Screening Recommendations for the Elderly
XI,
",e
Mark H. Beers, MD, Arlene Fink, PhD, and John C. Beck, MD
Introduction The American nation is growing older. I During the past two decades, the population over 65 has grown more than twice as quickly as the rest of the US population. In 1986, 41% of the elderly were 75 years of age and older; by the year 2000, half the elderly are expected to be over age 75. The 85-and-over population is growing especially rapidly. This group is expected to be seven times as large by the middle of the next century as it was in 1980. The number of functionally impaired elderly is already large and is expected to grow rapidly.2 As the population ages and becomes more impaired, concern for the prevention of disease and promotion of good health increases.3 Studies have documented the potential contributions of preventive health care programs.4 Advocates assert that preventive programs would result in a healthier and more industrious older population that could assist in reducing the nation's expenses for medical care and social support and contribute to the gross national product.5 Investigators have documented a high prevalence of undetected, correctable medical conditions among older adults living in the community.6 As many as 94% of elderly persons screened in a community program were found to have some positive finding requiring advice or information.7 Little information is available, however, regarding the screening tests that should be an integral component of a public health program for older persons. Unlike screening in office practice, public health programs do not focus on treatment but, instead, emphasize referrals and prevention. Many, like the California Preventive Health for the Aged Program, are publicly funded, use trained nurses, and
are mobile, thus limiting their use of some screening equipment. Among the considerations for screening services for public health programs would be the accuracy of such tests in detecting prevalent, asymptomatic disease, the availability and appropriateness of use of screening, and the availability of beneficial treatment of the diseases that are discovered. We synthesized findings from the literature, the US Preventive Services Task Force,8,9 and experts in geriatrics, gerontology, and health policy research to identify screening services that are appropriate for public health programs conducted by nurses.
Methods Data Sources Expert Panels. We identified laboratory screening tests, periodic medical review, hypertension, mental health, dermatological problems, ophthalmological problems, dental problems, and hearing problems as areas of greatest concern. Using these as a starting point, we consulted with experts in geriatric medicine and gerontology to help us select specific topics (e.g., stool guaiacs as a laboratory screening test or glaucoma as an ophthaLmological condition). We assembled 24 members of UCLA's academic faculty and clinical exThe authors are with the School of Medicine and the School of Public Health, University of California, Los Angeles. Requests for reprints should be sent to Dr. Mark H. Beers, UCLA, Center for Health Sciences, School of Medicine, Multicampus Division of Geriatric Medicine and Gerontology, Los Angeles, CA 90024. This paper was submitted to the journal October 10, 1990, and accepted with revisions March 8, 1991.
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perts into eight panels corresponding to the areas listed above. Panel members were selected for their knowledge of preventive health care and ofthe elderly. Panels ranged in size from four to six members, with at least one physician-member of UCLA's Multicampus Division of Geriatric Medicine and Gerontology and one health services researcher with expertise in geriatrics and consensus methods. Other members were expert in one or more of the study topics. We adopted a two-round consensus method that has been used successfully to resolve issues of uncertainty in health care.10,11 During the first round, panelists worked independently and without discussion to complete a written questionnaire. They sent the results for synthesis and then met to discuss the findings. Areas of agreement and disagreement were discussed, with the major emphasis on resolution of disagreements. After discussion, the panelists rerated each question. Literature Review. Our review included studies that were published in English between 1978 and January 1989. We relied on a selective list of investigations considered by experts to be important in guiding geriatric health care practice rather than striving for a review of all published studies. Inclusion criteria. The purpose of the literature review was to synthesize current knowledge from methodologically sound studies regarding the incidence and prevalence of selected undetected disorders in the elderly and the effectiveness of screening and early treatment. By screening, we meant any methods of detecting disease, regardless of stage or severity; prevention meant primary and secondary measures. Tertiary prevention was not considered in this project. The methods of screening included physical examination and history; patient questionnaires; instruments such as the sigmoidoscope and ophthalmoscope; and laboratory tests such as fasting glucose and thyroid function tests. Exclusion citeria. We did not review essays or methodologic studies (e.g., to determine the psychometric properties of a measure of function or mental status), although we examined their reference lists for data sources appropriate to our review. We did not include articles whose main purposes were to investigate the treatments and outcomes of care unrelated to screening. We excluded review articles, except in the case of hypertension, because the results of research had been extensively synthesized. 1132 American Journal of Public Health
Sources ofinfonmation. We identified literature through several mechanisms. All members of the expert panels recommended research studies on screening, and references in those papers were also reviewed. We conducted a MEDLINE search simultaneously. Abstraction of infornation. We reviewed all articles suggested by the project members, located through secondary sources, or uncovered by the computerized search (see Appendix A), but we abstracted only those that met our inclusion criteria (see Appendix B). We developed an abstraction form for recording the contents of each article. Ten articles were reviewed by three members of the team to establish the reliability of the abstraction process. We focused on the extent to which the inclusion and exclusion criteria discriminated among articles and whether agreement existed on their contents. When we were satisfied with the form's capability to facilitate consistent results, we each reviewed articles; every fifth article received a second review to ensure the continued uniformity of the abstraction process. Evaluation of the literature. The literature was evaluated on the basis of the quality of the research design using methods similar to those of the Canadian Task Force on the Periodic Health Examination,12 the US Preventive Services Task Force,8 and the RAND/UCLA Variations Study.13 The best evaluations were assigned to studies with the most rigorous designs (e.g., randomized, controlled trials). Only studies that provided convincing evidence through methodological rigor (e.g., controlled studies) were deemed acceptable. US Preventive Services Task Force. The results of the US Preventive Services Task Force became available in 1989. The credentials of the Task Force panel members and the methods used to arrive at recommendations are described elsewhere.8 Our study could not rely solely on the results of the Task Force for three reasons. First, the panelists did not explore all the topics in which we were interested, such as functional assessment. Second, although some Task Force recommendations directly affect older persons, the elderly are not the primary focus, and no geriatricians served on the Task Force's 20-member panel. There are many topics, such as the evaluation of dementia or the prevention of functional impairment, for which the perspective of geriatricians and gerontologists may differ from that of other clinicians and researchers. The third
reason for not relying solely on the Task Force is that we were interested in public health programs rather than case management by clinicians. The Task Force addressed some diseases that occur almost exlusively in the elderly, such as glaucoma, and it also made specific recom-
mendations for the elderly regarding hearing impairment and bacteriuria. This information was used as a major source of data in this study.
