Health Trajectories in Nursing ScienceHealth Trajectories in Nursing Science

Elizabeth C. Clipp, RN, PhDElizabeth C. Clipp, RN, PhD

Professor and Associate Dean for ResearchProfessor and Associate Dean for Research

Duke University School of NursingDuke University School of Nursing

OverviewOverview

• My background and contextMy background and context– Why a focus on health trajectories?Why a focus on health trajectories?

• Health trajectories: ConceptsHealth trajectories: Concepts • Health trajectories: Empirical Health trajectories: Empirical

Examples Examples

BackgroundBackground• Master’s prepared nurseMaster’s prepared nurse• NIMH Fellow -- Developmental PsychologyNIMH Fellow -- Developmental Psychology

– Glen Elder & Uri Bronfenbrenner (Mentors)Glen Elder & Uri Bronfenbrenner (Mentors)– Applied a clinical lens to Applied a clinical lens to

• Life span developmental psychologyLife span developmental psychology• Life Course SociologyLife Course Sociology• Large longitudinal data sets (Berkley Oakland, Terman, Large longitudinal data sets (Berkley Oakland, Terman,

BLSA)BLSA)• Dissertation: linking early loss events and late life functioningDissertation: linking early loss events and late life functioning

• Postdoctoral Fellow: Duke Aging Center Postdoctoral Fellow: Duke Aging Center • Caregiver longitudinal well-being study (predictors of Caregiver longitudinal well-being study (predictors of

institutionalization)institutionalization)

• 20 years in Department Medicine / Geriatrics20 years in Department Medicine / Geriatrics• Health Trajectories in Later Life Health Trajectories in Later Life • National Longitudinal Caregiving StudyNational Longitudinal Caregiving Study

During the last 4 years --During the last 4 years --

• Duke University School of Nursing (2001-Duke University School of Nursing (2001-present)present)

• P20 Center (Trajectories of Aging & Care in Nursing P20 Center (Trajectories of Aging & Care in Nursing Science 2001-2003)Science 2001-2003)

• P20 Center (Trajectories of Aging & Care in Nursing P20 Center (Trajectories of Aging & Care in Nursing Science 2004-2007)Science 2004-2007)

• Hartford Interdisciplinary Research Center Hartford Interdisciplinary Research Center (longitudinal Pilots) (longitudinal Pilots)

• PhD Program (Trajectories of Chronic Illness and PhD Program (Trajectories of Chronic Illness and Care Systems)Care Systems)

• ADR since 9/05ADR since 9/05

Duke University Medical Center – Durham NCDuke University Medical Center – Durham NC

Duke School of Nursing Faculty and StaffDuke School of Nursing Faculty and Staff

New Building -- Duke University School of Nursing Summer 2006

Health TrajectoriesHealth TrajectoriesIn ConceptIn Concept

What is a trajectory?What is a trajectory?• DictionaryDictionary: :

– Curve that a body describes in space; the path, Curve that a body describes in space; the path, progression, or line of developmentprogression, or line of development

• Scientific LiteratureScientific Literature: : – course of a dependent variable plotted over timecourse of a dependent variable plotted over time– sequence of transitionssequence of transitions

• ““Transitions give trajectories their distinctive shape and Transitions give trajectories their distinctive shape and meaning (Elder)”meaning (Elder)”

– patterns of human functioning / symptoms (nursing)patterns of human functioning / symptoms (nursing)

• AnalyticallyAnalytically: : – longitudinal data incorporating at least 3 time pointslongitudinal data incorporating at least 3 time points

Health TrajectoriesHealth Trajectories

• Not a statistical approachNot a statistical approach• Rather, Rather, a way of thinkinga way of thinking about about

– Health dynamicsHealth dynamics– Clinical phenomena of interest to nursesClinical phenomena of interest to nurses– Individual differences in health dynamics, Individual differences in health dynamics,

specifically in clinical phenomena of interest specifically in clinical phenomena of interest to nurses to nurses

– Exploiting longitudinal data in clinically Exploiting longitudinal data in clinically relevant ways. relevant ways.

