Mohammed T. Abou-Saleh

COMPREHENSIVE INTERVIEWS 175of the continuities underlying the progression of functionaldecline.MECHANISMSThreats to quality of life, such as those measured by the CARE,may arise from health and social conditions; the presence of thelatter can be suggested by certain syndromes. The CARE itemsinclude syndromes of cardiac failure or angina, arthritic pain,respiratory problems, effort intolerance, cognitive deficits, Parkinson’sdisease, stroke, perceptual deficits, vertigo, falls,experience of crime, and social isolation and desolation. Conversely,there are characteristics of the threatened qualities of lifethat suggest certain mechanisms: one scale of functioning in theCARE is composed of higher-order tasks that are principallyaffected by cognitive mechanisms; similarly, certain somatic itemsare phrased to suggest a mood disorder and others to suggest aphysical disorder. More directly, there are items to record whatthe individual blames as the cause of his/her threatened quality oflife.BIOMETRICSSatisfactory reliability, validity and operational characteristics fordiscriminating diagnoses of the CARE scales have been established14–18 . Transition tables show a range of incidence, chronicityand recovery from threats to quality of life 19 ; these also reflect apower to predict specific quality-of-life outcomes. Cross-tabulationsreveal that the various domains are sufficiently independentto be usefully measured separately but that there is substantialinteraction between them. 20,21CULTURE-FAIR INDICATORSEthno-racial and educational variation in qualities of life havebeen found with CARE indicators 22,23 , as with comparableinstruments 24 . In order to minimize the confound of bias enteringinto such comparisons, item response theory has been applied toconstruct culture-fair CARE scales of mood, cognition andfunctioning in the activities of daily living 25 .MODULAR USESAlthough the full CARE is more than the sum of its parts, thescales can be, and have been, used alone and in variouscombinations. This has enabled the assembly of its differentversions.WHOLE-PERSON VIEW 26Profiles of CARE indicator severity scales are generated bycomputer algorithms, giving an overview of the person’s strengthsand vulnerabilities for preserving and improving quality of life.Global concepts are also embodied in items on self-perceivedgeneral health and in visual analog scales on physical andpsychological distress and task and social functioning: asupplementary single-page rapidly completed set of visual analogscales (the QoL-100) has proved useful for a snap-shot of thequality of life potentials of seriously ill patients or where frequentfollow-up assessments are needed. Psychiatric diagnoses havebeen generated using a computerized decision tree 27,28 .APPLICATIONSTaken together with its versions and supplements, the CARE hasbeen applied to epidemiological 29 surveys 30–33 , public healthpolicy 34–39 and clinical management in primary medical care 40 ,home care 41 and occupational therapy. A Training Manual isavailable.FURTHER DEVELOPMENTThe Stroud Center’s program is designed to contribute tounderstanding the nature of the parts and the connected wholeof a person’s quality of life. Experience with applications,modifications and analyses of the CARE is leading to new andbetter ways of assessing quality of life.REFERENCES1. Gurland BJ, Kuriansky JB, Sharpe L et al. The ComprehensiveAssessment and Referral Evaluation (CARE)—rationale,development and reliability. Int J Aging Hum Dev 1977; 8: 9–42.2. Gurland BJ, Wilder DE. The CARE interview revisited:development of an efficient, systematic, clinical assessment. JGerontol 1984; 39: 129–37.3. Gurland B, Golden R, Teresi J, Challop J. The SHORT-CARE: anefficient instrument for the assessment of depression, dementia anddisability. J Gerontol 1984; 39: 166–9.4. Mann A, Gurland B, Cross P. A comparison of the long-term care ofthe elderly in New York and London and implications of thedifferences. In Radebaugh TS, Gruenberg EM, Kramer M, CooperB (eds), The Chronically Mentally Ill: An International Perspective.Baltimore, MD: Johns Hopkins School of Hygiene and PublicHealth, 1985, 117–29.5. Gurland B, Lantigua R, Teressi J et al. The CLIN-CARE: atechnique for comprehensive assessment: preliminary report ofbiometric properties. In Wykle ML (ed.), Elderly Rehabilitation asArt and Science. New York: Springer, 1990, 78.6. Wilder DE, Gurland BJ, Chen J. Interpreting subject and informantreports of function in screening for dementia. Int J Geriat Psychiat1994; 9: 887–96.7. Katz S, Gurland BJ. Science of quality of life of elders: challengesand opportunity. In Birren J, Lubben JE, Rowe JC, Deutchman DE(eds), The Concept and Measurement of Quality of Life in the FrailElderly. New York: Academic Press, 1991, 335–43.8. Gurland BJ, Katz S. Quality of life and mental disorders of elders. InKatschnig H, Freeman H, Sartorius N (eds), Quality of Life inMental Disorders. Chichester: Wiley (in press).9. Kuriansky J, Gurland B. The Performance Test of Activities ofDaily Living. Int J Aging Hum Dev 1976; 7: 343–52.10. Fulmer T, Gurland B. Restriction as elder mistreatment: differencesbetween caregiver and elder perceptions. J Ment Health Aging 1996;2(2): 89–99.11. Gurland BJ, Cross P, Chen J et al. A new performance test ofadaptive cognitive functioning: the Medication Management (MM)Test. Int J Geriat Psychiat 1994; 9: 875–85.12. Gurland BJ, Katz S, Chen J. Index of Affective Suffering: linking aclassification of depressed mood to impairment in quality of life. AmJ Geriat Psychiat 1997; 5(3): 192–210.13. Gurland BJ, Katz SI. Subjective burden of depression. Am J GeriatPsychiat 1997; 5(3): 188–91.14. Golden RR, Teresi JA, Gurland BJ. Development of indicatorscalesfor the Comprehensive Assessment and Referral EvaluationInterview schedule. J Gerontol 1984; 39: 138–46.15. Gurland BJ, Wilder DE. The CARE interview revisited:development of an efficient, systematic, clinical assessment. JGerontol 1984; 39: 129–37.16. Teresi JA, Golden RR, Gurland BJ. Concurrent and predictivevalidity of indicator-scales developed for the ComprehensiveAssessment and Referral Evaluation interview schedule. J Gerontol1984; 39: 158–65.