The Synthesis of Data Our final recommendation for each topic is based on all data sources from which information was available. We assumed that a screening test should receive the highest recommendation if its use is supported by the literature and the US Preventive Services Task Force, it is not currently used appropriately, and it can effectively uncover prevalent, undetected disease for which beneficial treatment is available. Throughout this project, we used the risk-benefit definition of appropriateness, meaning that a screen is appropriate when its potential benefit outweighs its potential risks. We based our assessment on the effectiveness of screening tests, i.e., the benefit for a given medical problem under average conditions of use.14 In this project, available meant that no barriers (such as lack of coverage by Medicare or scarcity of personnel or equipment) existed to prevent patients from receiving a test or treatment. We also included attention to compliance in our definition of availability because patients might not avail themselves of tests or treatments (e.g., hearing aids) if a social stigma or extreme discomfort were associated with them. By prevalent, we meant that the disease or condition occurred in a high enough percentage of elderly persons to warrant screening. We defined undetected disease as a disease or condition that is unknown to the patient or his or her doctor. A test or treatment was determined to be appropriate if those people who should be receiving it were receiving it. We called a treatment beneficial if it could help a substantial proportion of persons with the disease or condition while harming relatively few. To arrive at our recommendations, we scored each topic (e.g., dental caries, screening for diabetes) on seven items: (1) extent of support from the US Preventive Services Task Force; (2) extent of support from the consultant experts; (3) extent of support from the literature; (4) prevalence of asymptomatic disease associated with
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the topic; (5) benefit of treatment for the disease; (6) current availability of treatment; and (7) current use ofscreening. We used a 9-point scale, with 1 = strongly negative (i.e., low prevalence, and little or no support, benefit, or availability), 5 = equivocal (i.e., average, neutral, or uncertain support, prevalence, or availability), and 9 = strongly positive (i.e., high prevalence, and much support, benefit, and availability). The final score for each topic was the mathematical average of ratings on all seven items. The strength of our recommendations is based on this final score according to the following scale. 9 = strongly recommended, 8 = recommended, 7 = recommended with reservation, 6 = equivocal, 5 = equivocal, 4 = equivocal, 3 = not recommended with reservation, 2 = not recommended, 1 = strongly not recommended. For example, a particular screening test might be strongly recommended by the US Task Force (9), and strongly recommended by the UCLA experts (9), although there is little or no literature supporting its use (5). The disease might be common, occurrng in over 10% of the population (8). Moderately effective treatment (7) might exist, but the availability of that treatment might be limited due to its high price that is not reimbursed under Medicare and the reluctance of many individuals to undergo the treatment (2). Without new programs to encourage use of this screening procedure, it might be unavailable currently to most elderly persons (8). Such a scenario would receive a final score of 6.9, which we would round off to 7. We support the use of tests that score 7 or better; tests scoring between 4 and 6 are equivocal; and tests scoring between 1 and 3 are not recommended.
Results Data Sources Expert Panels.Topics discussed by the panels and their opinions follow.
Hearing Hearing loss is extremely common in late life, affecting 25% to 35% ofolder persons, and it increases dramatically with advancing age. Mild hearing loss is more likely to be undetected. The most common causes of hearing loss in late life are presbycusis, cerumen impaction, and noise-induced sensory neuronal hearing loss. The best screening test for presbycusis and noise-induced hearing loss is pure-tone audiometry; the best screening
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test for cerumen impaction is otoscopic visualization of the auditory canal. Beneficial treatment exists for all three causes of hearing loss, although amplification is sometimes less successful for noise-induced hearing loss than for presbycusis. The use of amplification is limited because of its cost and the social stigma associated with using hearing aids.
Laboratory screening tests Approximately 2% to 3% of elderly persons have undetected disease that can be diagnosed by routine laboratory tests. The most common undetected diseases (and the best screening methods for detecting each) are anemia (hematocrit or hemoglobin), bacteriuria (urinalysis), hyperlipidemia (serum cholesterol), diabetes (fasting blood sugar), bleeding colonic lesions (stool guaiac), hypothyroidism (TSH), and electrolyte disturbances caused by diuretics and nonsteroidal antiinflammatory agents (serum electrolytes). Beneficial treatments exist for hypothyroidism, bleeding colonic lesions (including early cancer), diabetes, and iatrogenic electrolyte disturbances. The benefits of treating anemia depend on the cause. The benefits of treating hypercholesterolemia probably depend on the age of the patient: treating elevated cholesterol in the very old may not be appropriate. Treating asymptomatic bacteriuria is probably beneficial in men but not in women. There is some limitation to the availability of treatment of diabetes due to the cost of medications and monitoring equipment and compliance with diet, medications, and monitoring. Treatment is limited for iatrogenic complications of medication use because physicians are often reluctant to change medical therapy on the advice of nonphysicians or because medical conditions necessitate their continued use. Hyperlipidemia treatment is limited due to the cost and side-effects of medication and compliance with dietary restrictions and exercise programs.
Periodic medical review Over 50% of the elderly have some undetected disease or condition. The percentage that could be detected through medical history and limited physical examination could not be determined; however, the most common undetected diseases and conditions (and the best screening method for detecting each) that are likely to be found through periodic review are colon cancer (stool guaiacs), breast cancer (breast examination and mammography), coronary artery disease
(history), urinary incontinence (history), inappropriate use of medication (medication review), impaired social functioning (screening scales), impaired physical functioning (screening scales), falls (history), and nutritional problems (weight and height). In almost all cases, these tests and procedures are either not currently available to the majority of elderly persons or are not used appropriately at the current time. Beneficial treatment exists for early colon cancer, early breast cancer, and coronary artery disease. Treatments for the other diseases and conditions are limited at best, and, in some cases, attempts at treatment may be harmful. Treatment availability is limited for urinary incontinence, correcting inappropriate use of medication, and improving poor social and physical functioning, nutritional problems, and falls.