Health trajectories seek to identify patterns of Health trajectories seek to identify patterns of clinically-relevant clinically-relevant individual differencesindividual differences and to and to

consider the consider the significance of outlierssignificance of outliers

• Individual DifferencesIndividual Differences: Tendency of : Tendency of individual subjects to maintain the same individual subjects to maintain the same relative rank on a specific characteristic relative rank on a specific characteristic as compared to the groupas compared to the group

• OutliersOutliers become interesting and clinically become interesting and clinically relevant – not a source of errorrelevant – not a source of error

Health trajectory approach ≠ traditional Health trajectory approach ≠ traditional longitudinal approachlongitudinal approach

Health Trajectory ResearchHealth Trajectory Research““Splitting”Splitting”

• Repeated measures on the same Repeated measures on the same subjectssubjects over time (person centered) over time (person centered)

• Stability and change patterns in clinical Stability and change patterns in clinical phenomena of interest to nursesphenomena of interest to nurses

• Use clinical cut-points or software to Use clinical cut-points or software to identify clinically relevant subgroupsidentify clinically relevant subgroups

• Identify factors that differentiate Identify factors that differentiate trajectory patternstrajectory patterns

• Based on trajectory patterns, Based on trajectory patterns, interventions can be optimally targeted interventions can be optimally targeted and timed. and timed.

• Useful approaches: LCA, HLMUseful approaches: LCA, HLM• Useful software: Latent Gold, M-PlusUseful software: Latent Gold, M-Plus

Longitudinal ResearchLongitudinal Research““Lumping”Lumping”

• Repeated measures on the same Repeated measures on the same units of analysisunits of analysis over time (e.g., over time (e.g., patients, providers, systems, patients, providers, systems, counties). counties).

• Many analytic approaches, with the Many analytic approaches, with the more traditional approaches more traditional approaches focusing on central tendency of the focusing on central tendency of the sample.sample.

OriginsOrigins

• Alcohol abuse literature Alcohol abuse literature – Intake patterns: alcoholism dxs, abstinenceIntake patterns: alcoholism dxs, abstinence

• Education literatureEducation literature– Tracking students by competenciesTracking students by competencies

• Criminology literature Criminology literature – Understanding recidivismUnderstanding recidivism

• Developmental PsychologyDevelopmental Psychology– Life course and life span perspectivesLife course and life span perspectives

Example: Trajectories of Behavior in Childhood Example: Trajectories of Behavior in Childhood leading to Various Adolescent Outcomesleading to Various Adolescent Outcomes

• 1,037 boys followed from age 6-15 with repeated measures of various 1,037 boys followed from age 6-15 with repeated measures of various external behaviors (aggression, opposition, hyperactivity)external behaviors (aggression, opposition, hyperactivity)

• 4 developmental trajectories identified: 4 developmental trajectories identified: Chronic ProblemChronic Problem, , High-High-sporadicsporadic, , Moderate-sporadicModerate-sporadic, , no problemno problem..

• Results showed that boys who followed one trajectory for one behavior Results showed that boys who followed one trajectory for one behavior did not necessarily follow same trajectory for another type of behavior did not necessarily follow same trajectory for another type of behavior

• Different behavioral trajectories led to different types of juvenile Different behavioral trajectories led to different types of juvenile delinquency.delinquency.– Chronic opposition trajectory led to covert delinquency (theft).Chronic opposition trajectory led to covert delinquency (theft).– Chronic aggression trajectory led to overt delinquency (physical Chronic aggression trajectory led to overt delinquency (physical

violence) and to the most serious acts.violence) and to the most serious acts.

Trajectories of Boys’ Physical Aggression, Opposition, and Hyperactivity on the Path to Violent and Non-violent Juvenile Delinquency, Nagin D, Tremblay R, Child Development, Sept 1999.

Why should Why should nurse scientistsnurse scientists take a take a trajectory approach?trajectory approach?

• Nurses focus on health, which is an fundamentally Nurses focus on health, which is an fundamentally dynamic dynamic

• Studies that examine serial measures or transitions Studies that examine serial measures or transitions provide important information about periods of provide important information about periods of stability, decline or recovery.stability, decline or recovery.

