34% in the operated group (rate ratio 0.66, 95% confidence interval 0.45 to 0.96, p = 0.03). Activity, anxiety, depression, confidence, visual disability, and handicap all improved in the operated group compared with the control group. Four participants in the operated group had fractures (3%), compared with 12 (8%) in the control group (p = 0.04). CONCLUSION: First eye cataract surgery reduces the rate of falling, and risk of fractures and improves visual function and general health status.

Accidental Falls↗
PubMed2002

The validity, reliability and responsiveness of the Nottingham Extended Activities of Daily Living scale in patients undergoing total hip replacement.

PURPOSE: The Nottingham Extended Activities of Daily Living (EADL) scale is a popular outcome measure in stroke research. Its psychometric properties have not been tested in other conditions. METHODS: EADL has been measured before, three and six months after hip arthroplasty. A sample was retested for reliability. Comparisons were made with the SF-36 and London Handicap Scale. Standard psychometric parameters were calculated. RESULTS: The sub-scales and total score were approximately unidimensional on factor analysis and Cronbach's alpha, but did not form an adequate hierarchical (Guttmann) scale. Associations with other scales were in the expected direction and of approximately the expected strength, supporting concurrent and construct validity. Reliability was good. Responsiveness was poor compared with the other scales. CONCLUSIONS: The EADL is valid in patients with arthritis of the hip, and is reliable. However, it underestimates the size of health gain after hip arthroplasty compared with other scales.

Activities of Daily Living↗
PubMed2001

Hypovitaminosis D and 'functional hypoparathyroidism'-the NoNoF (Nottingham Neck of Femur) study.

BACKGROUND: calcium and vitamin D deficiency are common in elderly people and lead to increased bone loss, with an enhanced risk of osteoporotic fractures. Although hip fractures are a serious consequence, few therapeutic measures are given for primary or secondary prevention. A combination of calcium and vitamin D may not be the most effective treatment for all patients. OBJECTIVE: to investigate the effects of hypovitaminosis D on the calcium-parathyroid hormone endocrine axis, bone mineral density and fracture type, and the optimal role of combination calcium and vitamin D therapy after hip fracture in elderly patients. DESIGN: a population-based, prospective cohort study. METHODS: 150 elderly subjects were recruited from the fast-track orthogeriatric rehabilitation ward within 7 days of surgery for hip fracture. This ward accepts people who live at home and are independent in activities of daily living. All subjects had a baseline medical examination, biochemical tests (parathyroid hormone, 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D) and were referred for bone densitometry. RESULTS: at 68%, the prevalence of hypovitaminosis D (25-hydroxyvitamin D<30 nmol/l) was high. However, only half the patients had evidence of secondary hyperparathyroidism, the rest having a low to normal level of parathyroid hormone ('functional hypoparathyroidism'). Patients with secondary hyperparathyroidism and hypovitaminosis D had a higher mean corrected calcium, higher 1,25-dihydroxyvitamin D, lower hip bone mineral density and an excess of extracapsular over intracapsular fractures than the 'functional hypoparathyroid' group (P<0.01). CONCLUSION: there is a high prevalence of hypovitaminosis D in active, elderly people living at home who present with a hip fracture. However, secondary hyperparathyroidism occurs in only half of these patients. This subgroup attempts to maintain calcium homeostasis but does so at the expense of increased bone turnover, leading to amplified hip bone loss and an excess of extracapsular over intracapsular fractures. Combination calcium and vitamin D treatment may be effective in preventing a second hip fracture in these patients, but its role in patients with hypovitaminosis D without secondary hyperparathyroidism and 'vitamin D-replete' subjects needs further evaluation.

Aged↗
PubMed2001

Visual problems and falls.

Visual impairment is a risk factor for falls, on average approximately doubling falls risk in a wide variety of studies. Falls risk increases as visual impairment worsens. The relationship is almost certainly causal. Vision accounts for perhaps a quarter to a half of all falls, although this estimate is imprecise. Visual impairment in 70% or more of elderly people is remediable with relatively simple interventions (correcting refractive errors and cataract surgery), making it an important potential target for intervention at the population level. However, no intervention has yet been proven to reduce falls risk in a randomized controlled trial.

Accidental Falls↗
PubMed2001

Effect of experience of severe stroke on subjective valuations of quality of life after stroke.

Previous work suggests that the quality of life associated with severe disability after stroke is rated very poorly by members of the public, often as being worse than death. Other evidence suggests that experience of illness alters perceptions of its severity. This was tested for severe stroke. Eleven patients with severely disabling stroke, but able to complete a standard gamble interview, 22 age and sex matched controls, and 20 health professionals participated. A standard gamble interview was carried out to determine the quality of life (utility) associated with three hypothetical scenarios representing mild, moderate, and severe stroke, and current health. A sample was retested for reliability, and comparisons were made with other measures of health status. All three subject groups showed wide variation in the utilities they attached to each of the scenarios. The control subjects' valuations were lower than those of either patients or staff members, especially for moderate stroke (median 0.30, 0.73, and 0.68 respectively). There were weak to moderate correlations between utilities and other measures of health status including the Barthel index (r=0.51) and Rivermead mobility score (r=0.24). Test retest-reliability was modest (reliability coefficient 0.75), but indicators of the internal validity of the results were good. In conclusion, it cannot be assumed that general population valuations are valid for patient groups. In clinical practice it is unsafe to make any assumption about subjective quality of life after stroke, due to the wide range of valuations given, although many people rate severe and moderate stroke at least as bad as death.