Ophthalmological disorders Approximately 10% of elderly persons have undetected eye disease or visual impairment, and the prevalence increases with age. The most common diseases and conditions are glaucoma, cataracts, macular degeneration, and uncorrected refractive error; the oldest-old (persons over 85) are most likely to suffer from macular degeneration. The panel suggested that when screening is performed by nonophthalmologists or nurses, tonometry is the best screening for glaucoma because it is inexpensive, administration takes minimal training, and expensive or bulky equipment is not required. Testing visual acuity is the best screening procedure for all of the other diseases mentioned. Persons with impaired visual acuity should be referred to an eye specialist for futher evaluation. The minimal barriers to obtaining these procedures are mostly due to lack of reimbursement by some Medicaid programs. Visual acuity testing is generally used appropriately, but tonometry is gen-
erally not. The treatment for glaucoma is generally available and beneficial; treatment for cataracts is available and beneficial; treatment for macular degeneration is not beneficial and, if laser treatment is perfonned inappropriately or incorrectly, may be harmful; treatment for uncorrected refractive error is beneficial and generally available, limited only by cost and reimbursement.
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Mental health Depression can be defined by strict criteria as stated in the DSM-III-Rl5 or by a looser definition of affective disorder serious enough to impact on functioning and well-being. Using the strict definition, 1% to 3% of elderly persons suffer from unrecognized depression, but using the looser definition, 7% to 11% are affected. Few data are available on either the best methods for screening for depression in the elderly or the accuracy of the screening. The panel suggested that the eightitem Medical Outcome Study scale16 might be useful, especially if followed by the Diagnostic Interview Schedule17, screening version. The CES-Dl8 or Zung19 scales might be useful alternatives. None of these screening tests is available or used appropriately at this time. Treatment of depression is beneficial, although its availability is limited by toxic side-effects of medication and lack of resources for counseling and other psychological therapies. Nearly 4% of the elderly suffer from unrecognized dementia or chronic cognitive impairment, although we recognize that in some populations the prevalence may be higher.20 The prevalence of these conditions increases with age. The panel suggested that the Folstein Mini-Mental State21 is the best screening procedure, although this is only useful in Englishspeaking populations. Although these tests are available, they are not currently used appropriately. Currently no good treatment is available for 80% of elderly persons suffering from cognitive decline; the remaining 20% may be helped by treating reversible illness, including depression. The availability and benefit of treatment are highly dependent on the exact cause and could not be estimated overall.
Dematoloical disorders More than half of elderly persons have undetected dermatological disorders severe enough to lead to complications or complaints, with a higher incidence in sunny states such as California. The percentage of undetected disorders that do not result in the seeking of care could not be estimated. The most common diseases and conditions in this category are fungal infections, skin cancer, drug eruptions, photoaging, and xerosis. Visual inspection by a trained observer is the best screening procedure, although a history of symptoms of dry skin is also important for finding cases of xerosis. 1134 American Journal of Public Health
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Treatments for fungal infections, skin cancer, drug eruptions, and xerosis are both available and beneficial. The treatment of photoaging is probably not beneficial and generally not available, due to the cost of the medications and side-effects such as excessive skin dryness and
pruritus.
Dental disorders Nearly 50% of the elderly have undetected dental disease. The prevalence of undetected disease is likely to be highest for those with impaired mobility or limited finances. The most common diseases and conditions are caries, advanced gingivitis and periodontitis, xerostomia, and oral lesions including oral cancer. Clinical examination is the best screening procedure in all cases. Beneficial treatments exist for caries, and, with certain limitations, for periodon-
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titis, xerostomia, and oral lesions. The benefit of treatment of oral lesions depends on its characteristics. Treatment is available for each condition, although the availability of treatment for xerostomia is somewhat limited. Literature Review. We reviewed 139 studies, 33 of which met our criteria for abstraction. We reviewed five pertaining to ophthalmology and three on periodic review of medical care but did not abstract data from them because they failed to meet our criteria. For most topics, the literature contributed limited data or no data at all. Table 1 is a complete list of topics studied and the articles abstracted. Our review of the published literature disclosed a paucity of data on the effectiveness of screening. About two thirds of studies focused on the incidence and prevalence of disease, and the remainder emphasized the effectiveness of screening
tests. Half the studies were supported by federal sources and one quarter used data collected between 1980 and 1983. In the 16 (48%) studies that specified duration, ten (33%) collected data for less than 2 years. Most studies relied on local samples rather than statewide or national groups. Seven assessed randomly chosen samples, but none of these was a randomized controlled trial. Approximately 40% used physical examinations as the main source of data. More than half analyzed findings in terms of the age of the sample, and about half focused exclusively on the elderly. In 22 (66%) studies, participants were White. Ten important review articles were identified that had examined the subject of screening for hypertension in the elderly.22-31 Hypertension has been established as a risk factor for many serious problems, such as stroke, coronary artery disease, congestive heart failure, and multi-infarct dementia. Although some controversy still remains as to whether treating isolated systolic hypertension decreases mortality and morbidity, the general consensus is that treating both systolic and diastolic hypertension are useful and that detecting asymptomatic hypertension in the elderly is advantageous. US Preventive Services Task Force. The Task Force provided data on 13 of this study's 34 specific topics. In some cases, the Task Force addressed issues that affect the elderly, but it did not specifically address whether screening needs were different in elderly populations. For four topics (hearing impairment, bacteriuria, elevated cholesterol, and visual acuity), the Task Force did specifically address the elderly, and in another three topics (glaucoma, dementia, and oral cancer), it reviewed topics that affect the elderly almost exclusively, although it did not specifically comment on the elderly. The Task Force recommended screening for hearing loss, elevated cholesterol, and loss of visual acuity.
Recommendations Table 2 describes this study's recommendations and the bases on which they were made. We recommend the following without reservation: vision testing for refractive error; inspection of the skin surface for fungal infection, skin cancer, drug eruptions, and xerosis; interview for history of xerosis symptoms; audiometric testing for presbycusis and survey scales for hearing loss; otoscopic inspection for cerumen impaction; dental examination for caries; measurement ofblood pressure
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for hypertension; and breast examination and mammography for cancer.
Discussion The recommendations presented here are applicable to public health screening programs that aim to refer large numbers of community-dwelling elders 1136 American Journal of Public Health
and rely on nurses who often travel to deliver services. This study focused on screening for programs staffed by public health nurses, so some tests receiving low ratings might be appropriate for programs relying on physicians. The ophthalmoscope, for example, is an effective screening device for glaucoma when used by a trained ophthalmologist.