• Examining trajectories permits the identification of Examining trajectories permits the identification of factors that anticipate decline or enhance recovery.factors that anticipate decline or enhance recovery.

• Trajectories provide clues to Trajectories provide clues to whowho need interventions need interventions and and whenwhen interventions are likely to be most effective. interventions are likely to be most effective.

Health TrajectoriesHealth TrajectoriesEarly empirical workEarly empirical work

Examples1. Early work with the Terman Archive (1980s)

Crude forms

2. EPESE data (1990s)2a: Trajectory Delineation2b: Trajectory Prediction

3. National Longitudinal Caregiver Study (2000-2001)Latent class analysis (M-Plus)

Example 1: Terman Archive Example 1: Terman Archive (1922-1992)(1922-1992) • 1500 school children in 1922 with high IQs were 1500 school children in 1922 with high IQs were

followed to study human development and its social followed to study human development and its social and psychological correlates and psychological correlates

• Follow-ups 1928, 1936, and Q5 yrs to 1960. In 1940, Follow-ups 1928, 1936, and Q5 yrs to 1960. In 1940, 96% of the sample was still active. After 1960, follow-96% of the sample was still active. After 1960, follow-ups continued in 1972, 1977, 1982, 1986 and the last ups continued in 1972, 1977, 1982, 1986 and the last data collection was in the early 1990s. data collection was in the early 1990s.

• 1991 Nurse lens: 1991 Nurse lens: – 857 with coded health info from 1940 to 1986 (age 857 with coded health info from 1940 to 1986 (age

35-70s/80s)35-70s/80s) – What health trajectories describe these men from mid- to What health trajectories describe these men from mid- to

later life? What are the correlates of these trajectories?later life? What are the correlates of these trajectories?

Terman Archive (available data)Terman Archive (available data)

• 3 items repeated at each of 8 waves 1945-1986: 3 items repeated at each of 8 waves 1945-1986: Self-rated health, energy/vitality, alcohol Self-rated health, energy/vitality, alcohol consumptionconsumption

• Pages of uncoded material in response to Pages of uncoded material in response to "describe health and health changes "describe health and health changes experienced since the last testing and how experienced since the last testing and how health influenced overall life”health influenced overall life”

• Year of travel & recoding the archiveYear of travel & recoding the archive– summary sheets, code development, physician summary sheets, code development, physician

ratings, reliability checksratings, reliability checks

Terman ArchiveTerman ArchiveTrajectories Trajectories

• Developed a typology of 5 temporal health patterns Developed a typology of 5 temporal health patterns over a span of 45 years (1940-86) over a span of 45 years (1940-86)

• Called these patterns “trajectories”Called these patterns “trajectories”

• Trajectories relied on coding data based on nursing Trajectories relied on coding data based on nursing knowledge/ clinical experience (i.e., visual knowledge/ clinical experience (i.e., visual inspection of temporal patterns) inspection of temporal patterns)

• Trajectories strongly related to age, education, Trajectories strongly related to age, education, primary illnesses, alcohol use, energy and vitalityprimary illnesses, alcohol use, energy and vitality

Simple Trajectory FormsSimple Trajectory FormsA place to startA place to start

Stability:Stability:

““High Stable”, “Low Stable”High Stable”, “Low Stable”

Change:Change:

““Improving”, “Fluctuating”,“Declining”Improving”, “Fluctuating”,“Declining”

Stable Good HealthStable Good Health

Decline and Decline and RecoveryRecovery

Linear DeclineLinear Decline Decline at End of LifeDecline at End of Life

Stable Poor HealthStable Poor HealthTerman MenTerman Men

Age ~34-76Age ~34-76

8 Time Points 8 Time Points 1945-19861945-1986

Development of IdeasDevelopment of Ideas

• Construction of crude physical health trajectories that Construction of crude physical health trajectories that related meaningfully to personal/psychosocial related meaningfully to personal/psychosocial indicators (Terman Archive) indicators (Terman Archive)

• Clinical patterns vs. population-based researchClinical patterns vs. population-based research• Individual change vs. Group changeIndividual change vs. Group change• Person approach vs. Variable approach Person approach vs. Variable approach • Signal vs. noiseSignal vs. noise

Trajectories of Health: Clipp, Elder & Pavalko. Trajectories of Health: Clipp, Elder & Pavalko. Behavior, Health and Behavior, Health and AgingAging, 1992., 1992.

