Complications with Assessing Disability in Aged Care: When Does Does Not Apply Apply

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Complications with Assessing Disability in Aged
Care When Does Does Not Apply Apply?

• E. Helmes A. Campbell
• Department of Psychology
• James Cook University

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• Disabilities are common in residential care
  facilities
• Severe levels of disability may affect other
  domains of function
• Example impaired mobility limits social
  interactions

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• Many rating scales and self-report instruments
  include a neutral, or Cannot Say option
• Examples early MMPI, 16PF (5th edition), Likert
  scales with uneven number of options (5-, 7-, or
  9-point scales)

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• Responses to such neutral points are ambiguous
• Neutral?
• Indifferent?
• Lacks understanding of content?
• Lacks knowledge need to answer?
• Hostility?

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• What of seemingly more direct Does Not Apply
  or Not Applicable options?
• Bristol Activities of Daily Living Scale (Bucks
  et al., 1996) all 19 items
• MOSES (Helmes, et al., 1987) 18 of 40 items

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11. FINDING WAY AROUND INSIDE (For example,
ability to find his room, the washroom, the
dining room) How often during the daytime in the
past week did the resident become disoriented
(confused) in finding his or her way around the
inside of the residence? 1. Not at all 2.
Seldom (only one to three times during the
week) 3. At times (either once or twice a day on
more than three days, or several times a day on
one to three days) 4. Often (several times a day
or on more than three days) 5. Question does not
apply -- the resident never moved around inside
the building without assistance from the staff
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Content Interpretation?

• Pruchno et al. (1988)
• 5 of 18 items inability to speak implies
  greater levels of disability, so score as 5gt4
• 11 items equivalent to non-occurrence, so equate
  with Not at All, so score as 50
• 536 nursing home residents, 24/40 items retained
  after changed scoring confirmatory factor
  analysis

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Samples

• Norming sample 2921 unique cases
• Psychogeriatric 397
• Nursing home 918
• Home for the Aged 563
• Continuing Care 447
• 924 (31.6) males, 1985 (68) females
• Mean age 78.9 (SD 10.9)
• 490 Single, 688 Married, 1588 Widowed, 123
  Divorced or Separated

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Scoring Variations

• All Does Not Apply coded as 5
• Pruchno et al. variation
• Listwise deletion of any case with a Does Not
  Apply score (as in 1987 components analysis)

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Analysis

• Scoring key as target 8 items on each of 5
  dimensions
• 12 covariance matrices (3 scoring variations x 4
  samples)
• EQS confirmatory factor analysis
• M-Plus distribution-free confirmatory analysis

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Results

• All solutions not optimal cross-loading items
• Fewer model mis-specifications with M-Plus
• No clear pattern M-Plus suggests poorer fit with
  Exclude scoring option (CFI but not RMSEA)

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Results Method of Analysis




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Results Method of Compensation - CFI
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Results Method of Compensation - RMSEA
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Results Method of Compensation Number of Low
Loadings
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Results

• Pruchno approach more model mis-specifications
• Pruchno approach more marginal loadings
• Exclude approach fewest marginal loadings,
  mis-specifications with EQS (not so with M-Plus)
• Deletion method results in fewer items with low
  loadings (i.e. clearer structure)

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Conclusions

• Minimal differences across methods of
  compensation for Does Not Apply option
• No method gives univocally better fit
• Listwise deletion gives clearer structure but at
  cost of smaller and likely biased sample

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Alternative Item Response Theory

• IRT provides information on performance of
  response options
• Preliminary results of analysis of nursing home
  data using GGUM (Roberts et al., 2004)
  Generalized Graded Unfolding Model

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Disorientation Item 16 5 more extreme than 4
8 of 18 items
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Withdrawal Item 40 Does not Apply Most Severe
10 of 18 items