From the perspective of clinical geriatrics, many of the tests and procedures that are not supported by this study may still be appropriate when performed by physicians and other health professionals and used for purposes other than screening. Recording mental status, for example, may provide useful baseline data for determining changes in mental status. Also,
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Screening Recommendations for the Elderly
asking about symptoms of depression, which are often missed by primary care practitioners,32 is generallly considered important in primary care geriatric medicine. Measuring renal function with serum creatine may also result in useful baseline data, and following serum electrolytes can be useful in persons on medications, such as nonsteroidal anti-inflammatory drugs, when renal function is known to be impaired. Reviewing medication use is almost certainly important in geriatric care when performed by a primary care physician, although screening for inappropriate medication use by others cannot be supported by our research. Thus, recommendations made here for the exclusion of certain measures from screening programs should not be interpreted to mean that these measures should be excluded from good clinical geriatric care. We limited our investigation of screening to eight broadly defined topics, and these do not encompass all the needs of the elderly. We did not explore screening for vaccination status, for example, or for review of gastrointestinal problems or joint disease. A complete screening package might require other procedures or questions not discussed here. Moreover, the information on which we based our recommendations may change at any time. New research or alterations in reimbursement policies for hearing aids or dental work, for example, would necessitate changes in our ratings. If changes in reimbursement policies were to make hearing aids available to more persons, our ratings for audiometry would move from recommended with reservation to recommended or strongly recommended. Better data are needed to guide screening prgrams, and research is needed on such topics as the response of patients and physicians to referrals from screening programs and their outcomes. We need, for example, to determine whether depression screening scales can be used efficiently and accurately in a population of elderly persons, whether physicians are responsive to referrals about depression, and whether patients receive beneficial treatments sooner because of screening. Research is also needed on ways to get patients to use their medications correctly. If inappropriate use (including noncompliance with therapy, use of interacting drugs, or use of drugs that might impair function or cognition) is uncovered, what should be done to alter patients' and physicians' behavior? In fact, additional research on screeniing is needed for each of the topics explored in this study.
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We urge cautious confidence in applying our recommendations. Despite their limitations, they represent the best possible efforts of some leading experts in geriatric health care to weigh scientific and experimental evidence. It is obvious from this investigation, however, that more information is sorely needed to strengthen the foundation on which health policy on screening in the elderly can be established. El
Acknowledgments This project was supported by a contract from the California Department of Public Health. The authors are most grateful to Ms. Rhoda Slagel, ofthe California Preventive Health for the Aged Program. We are also indebted to Ms. Nancy Marr for assistance in conducting the literature review, assembling the bibliography, and scheduling the panels and to Ms. Ana Shiwoku for assistance in preparation of the manuscript and organization of the project.
References 1. Aging America: Trends and Projections. US Senate Committee on Aging in conjunction with the American Association of Retired Persons, the Federal Council on the Aging and the US Administration on Aging: 1987-1988 Edition. 2. Dawson D, Hendershot G, Fulton J. Aging in the eighties: functional limitations of individuals age 65 and over. Advance Data, No. 133. National Center for Health Statistics, June 10, 1987. 3. Year 2000 Health Promotion/Disease Prevention Objectivesforthe Nation. US Dept of Health and Human Services. November 1989. Draft. 4. Bayer R, Moreno JD. Health promotion: ethical and social dilemmas of government policy. Health Aff 1986;5:72-85. 5. Simon S, Wilson LB, Hernalin J, et al. Aging and Prevention: New Approaches for Preventing Health and Mental Problems in Older Adults. New York, NY: The Haworth Press; 1983. 6. Currie CT, Moore JT, Friedman SW, et al. Assessment of elderly patients at home: a report of fifty cases. J Am Geriatr Soc.
1981;29:398-401. 7. Rubenstein LZ, Josephson KR, NichoSeamons M, et al. Comprehensive health screening of well elderly adults: an analysis of a community program. Gerontology.
1986;41:342-352. 8. US Preventive Services Task Force. Guide to Clinical Preventive Services. Baltimore, Md: Williams & Wilkins; 1989. 9. Lawrence RS, Micralide AD, Kamero DB, Woolf SH. Report ofthe US Preventive Service Task Force. JAMA 1990;263:436-437. 10. Park E, Fink A, Brook RH. Physicians ratings of appropriate indications for three procedures: theoretical indications vs. indications used in practice. Am J Public
Health. 1989;79:445-447. 11. Park E, FinkA, Brook RH. Physicians ratings of appropriate indications for six med-
ical-surgical procedures. Am J Public Health. 1986;76:766-772. 12. Canadian Task Force on Periodic Health Examination. Can Med Assoc J. 1979;121:1193-1254. 13. FinkA, Brook RH, KosecoffJ. Sufficiency of clinical literature on new appropriate uses of six medical and surgical procedures. West JMed. 1987;147:609-614. 14. Institute of Medicine. Assessing Medical Technologies. Washington, DC: National Academy Press, 1985. 258. 15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed, rev. Washington DC: American Psychiatric Association; 1987. 16. Burnam MA, Wells KB, Leake B, et al. Development of a brief screening instrument for detecting depressive disorders. Med Care. 1988;26:775-789. 17. Robins LN, Helzer JE, Crougham J, et al. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry. 1981;38:381-389. 18. RadloffLS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychiatr Meas. 1977;1:385-401. 19. Zung WW. A self rating depression scale. Arch Gen Psychiatry. 1965;12:63-70. 20. Evans DA, Funkenstein HH, Albert MS, et al. Prevalence of Alzheimer's disease in a community population of older persons: higher than previously reported. JAMA. 1989;262:2551-2556. 21. Folstein MF, Folstein S, McHugh PR. MiniMental State: a practical method for grading the cognitive state of patients for the clinician.JPsychiatrRes. 1975;12: 189-198. 22. Kannel WB. Prevalence, incidence, and hazards of hypertension in the elderly. Am HeartJ. 1986;112:1362-1363. 23. Tuck ML, Griffiths RF, Johnson LE, et al. UCLA geriatric grand rounds: hypertension in the elderly. J Am Geriatr Soc. 1988;36:630-643. 24. Applegate WB, Dismuke SE, Runyan JW. Treatment of hypertension in the elderly: a time for caution? J Am Geniatr Soc. 1984;32:21-23. 25. Radin AM, Black HR. Hypertension in the elderly: the time has come to treat. JAm Genatr Soc. 1981;29:193-200. 26. Gifford RW. Myths about hypertension in the elderly. Med Clin North Am. 1987;71:1003-1011. 27. O'Malley K, O'Callaghan W, O'Brien ET. Hypertension in the elderly: an overview. CurrMedRes Opin. 1982(7,suppl 1):53-62. 28. Smith WM. The case for treating hypertension in the elderly. Am J Hypertens. 1988;1:173S-178S. 29. Emeriau JP, Decamps A, Manciet G, et al. Hypertension in the elderly. Am J Med. 1978;82:1-8. 30. ApplegateWB. Hypertensioninelderlypatients. Ann Intem MedJ 1989;110:901-915. 31. Kannel WB, Dawber TR, McGee DL. Perspectives on systolic hypertension: the Framingham study. Circulation. 1980;61:1179-1182. 32. Wells KB, Stewart A, Hays RD, et al. The functioning and well-beingaof depressed patients: results from the medical outcomes study. JAMA4. 1989;262:914-919.