• ““In thinking about older people: It has long been clear that for some, In thinking about older people: It has long been clear that for some, much of life is marked by sustained good health until the end of life, much of life is marked by sustained good health until the end of life, while for others, life is characterized by sudden or gradual declines in while for others, life is characterized by sudden or gradual declines in function, sometimes punctuated by intervals of complete or partial function, sometimes punctuated by intervals of complete or partial recovery.recovery.

• These temporal patterns are multidimensional, dynamic, and result from These temporal patterns are multidimensional, dynamic, and result from a combination of factors including genetic endowment, active disease a combination of factors including genetic endowment, active disease states, age-related changes, coping resources, life events, lifestyle states, age-related changes, coping resources, life events, lifestyle patterns, and access to care. The complexity of these patterns accounts patterns, and access to care. The complexity of these patterns accounts for why acute illnesses present and retreat and why chronic illnesses for why acute illnesses present and retreat and why chronic illnesses accumulate and interact to form intricate clinical profiles.accumulate and interact to form intricate clinical profiles.

• These temporal patterns can be described as health trajectories.These temporal patterns can be described as health trajectories.

• Nurses work to effectively intervene within these unfolding patterns of Nurses work to effectively intervene within these unfolding patterns of functioning and clinical symptoms - with the goal of positively functioning and clinical symptoms - with the goal of positively reorienting problematic trajectories”.reorienting problematic trajectories”.

Example 2 Example 2 Trajectory Delineation and Prediction:Trajectory Delineation and Prediction:

Observations from the Duke EPESEObservations from the Duke EPESE

Trajectory DelineationTrajectory DelineationStudy AimsStudy Aims

• To empirically identify and describe 7-To empirically identify and describe 7-year trajectories of health among older year trajectories of health among older men across 4 domains: men across 4 domains: – DepressionDepression– Self-rated healthSelf-rated health– Cognitive functionCognitive function– Physical functionPhysical function

• To consider correlates and predictors of To consider correlates and predictors of these trajectory patterns. these trajectory patterns.

DataData• Established Populations for Epidemiologic Established Populations for Epidemiologic

Studies of the Elderly (EPESE; Duke Site)Studies of the Elderly (EPESE; Duke Site)

• Longitudinal, with 3 detailed, face-to-face Longitudinal, with 3 detailed, face-to-face interviews in 1985, 1989, 1993interviews in 1985, 1989, 1993

• 1,473 men age 65+1,473 men age 65+

• Adjusted response rates, excluding Adjusted response rates, excluding mortality exceeded 90%mortality exceeded 90%

Four Health Domains Four Health Domains Time Frame: 1986-1993Time Frame: 1986-1993

• Perceived Health (standard self-reports) Perceived Health (standard self-reports)

• Functional Health (ADLs, IADLs)Functional Health (ADLs, IADLs)

• Cognitive Functioning (SPMSQ)Cognitive Functioning (SPMSQ)

• Depression (CES-D)Depression (CES-D)

P1: 1,473 P1: 1,473

P2: 1,095P2: 1,095

P3: 805P3: 805

Trajectory DelineationTrajectory Delineation

• 7-year health domains (measures)7-year health domains (measures)– Self-rated health (standard single-item)Self-rated health (standard single-item)– Depression (CES-D)Depression (CES-D)– Cognitive function (SPMSQ)Cognitive function (SPMSQ)– Physical function (ADLs/IADLs)Physical function (ADLs/IADLs)

• Distribution of measures examined; clinically-relevant Distribution of measures examined; clinically-relevant cut points selectedcut points selected

• Patterns of stability and change in the indicators Patterns of stability and change in the indicators assessed across the 7-year intervalassessed across the 7-year interval

Observations Observations (con’t)(con’t)

Based on the Terman work (informed by clinical Based on the Terman work (informed by clinical observation), we looked for and again found that observation), we looked for and again found that five trajectories summarized the 7-year health five trajectories summarized the 7-year health histories:histories:

High StableHigh Stable

Low StableLow Stable

ImprovingImproving

DecliningDeclining

FluctuatingFluctuating

ObservationsObservations

• Means analysis -- we found relative Means analysis -- we found relative stabilitystability in in in the four health domains (depression, self-in the four health domains (depression, self-reported health, cognitive functioning, and reported health, cognitive functioning, and physical functioning).physical functioning).