Aged↗
PubMed2000

A comparison of the responsiveness of the Nottingham extended activities of daily living scale, London handicap scale and SF-36.

PURPOSE: Clinical trials require scales which are sensitive to the effects of intervention. This study examined the sensitivity to change of three generic health status measurement scales commonly used in evaluations of interventions in chronic, disabling disease. METHODS: Questionnaires comprising the SF-36, London Handicap Scale and Nottingham Extended Activities of Daily Living scale were administered to 81 patients before and after hip replacement. Changes were quantified as 'effect sizes'. RESULTS: Eighty nine per cent of patients reported improvements three months after surgery. The largest changes were seen on the SF-36 pain scale (effect size 1.2 at three months, 1.5 at 6-12 months), physical function (1.1, 1.3) and role limitation--physical (0.8, 1.2) scales. The London Handicap Scale also measured large changes (effect sizes 0.6, 0.9), but the Extended Activities of Daily Living scale was insensitive to change (effect sizes 0.1, 0.2). CONCLUSIONS: Some of the SF-36 dimensions were very sensitive to change. The London Handicap Scale was also reasonably responsive, and has the advantage of being a single, utility-based, score. The simpler Extended ADL score was poorly responsive.

Activities of Daily Living↗
PubMed2000

Measuring the outcomes of day hospital attendance: a comparison of the Barthel Index and London Handicap Scale.

OBJECTIVE: To assess the ability of two scales to measure the effects of attendance at a geriatric day hospital. DESIGN: 'Before-and-after' measurements. SETTING: Day hospital serving a defined, urban, catchment area. SUBJECTS: One hundred and three consecutive new patients over a three-month period. INTERVENTION: Day hospital attendance for as long as the multidisciplinary team thought warranted. OUTCOME MEASURES: Barthel Index and London Handicap Scale. RESULTS: Seventy-six patients (74%) attended for broadly defined 'rehabilitation'. Measurements on the Barthel Index and London Handicap Scale were completed on 54 of these. Repeat measurements after discharge from the day hospital were achieved on 37 patients. Patients attended between two and 57 times, with a median of eight. Mean Barthel Index did not change over the period of attendance. There was a small improvement in mean handicap score. Eight patients were identified post hoc who attended for 10 or more sessions, and they experienced a large mean reduction in handicap. CONCLUSION: Overall, neither the Barthel Index nor the London Handicap Scale changed much during attendance at the day hospital. Generally very short lengths of attendance may have explained this. For patients with more prolonged attendance, who might be expected to change more, the London Handicap Scale proved more responsive than the Barthel Index.

Activities of Daily Living↗
PubMed1998

A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The Gospel Oak Project VII.

BACKGROUND: Population-based studies suggest substantial co-morbidity between physical illness and depression in late-life. However, a causal relationship has not been established. If a relationship exists, it is important to establish which aspects of poor health determine risk for depression, and which factors confer vulnerability or resilience in the face of poor health. We investigate the role of disablement, measured as impairment, disability and handicap. METHODS: A prospective population-based cohort study, comprising an index assessment and 1 year follow-up, of all residents aged 65 years or over, of an electoral ward in London, UK (N = 889). RESULTS: The prevalence of SHORT-CARE pervasive depression was 17.7% at index assessment. The 1 year onset rate for pervasive depression was 12.0%, and the 1 year maintenance rate 63.2%. There was a high mortality rate among the depressed. Disablement, particularly handicap was the most important predictor of the onset of depression (population attributable fraction, 0.69). Lack of contact with friends was a direct risk factor but also modified the association between handicap and depression. Marriage was protective for men, but a risk factor for women. Maintenance of depression was predicted by low levels of social support and social participation, rather than by disablement. CONCLUSIONS: It seems likely that disablement, specifically handicap, is the chief cause of onsets of depression in late-life. Genetic predisposition, early adversity and serious life events may play a less prominent role than in earlier life. Effective prevention of late-life depression requires attention at the structural level to the sources of handicap within communities.

Activities of Daily Living↗
PubMed1998

The prevalence of diagnoses, impairments, disabilities and handicaps in a population of elderly people living in a defined geographical area: the Gospel Oak project.