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American Journal of Public Health 1139
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1140 American Joumal of Public Health
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XI,
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Mark H. Beers, MD, Arlene Fink, PhD, and John C. Beck, MD
Introduction The American nation is growing older. I During the past two decades, the population over 65 has grown more than twice as quickly as the rest of the US population. In 1986, 41% of the elderly were 75 years of age and older; by the year 2000, half the elderly are expected to be over age 75. The 85-and-over population is growing especially rapidly. This group is expected to be seven times as large by the middle of the next century as it was in 1980. The number of functionally impaired elderly is already large and is expected to grow rapidly.2 As the population ages and becomes more impaired, concern for the prevention of disease and promotion of good health increases.3 Studies have documented the potential contributions of preventive health care programs.4 Advocates assert that preventive programs would result in a healthier and more industrious older population that could assist in reducing the nation's expenses for medical care and social support and contribute to the gross national product.5 Investigators have documented a high prevalence of undetected, correctable medical conditions among older adults living in the community.6 As many as 94% of elderly persons screened in a community program were found to have some positive finding requiring advice or information.7 Little information is available, however, regarding the screening tests that should be an integral component of a public health program for older persons. Unlike screening in office practice, public health programs do not focus on treatment but, instead, emphasize referrals and prevention. Many, like the California Preventive Health for the Aged Program, are publicly funded, use trained nurses, and
are mobile, thus limiting their use of some screening equipment. Among the considerations for screening services for public health programs would be the accuracy of such tests in detecting prevalent, asymptomatic disease, the availability and appropriateness of use of screening, and the availability of beneficial treatment of the diseases that are discovered. We synthesized findings from the literature, the US Preventive Services Task Force,8,9 and experts in geriatrics, gerontology, and health policy research to identify screening services that are appropriate for public health programs conducted by nurses.
Methods Data Sources Expert Panels. We identified laboratory screening tests, periodic medical review, hypertension, mental health, dermatological problems, ophthalmological problems, dental problems, and hearing problems as areas of greatest concern. Using these as a starting point, we consulted with experts in geriatric medicine and gerontology to help us select specific topics (e.g., stool guaiacs as a laboratory screening test or glaucoma as an ophthaLmological condition). We assembled 24 members of UCLA's academic faculty and clinical exThe authors are with the School of Medicine and the School of Public Health, University of California, Los Angeles. Requests for reprints should be sent to Dr. Mark H. Beers, UCLA, Center for Health Sciences, School of Medicine, Multicampus Division of Geriatric Medicine and Gerontology, Los Angeles, CA 90024. This paper was submitted to the journal October 10, 1990, and accepted with revisions March 8, 1991.
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perts into eight panels corresponding to the areas listed above. Panel members were selected for their knowledge of preventive health care and ofthe elderly. Panels ranged in size from four to six members, with at least one physician-member of UCLA's Multicampus Division of Geriatric Medicine and Gerontology and one health services researcher with expertise in geriatrics and consensus methods. Other members were expert in one or more of the study topics. We adopted a two-round consensus method that has been used successfully to resolve issues of uncertainty in health care.10,11 During the first round, panelists worked independently and without discussion to complete a written questionnaire. They sent the results for synthesis and then met to discuss the findings. Areas of agreement and disagreement were discussed, with the major emphasis on resolution of disagreements. After discussion, the panelists rerated each question. Literature Review. Our review included studies that were published in English between 1978 and January 1989. We relied on a selective list of investigations considered by experts to be important in guiding geriatric health care practice rather than striving for a review of all published studies. Inclusion criteria. The purpose of the literature review was to synthesize current knowledge from methodologically sound studies regarding the incidence and prevalence of selected undetected disorders in the elderly and the effectiveness of screening and early treatment. By screening, we meant any methods of detecting disease, regardless of stage or severity; prevention meant primary and secondary measures. Tertiary prevention was not considered in this project. The methods of screening included physical examination and history; patient questionnaires; instruments such as the sigmoidoscope and ophthalmoscope; and laboratory tests such as fasting glucose and thyroid function tests. Exclusion citeria. We did not review essays or methodologic studies (e.g., to determine the psychometric properties of a measure of function or mental status), although we examined their reference lists for data sources appropriate to our review. We did not include articles whose main purposes were to investigate the treatments and outcomes of care unrelated to screening. We excluded review articles, except in the case of hypertension, because the results of research had been extensively synthesized. 1132 American Journal of Public Health
Sources ofinfonmation. We identified literature through several mechanisms. All members of the expert panels recommended research studies on screening, and references in those papers were also reviewed. We conducted a MEDLINE search simultaneously. Abstraction of infornation. We reviewed all articles suggested by the project members, located through secondary sources, or uncovered by the computerized search (see Appendix A), but we abstracted only those that met our inclusion criteria (see Appendix B). We developed an abstraction form for recording the contents of each article. Ten articles were reviewed by three members of the team to establish the reliability of the abstraction process. We focused on the extent to which the inclusion and exclusion criteria discriminated among articles and whether agreement existed on their contents. When we were satisfied with the form's capability to facilitate consistent results, we each reviewed articles; every fifth article received a second review to ensure the continued uniformity of the abstraction process. Evaluation of the literature. The literature was evaluated on the basis of the quality of the research design using methods similar to those of the Canadian Task Force on the Periodic Health Examination,12 the US Preventive Services Task Force,8 and the RAND/UCLA Variations Study.13 The best evaluations were assigned to studies with the most rigorous designs (e.g., randomized, controlled trials). Only studies that provided convincing evidence through methodological rigor (e.g., controlled studies) were deemed acceptable. US Preventive Services Task Force. The results of the US Preventive Services Task Force became available in 1989. The credentials of the Task Force panel members and the methods used to arrive at recommendations are described elsewhere.8 Our study could not rely solely on the results of the Task Force for three reasons. First, the panelists did not explore all the topics in which we were interested, such as functional assessment. Second, although some Task Force recommendations directly affect older persons, the elderly are not the primary focus, and no geriatricians served on the Task Force's 20-member panel. There are many topics, such as the evaluation of dementia or the prevention of functional impairment, for which the perspective of geriatricians and gerontologists may differ from that of other clinicians and researchers. The third
reason for not relying solely on the Task Force is that we were interested in public health programs rather than case management by clinicians. The Task Force addressed some diseases that occur almost exlusively in the elderly, such as glaucoma, and it also made specific recom-
mendations for the elderly regarding hearing impairment and bacteriuria. This information was used as a major source of data in this study.