• In other words -- “High Stable” trajectories In other words -- “High Stable” trajectories within all four health domains most commonly within all four health domains most commonly characterized the EPESE men. characterized the EPESE men.

• However, group means masked substantial However, group means masked substantial variability, as shown by Z-scores; other 4 variability, as shown by Z-scores; other 4 trajectories were observed fairly evenly.trajectories were observed fairly evenly.

Observations Observations (con’t)(con’t)

After eliminating “High Stable” menAfter eliminating “High Stable” men

• Men with lower self-rated health tended to Men with lower self-rated health tended to demonstrate higher levels of depressiondemonstrate higher levels of depression

• Most of the men (65%) with low levels of Most of the men (65%) with low levels of physical functioning also had low levels of physical functioning also had low levels of cognitive functioningcognitive functioning

• Began to think about the interrelationships Began to think about the interrelationships among clinical trajectoriesamong clinical trajectories

ConclusionsConclusions• Most community-dwelling older men enjoy high levels of health Most community-dwelling older men enjoy high levels of health

over time (high self-ratings, little or no evidence of depression or over time (high self-ratings, little or no evidence of depression or ADL challenge, and high levels of cognitive functioning). ADL challenge, and high levels of cognitive functioning).

• However, this “high stable” group drives measures of central However, this “high stable” group drives measures of central tendency and masks several clinically meaningful patterns of tendency and masks several clinically meaningful patterns of stability and change among many other men.stability and change among many other men.

Trajectory PredictionTrajectory PredictionThinking about Health Trajectories as OutcomesThinking about Health Trajectories as Outcomes

• What are the demographic and health What are the demographic and health history predictors of 7-year health history predictors of 7-year health trajectories?trajectories?– Self-Related HealthSelf-Related Health– DepressionDepression– Cognitive FunctioningCognitive Functioning– Physical FunctioningPhysical Functioning

Predictor PoolPredictor Pool(3 Variable sets)(3 Variable sets)

• 15 demographic and social indicators15 demographic and social indicators

• 9 medical and health service use 9 medical and health service use indicatorsindicators

• 4 baseline indicators of each health 4 baseline indicators of each health domaindomain

Demographic and Social PredictorsDemographic and Social Predictors

Age, Race, Education, IncomeAge, Race, Education, Income

Urban/Rural ResidenceUrban/Rural Residence

Marital, Working, Veteran StatusMarital, Working, Veteran Status

Freq. of Church AttendanceFreq. of Church Attendance

Perceived Adequacy of FinancesPerceived Adequacy of Finances

Number of Negative Life EventsNumber of Negative Life Events

4 Dimensions of Social Support4 Dimensions of Social Support

Medical and Health Service Use PredictorsMedical and Health Service Use Predictors

Diagnosis of Stroke, Heart Attack, Diagnosis of Stroke, Heart Attack, Diabetes, HypertensionDiabetes, Hypertension

Chronic Illness Severity ScoreChronic Illness Severity Score

# Physician Visits / mo & yr# Physician Visits / mo & yr

Neglect Going to Doctor When Need to GoNeglect Going to Doctor When Need to Go

Current SmokerCurrent Smoker

Analytic StrategiesAnalytic Strategies

• Bivariate Means Analysis (ANOVAs)Bivariate Means Analysis (ANOVAs)

• Logistic Regressions with “High Stable” Logistic Regressions with “High Stable” Men as the Reference GroupMen as the Reference Group

