Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0174 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYThe Comprehensive Assessment and Referral Evaluation (CARE):An Approach to Evaluating Potential for Achieving Quality of LifeBarry Gurland and Sidney KatzColumbia University Stroud Center, New York, USAPURPOSESThe CARE covers a wide range of indicators of a person’spotential for achieving a preferred quality of life. Its boundedfocus is on health and social problems associated with aging,including psychiatric disorders. Originally developed for intensivestudies of community-dwelling elders 1 , the rater-administeredCARE has given rise to versions that have been made briefer byconcentrating on key scales (the CORE-CARE 2 and the SHORT-CARE) 3 , suitable for residents of institutions (the IN-CARE) 4 ,clinically focused (the CLIN-CARE) 5 , and capable of selfadministration(the SELF-CARE). There is also an INFOR-MANT version 6 of the CARE.THEORETICAL BASE 7The phrase ‘‘quality of life’’ is invoked to direct attention toprocesses of striving to achieve or preserve a preferred mannerof living. The processes involve strategies that allow relevantchoices to be made and implemented. The strategies can beimpeded by certain health and social problems that mayoccasion help-seeking contacts with informal or formal caregiversor services. The CARE seeks to assess the person’sability to deal with the strategies necessary for choosing andattaining a preferred manner of living. It does not attempt todefine the latter. Information on processes can come from manysources, touching on many aspects of living, reaching beyondthe person’s immediate status into the present and historicalcontext, modified by expectations of the future, and qualifiedby personal and cultural preferences. It is recognized that thegathering of such information is very constrained by itscomplexity, openness to change and inherent uncertainties, aswell as by the necessary rigidities of the systematic assessmentprocedures.STYLEThe general style of the CARE relies on scripted questions withpre-coded answers. The questioning is tactful and with anorganization that is understandable to the interviewee, Headerquestions allow sections to be skipped if unlikely to be productive.Computer-assisted programs guide interview administration, so asto avoid missed or conflicting ratings. Information can beanalyzed at the level of discrete items, global ratings, scales,hierarchically-arranged classes of severity, and threshold scoresrelating to diagnosis and need for investigation and possibletreatment.DOMAINSEach domain targets the capacity to meet a distinctive challengeto achieving a preferred quality of life. Nineteen quality of lifedomains 8 have been identified and matched to items in the CARE:moving purposefully (mobility); maintaining self routinely (basicactivities of daily living); using the immediate environment(instrumental activities of daily living); manipulating householdappliances (technological activities of daily living); finding one’sway around (navigational orientation); keeping track of time andspace (continuity orientation); gathering information (receptivecommunication); expressing needs (expressive communication);preserving health (health and safety practices); protecting physicaland mental comfort (emotional and physical status); engaging insocial relations; exercising choice; managing material resources;finding the best environment; obtaining meaningful gratifications;recognizing one’s own state of health (self-perceived health);taking account of the future (pessimism, optimism. realism);balancing competing qualities of life; setting and achieving goals.The domain content and labels are keyed to adaptive behaviors inpursuit of quality of life (more conventional captions are shown inparentheses).SUBJECTIVITY AND OBJECTIVITYThe CARE does not beg the issue of whether quality of life isprimarily subjective or objective, preferring to regard both asimportant strategies in the pursuit of quality of life. Subjective(e.g. feelings, attitudes), quasi-objective (self-reports of objectivestatus) and mainly objective (tests and observations) aspects ofquality of life are represented, thus allowing their interrelationshipsand their respective effects and outcomes to be examined.For example, questions on activities of daily living probe selfreportedtask performance, views on the extent to which healthlimits desired activities, informant views on the elder’sfunctioning, tests of range of movement and observations onmobility. A supplement tests a simulation of various basic andinstrumental tasks (the Performance of Activities of DailyLiving, or PADL) 2 . Similarly, inquiries on cognitive statusrange from self-reported difficulties with memory to formal testsof memory and orientation, and a supplement (the MedicationManagement Test, or MMT) 10,11 tests higher-order cognitivelydrivenperformance.SEVERITY LEVELSThreats to quality of life are graded in terms of the degree towhich they overshadow living at a critical point in time(intensity) and over time, experiences, and situations (extensity).This approach has been more completely modeled within theCARE domain of emotional comfort, as expressed in the sevenlevels of the index of affective suffering (IAS) 12,13 . Each level isoperationalized by symptom criteria that convey the severitymeanings of suffering in a way not equaled by symptom scores ordiagnosis. This model of severity is also worked out for theCARE domains dealing with functioning in the activities of dailyliving. Current development is concerned with deriving a measure