The Synthesis of Data Our final recommendation for each topic is based on all data sources from which information was available. We assumed that a screening test should receive the highest recommendation if its use is supported by the literature and the US Preventive Services Task Force, it is not currently used appropriately, and it can effectively uncover prevalent, undetected disease for which beneficial treatment is available. Throughout this project, we used the risk-benefit definition of appropriateness, meaning that a screen is appropriate when its potential benefit outweighs its potential risks. We based our assessment on the effectiveness of screening tests, i.e., the benefit for a given medical problem under average conditions of use.14 In this project, available meant that no barriers (such as lack of coverage by Medicare or scarcity of personnel or equipment) existed to prevent patients from receiving a test or treatment. We also included attention to compliance in our definition of availability because patients might not avail themselves of tests or treatments (e.g., hearing aids) if a social stigma or extreme discomfort were associated with them. By prevalent, we meant that the disease or condition occurred in a high enough percentage of elderly persons to warrant screening. We defined undetected disease as a disease or condition that is unknown to the patient or his or her doctor. A test or treatment was determined to be appropriate if those people who should be receiving it were receiving it. We called a treatment beneficial if it could help a substantial proportion of persons with the disease or condition while harming relatively few. To arrive at our recommendations, we scored each topic (e.g., dental caries, screening for diabetes) on seven items: (1) extent of support from the US Preventive Services Task Force; (2) extent of support from the consultant experts; (3) extent of support from the literature; (4) prevalence of asymptomatic disease associated with
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the topic; (5) benefit of treatment for the disease; (6) current availability of treatment; and (7) current use ofscreening. We used a 9-point scale, with 1 = strongly negative (i.e., low prevalence, and little or no support, benefit, or availability), 5 = equivocal (i.e., average, neutral, or uncertain support, prevalence, or availability), and 9 = strongly positive (i.e., high prevalence, and much support, benefit, and availability). The final score for each topic was the mathematical average of ratings on all seven items. The strength of our recommendations is based on this final score according to the following scale. 9 = strongly recommended, 8 = recommended, 7 = recommended with reservation, 6 = equivocal, 5 = equivocal, 4 = equivocal, 3 = not recommended with reservation, 2 = not recommended, 1 = strongly not recommended. For example, a particular screening test might be strongly recommended by the US Task Force (9), and strongly recommended by the UCLA experts (9), although there is little or no literature supporting its use (5). The disease might be common, occurrng in over 10% of the population (8). Moderately effective treatment (7) might exist, but the availability of that treatment might be limited due to its high price that is not reimbursed under Medicare and the reluctance of many individuals to undergo the treatment (2). Without new programs to encourage use of this screening procedure, it might be unavailable currently to most elderly persons (8). Such a scenario would receive a final score of 6.9, which we would round off to 7. We support the use of tests that score 7 or better; tests scoring between 4 and 6 are equivocal; and tests scoring between 1 and 3 are not recommended.
Results Data Sources Expert Panels.Topics discussed by the panels and their opinions follow.
Hearing Hearing loss is extremely common in late life, affecting 25% to 35% ofolder persons, and it increases dramatically with advancing age. Mild hearing loss is more likely to be undetected. The most common causes of hearing loss in late life are presbycusis, cerumen impaction, and noise-induced sensory neuronal hearing loss. The best screening test for presbycusis and noise-induced hearing loss is pure-tone audiometry; the best screening
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test for cerumen impaction is otoscopic visualization of the auditory canal. Beneficial treatment exists for all three causes of hearing loss, although amplification is sometimes less successful for noise-induced hearing loss than for presbycusis. The use of amplification is limited because of its cost and the social stigma associated with using hearing aids.
Laboratory screening tests Approximately 2% to 3% of elderly persons have undetected disease that can be diagnosed by routine laboratory tests. The most common undetected diseases (and the best screening methods for detecting each) are anemia (hematocrit or hemoglobin), bacteriuria (urinalysis), hyperlipidemia (serum cholesterol), diabetes (fasting blood sugar), bleeding colonic lesions (stool guaiac), hypothyroidism (TSH), and electrolyte disturbances caused by diuretics and nonsteroidal antiinflammatory agents (serum electrolytes). Beneficial treatments exist for hypothyroidism, bleeding colonic lesions (including early cancer), diabetes, and iatrogenic electrolyte disturbances. The benefits of treating anemia depend on the cause. The benefits of treating hypercholesterolemia probably depend on the age of the patient: treating elevated cholesterol in the very old may not be appropriate. Treating asymptomatic bacteriuria is probably beneficial in men but not in women. There is some limitation to the availability of treatment of diabetes due to the cost of medications and monitoring equipment and compliance with diet, medications, and monitoring. Treatment is limited for iatrogenic complications of medication use because physicians are often reluctant to change medical therapy on the advice of nonphysicians or because medical conditions necessitate their continued use. Hyperlipidemia treatment is limited due to the cost and side-effects of medication and compliance with dietary restrictions and exercise programs.