OBJECTIVE: to measure the prevalence of impairments, disabilities and handicaps in a geographically-defined elderly population. DESIGN: cross-sectional analysis of an interview survey. SETTING: a single North London electoral ward (district). PARTICIPANTS: 654 residents (74%) over the age of 65 years were interviewed from a register of 889. A random sample of 225 had additional data collected which are reported in this analysis. MAIN OUTCOME MEASURES: point prevalence and distribution of the total number of reported diagnoses, impairments and disabilities, and distributions of the Office of Population Censuses and Surveys (OPCS) disability scale and the London Handicap Scale scores. RESULTS: participants had a median of three reported diagnoses and two impairments. Forty-three percent were in the least disabled OPCS disability category (i.e. below the disability threshold) and 41% were able to undertake all of 12 basic activities of daily living without difficulty. Overall handicap scores were heavily skewed towards no health-related disadvantage, with a median score of 83 out of 100, and 37% having a score of 90 or more. All indicators showed deteriorating health with increasing age, but age-adjusted gender differences were small. CONCLUSIONS: an elderly population's health problems were classified using a comprehensive framework, revealing high prevalences of diagnoses, impairments, disabilities and handicaps. The schema is appropriate for health care needs assessment and is a suitable basis for describing the population's health.

Aged↗
PubMed1998

Associations between diagnoses, impairments, disability and handicap in a population of elderly people.

BACKGROUND: 'Handicap' is the disadvantage for an individual that results from ill-health. It represents an important outcome in chronic disabling disease, but has proved difficult to measure until recently. The strength of association between handicap and other health status measures, and the relative contributions of health and socioeconomic variables to handicap have not been studied previously. METHODS: We undertook a cross-sectional survey of all people > 65 years old in a defined geographical area of North London. The interview was based on the short-CARE psychiatric survey tool, and in addition included measures of physical health and disability, the London Handicap Scale, income, social support and housing. In all, 654 residents (74%) from a register of 889 were interviewed. A random sample of 225 had additional data collected which are reported in this analysis. RESULTS: Strength of association with handicap scores increased progressively from diagnosis to impairment to disability. Variation in handicap with diagnosis was explained by impairment, and variation with impairment was mostly explained by disability. Age, housing quality, social support and income were associated with handicap score, but confounding by these did not explain the association between handicap and other aspects of disablement. Disease-associated variables explained quantitatively much more variation in handicap than socioeconomic variables. CONCLUSIONS: The most potent influences on handicap are disease and disability, justifying the high priority given by health services to detection, treatment and rehabilitation. Where this is not possible handicap may be reduced to some extent through socioeconomic intervention.

Aged↗
PubMed1997

Impairment, disability and handicap as risk factors for depression in old age. The Gospel Oak Project V.

BACKGROUND: An association between disablement and late-life depression is often reported in cross-sectional studies. However, many lack effect sizes, and do not control for confounding. Therefore, it is difficult both to quantify the overall impact of poor health on depression and to understand which aspects are most salient. METHODS: A catchment area survey of all over 65-year-old residents of an electoral district in London, UK, using a population register derived from a door-to-door census was undertaken. Depression was measured using SHORT-CARE, and the consequences of disease classified according to the WHO International Classification of Impairments, Disabilities and Handicaps. RESULTS: Six hundred and fifty-four subjects were interviewed out of an older population of 889. The prevalence of SHORT-CARE pervasive depression was 17%. Impairment, disability and, particularly, handicap were strongly associated with depression. The adjusted odds ratio for depression in the most handicapped quartile compared with the least was 24.2 (8.8-66.6). The population attributable fraction (PAF) for depression attributable to handicap was 0.78. The PAFs for recent life events and female gender were much lower. Handicap explained most of the depression associated with individual impairments and disabilities. Adjusting for handicap abolished or weakened the associations between depression and social support, income, older age, female gender and living alone. CONCLUSIONS: Even given some uncertainty in distinguishing handicap and depression as constructs, and the impossibility of deciding direction of causality, it seems likely that handicap is of central significance to late-life depression. Handicap may be more amenable to intervention than either impairment or disability.

Activities of Daily Living↗
PubMed1997

Social support deficits, loneliness and life events as risk factors for depression in old age. The Gospel Oak Project VI.

BACKGROUND: A companion paper reported a very strong cross-sectional association between handicap and late-life depression. Adjusting for handicap weakened associations between sociodemographic variables and depression. It was unclear whether handicap was a confounder, or a useful summary variable, mediating the effect of a range of sociodemographic disadvantages. This paper focuses on the cross-sectional relationship between depression and demographic variables, social support, and life events. METHOD: A community survey of all residents over the age of 65 years of an electoral district in London, UK. RESULTS: There was a moderate association between SHORT-CARE pervasive depression and the number of life events experienced over the previous year. Personal illness, bereavement and theft were the most salient events. There was a stronger, graded, relationship between the number of social support deficits (SSDs) and depression. Number of SSDs also related to age, handicap, loneliness and use of homecare services. Loneliness was itself strongly associated with depression; odds ratio 12.4 (7.6-20.0). CONCLUSIONS: Problems of collinearity, and the cross-sectional design of the study limited interpretation of the exact nature of the relationship between social support, loneliness, handicap and depression. However, the clustering of these four factors can be used to define a large part of the elderly population with a poor quality of life. An important avenue for future research will be the development and implementation of population intervention strategies designed to address some or all of these problems among older people in general.

Aged↗