Periodic medical review Over 50% of the elderly have some undetected disease or condition. The percentage that could be detected through medical history and limited physical examination could not be determined; however, the most common undetected diseases and conditions (and the best screening method for detecting each) that are likely to be found through periodic review are colon cancer (stool guaiacs), breast cancer (breast examination and mammography), coronary artery disease
(history), urinary incontinence (history), inappropriate use of medication (medication review), impaired social functioning (screening scales), impaired physical functioning (screening scales), falls (history), and nutritional problems (weight and height). In almost all cases, these tests and procedures are either not currently available to the majority of elderly persons or are not used appropriately at the current time. Beneficial treatment exists for early colon cancer, early breast cancer, and coronary artery disease. Treatments for the other diseases and conditions are limited at best, and, in some cases, attempts at treatment may be harmful. Treatment availability is limited for urinary incontinence, correcting inappropriate use of medication, and improving poor social and physical functioning, nutritional problems, and falls.
Ophthalmological disorders Approximately 10% of elderly persons have undetected eye disease or visual impairment, and the prevalence increases with age. The most common diseases and conditions are glaucoma, cataracts, macular degeneration, and uncorrected refractive error; the oldest-old (persons over 85) are most likely to suffer from macular degeneration. The panel suggested that when screening is performed by nonophthalmologists or nurses, tonometry is the best screening for glaucoma because it is inexpensive, administration takes minimal training, and expensive or bulky equipment is not required. Testing visual acuity is the best screening procedure for all of the other diseases mentioned. Persons with impaired visual acuity should be referred to an eye specialist for futher evaluation. The minimal barriers to obtaining these procedures are mostly due to lack of reimbursement by some Medicaid programs. Visual acuity testing is generally used appropriately, but tonometry is gen-
erally not. The treatment for glaucoma is generally available and beneficial; treatment for cataracts is available and beneficial; treatment for macular degeneration is not beneficial and, if laser treatment is perfonned inappropriately or incorrectly, may be harmful; treatment for uncorrected refractive error is beneficial and generally available, limited only by cost and reimbursement.
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Mental health Depression can be defined by strict criteria as stated in the DSM-III-Rl5 or by a looser definition of affective disorder serious enough to impact on functioning and well-being. Using the strict definition, 1% to 3% of elderly persons suffer from unrecognized depression, but using the looser definition, 7% to 11% are affected. Few data are available on either the best methods for screening for depression in the elderly or the accuracy of the screening. The panel suggested that the eightitem Medical Outcome Study scale16 might be useful, especially if followed by the Diagnostic Interview Schedule17, screening version. The CES-Dl8 or Zung19 scales might be useful alternatives. None of these screening tests is available or used appropriately at this time. Treatment of depression is beneficial, although its availability is limited by toxic side-effects of medication and lack of resources for counseling and other psychological therapies. Nearly 4% of the elderly suffer from unrecognized dementia or chronic cognitive impairment, although we recognize that in some populations the prevalence may be higher.20 The prevalence of these conditions increases with age. The panel suggested that the Folstein Mini-Mental State21 is the best screening procedure, although this is only useful in Englishspeaking populations. Although these tests are available, they are not currently used appropriately. Currently no good treatment is available for 80% of elderly persons suffering from cognitive decline; the remaining 20% may be helped by treating reversible illness, including depression. The availability and benefit of treatment are highly dependent on the exact cause and could not be estimated overall.
Dematoloical disorders More than half of elderly persons have undetected dermatological disorders severe enough to lead to complications or complaints, with a higher incidence in sunny states such as California. The percentage of undetected disorders that do not result in the seeking of care could not be estimated. The most common diseases and conditions in this category are fungal infections, skin cancer, drug eruptions, photoaging, and xerosis. Visual inspection by a trained observer is the best screening procedure, although a history of symptoms of dry skin is also important for finding cases of xerosis. 1134 American Journal of Public Health
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Treatments for fungal infections, skin cancer, drug eruptions, and xerosis are both available and beneficial. The treatment of photoaging is probably not beneficial and generally not available, due to the cost of the medications and side-effects such as excessive skin dryness and
pruritus.
Dental disorders Nearly 50% of the elderly have undetected dental disease. The prevalence of undetected disease is likely to be highest for those with impaired mobility or limited finances. The most common diseases and conditions are caries, advanced gingivitis and periodontitis, xerostomia, and oral lesions including oral cancer. Clinical examination is the best screening procedure in all cases. Beneficial treatments exist for caries, and, with certain limitations, for periodon-
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titis, xerostomia, and oral lesions. The benefit of treatment of oral lesions depends on its characteristics. Treatment is available for each condition, although the availability of treatment for xerostomia is somewhat limited. Literature Review. We reviewed 139 studies, 33 of which met our criteria for abstraction. We reviewed five pertaining to ophthalmology and three on periodic review of medical care but did not abstract data from them because they failed to meet our criteria. For most topics, the literature contributed limited data or no data at all. Table 1 is a complete list of topics studied and the articles abstracted. Our review of the published literature disclosed a paucity of data on the effectiveness of screening. About two thirds of studies focused on the incidence and prevalence of disease, and the remainder emphasized the effectiveness of screening
tests. Half the studies were supported by federal sources and one quarter used data collected between 1980 and 1983. In the 16 (48%) studies that specified duration, ten (33%) collected data for less than 2 years. Most studies relied on local samples rather than statewide or national groups. Seven assessed randomly chosen samples, but none of these was a randomized controlled trial. Approximately 40% used physical examinations as the main source of data. More than half analyzed findings in terms of the age of the sample, and about half focused exclusively on the elderly. In 22 (66%) studies, participants were White. Ten important review articles were identified that had examined the subject of screening for hypertension in the elderly.22-31 Hypertension has been established as a risk factor for many serious problems, such as stroke, coronary artery disease, congestive heart failure, and multi-infarct dementia. Although some controversy still remains as to whether treating isolated systolic hypertension decreases mortality and morbidity, the general consensus is that treating both systolic and diastolic hypertension are useful and that detecting asymptomatic hypertension in the elderly is advantageous. US Preventive Services Task Force. The Task Force provided data on 13 of this study's 34 specific topics. In some cases, the Task Force addressed issues that affect the elderly, but it did not specifically address whether screening needs were different in elderly populations. For four topics (hearing impairment, bacteriuria, elevated cholesterol, and visual acuity), the Task Force did specifically address the elderly, and in another three topics (glaucoma, dementia, and oral cancer), it reviewed topics that affect the elderly almost exclusively, although it did not specifically comment on the elderly. The Task Force recommended screening for hearing loss, elevated cholesterol, and loss of visual acuity.
Recommendations Table 2 describes this study's recommendations and the bases on which they were made. We recommend the following without reservation: vision testing for refractive error; inspection of the skin surface for fungal infection, skin cancer, drug eruptions, and xerosis; interview for history of xerosis symptoms; audiometric testing for presbycusis and survey scales for hearing loss; otoscopic inspection for cerumen impaction; dental examination for caries; measurement ofblood pressure
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for hypertension; and breast examination and mammography for cancer.
Discussion The recommendations presented here are applicable to public health screening programs that aim to refer large numbers of community-dwelling elders 1136 American Journal of Public Health
and rely on nurses who often travel to deliver services. This study focused on screening for programs staffed by public health nurses, so some tests receiving low ratings might be appropriate for programs relying on physicians. The ophthalmoscope, for example, is an effective screening device for glaucoma when used by a trained ophthalmologist.
From the perspective of clinical geriatrics, many of the tests and procedures that are not supported by this study may still be appropriate when performed by physicians and other health professionals and used for purposes other than screening. Recording mental status, for example, may provide useful baseline data for determining changes in mental status. Also,
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asking about symptoms of depression, which are often missed by primary care practitioners,32 is generallly considered important in primary care geriatric medicine. Measuring renal function with serum creatine may also result in useful baseline data, and following serum electrolytes can be useful in persons on medications, such as nonsteroidal anti-inflammatory drugs, when renal function is known to be impaired. Reviewing medication use is almost certainly important in geriatric care when performed by a primary care physician, although screening for inappropriate medication use by others cannot be supported by our research. Thus, recommendations made here for the exclusion of certain measures from screening programs should not be interpreted to mean that these measures should be excluded from good clinical geriatric care. We limited our investigation of screening to eight broadly defined topics, and these do not encompass all the needs of the elderly. We did not explore screening for vaccination status, for example, or for review of gastrointestinal problems or joint disease. A complete screening package might require other procedures or questions not discussed here. Moreover, the information on which we based our recommendations may change at any time. New research or alterations in reimbursement policies for hearing aids or dental work, for example, would necessitate changes in our ratings. If changes in reimbursement policies were to make hearing aids available to more persons, our ratings for audiometry would move from recommended with reservation to recommended or strongly recommended. Better data are needed to guide screening prgrams, and research is needed on such topics as the response of patients and physicians to referrals from screening programs and their outcomes. We need, for example, to determine whether depression screening scales can be used efficiently and accurately in a population of elderly persons, whether physicians are responsive to referrals about depression, and whether patients receive beneficial treatments sooner because of screening. Research is also needed on ways to get patients to use their medications correctly. If inappropriate use (including noncompliance with therapy, use of interacting drugs, or use of drugs that might impair function or cognition) is uncovered, what should be done to alter patients' and physicians' behavior? In fact, additional research on screeniing is needed for each of the topics explored in this study.
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We urge cautious confidence in applying our recommendations. Despite their limitations, they represent the best possible efforts of some leading experts in geriatric health care to weigh scientific and experimental evidence. It is obvious from this investigation, however, that more information is sorely needed to strengthen the foundation on which health policy on screening in the elderly can be established. El
Acknowledgments This project was supported by a contract from the California Department of Public Health. The authors are most grateful to Ms. Rhoda Slagel, ofthe California Preventive Health for the Aged Program. We are also indebted to Ms. Nancy Marr for assistance in conducting the literature review, assembling the bibliography, and scheduling the panels and to Ms. Ana Shiwoku for assistance in preparation of the manuscript and organization of the project.
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ical-surgical procedures. Am J Public Health. 1986;76:766-772. 12. Canadian Task Force on Periodic Health Examination. Can Med Assoc J. 1979;121:1193-1254. 13. FinkA, Brook RH, KosecoffJ. Sufficiency of clinical literature on new appropriate uses of six medical and surgical procedures. West JMed. 1987;147:609-614. 14. Institute of Medicine. Assessing Medical Technologies. Washington, DC: National Academy Press, 1985. 258. 15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed, rev. Washington DC: American Psychiatric Association; 1987. 16. Burnam MA, Wells KB, Leake B, et al. Development of a brief screening instrument for detecting depressive disorders. Med Care. 1988;26:775-789. 17. Robins LN, Helzer JE, Crougham J, et al. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry. 1981;38:381-389. 18. RadloffLS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychiatr Meas. 1977;1:385-401. 19. Zung WW. A self rating depression scale. Arch Gen Psychiatry. 1965;12:63-70. 20. Evans DA, Funkenstein HH, Albert MS, et al. Prevalence of Alzheimer's disease in a community population of older persons: higher than previously reported. JAMA. 1989;262:2551-2556. 21. Folstein MF, Folstein S, McHugh PR. MiniMental State: a practical method for grading the cognitive state of patients for the clinician.JPsychiatrRes. 1975;12: 189-198. 22. Kannel WB. Prevalence, incidence, and hazards of hypertension in the elderly. Am HeartJ. 1986;112:1362-1363. 23. Tuck ML, Griffiths RF, Johnson LE, et al. UCLA geriatric grand rounds: hypertension in the elderly. J Am Geriatr Soc. 1988;36:630-643. 24. Applegate WB, Dismuke SE, Runyan JW. Treatment of hypertension in the elderly: a time for caution? J Am Geniatr Soc. 1984;32:21-23. 25. Radin AM, Black HR. Hypertension in the elderly: the time has come to treat. JAm Genatr Soc. 1981;29:193-200. 26. Gifford RW. Myths about hypertension in the elderly. Med Clin North Am. 1987;71:1003-1011. 27. O'Malley K, O'Callaghan W, O'Brien ET. Hypertension in the elderly: an overview. CurrMedRes Opin. 1982(7,suppl 1):53-62. 28. Smith WM. The case for treating hypertension in the elderly. Am J Hypertens. 1988;1:173S-178S. 29. Emeriau JP, Decamps A, Manciet G, et al. Hypertension in the elderly. Am J Med. 1978;82:1-8. 30. ApplegateWB. Hypertensioninelderlypatients. Ann Intem MedJ 1989;110:901-915. 31. Kannel WB, Dawber TR, McGee DL. Perspectives on systolic hypertension: the Framingham study. Circulation. 1980;61:1179-1182. 32. Wells KB, Stewart A, Hays RD, et al. The functioning and well-beingaof depressed patients: results from the medical outcomes study. JAMA4. 1989;262:914-919.
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