Table 2Table 2

Significant Baseline Predictors of SELF-RATED HEALTH TrajectoriesSignificant Baseline Predictors of SELF-RATED HEALTH TrajectoriesUsing Logistic RegressionUsing Logistic Regressionaa , with “High Stable” (N=284) as reference group , with “High Stable” (N=284) as reference group

PredictorsPredictors

ImprovingImprovingN=83N=83

FluctuatingFluctuatingN=90N=90

DecliningDecliningN=76N=76

Age (4 categories)Age (4 categories) .91.91**

Race (black=1)Race (black=1) 2.602.60 **Years of Educ. (4 categories) Years of Educ. (4 categories) .89.89**

Urban vs. Rural (Rural =1)Urban vs. Rural (Rural =1)

Chronic Illness Sev. Score (3 categories ) Chronic Illness Sev. Score (3 categories ) 2.142.14**** 1.701.70 **

Neglect Going to Doctor (0-1)Neglect Going to Doctor (0-1) 1.611.61**

No. Doctor Visits (1-4+)No. Doctor Visits (1-4+) 1.121.12** 1.091.09**

Current Smoker (0-1)Current Smoker (0-1)Freq. of Church Attendance (4 categories)Freq. of Church Attendance (4 categories)

Perceived Adeq., Finances (3 categories)Perceived Adeq., Finances (3 categories) 0.540.54**

Cognitive Status (4 categories)Cognitive Status (4 categories)Depression (4 categories)Depression (4 categories) 1.161.16** 1.301.30****** 1.171.17** 1.40 ***1.40 ***

A Also controlling on Income, Marital and Working statuses, Veteran status and Service Connected Disability, Also controlling on Income, Marital and Working statuses, Veteran status and Service Connected Disability, History of Stroke, Diabetes, Heart Attack, Hypertension, No. Neg. Life Events, Amount of Social Support History of Stroke, Diabetes, Heart Attack, Hypertension, No. Neg. Life Events, Amount of Social Support Given, Amount of Social Support Received, No. People Interact With, Perceived Adequacy of Social Given, Amount of Social Support Received, No. People Interact With, Perceived Adequacy of Social Support, and Functional Impairment.Support, and Functional Impairment.

* p<.05, ** p<.01, *** p<.001

Odds RatiosOdds Ratios

Low StableLow StableN=68N=68

1.701.70 **

1.201.20******

.52.52 **

0.440.44 ****

2.502.50******

2.702.70****

.51.51 ****

0.320.32 ****

.78 *.78 *

PredictorsPredictors

ImprovingImprovingN=94N=94

FluctuatingFluctuatingN=91N=91

DecliningDecliningN=87N=87

Low StableLow StableN=68N=68

Age (4 categories)Age (4 categories) 1.071.07 ** 1.101.10 **** .31.31

Currently working (0-1)Currently working (0-1) .43.43 **

Veteran (0-1)Veteran (0-1) 1.801.80

Neglect Going to Doctor (0-1)Neglect Going to Doctor (0-1) 1.501.50 ** 2.102.10 ****** 2.502.50

Current Smoker (0-1)Current Smoker (0-1) 2.002.00 **

Freq. of Church Attendance (4 categories)Freq. of Church Attendance (4 categories) .78.78****

No. Negative Life Events (3 categories)No. Negative Life Events (3 categories) 1.861.86 **** 2.002.00

No. People Interact With (4 categories)No. People Interact With (4 categories) 1.011.01**

Social Support Received (4 categories)Social Support Received (4 categories) 1.181.18 ****

Per. Avail. of Soc. Support (3 categories)Per. Avail. of Soc. Support (3 categories) .67.67**** .62.62

Self-Rated Health (4 categories)Self-Rated Health (4 categories) .65.65 ** .70.70 ** .29.29

aa Also controlling on Race, Education, Income, Marital Status, Rural/Urban Residence, Service Also controlling on Race, Education, Income, Marital Status, Rural/Urban Residence, Service Connected Disability, History of Stroke, Diabetes, Heart Attack, Hypertension, Chronic Illness Severity Connected Disability, History of Stroke, Diabetes, Heart Attack, Hypertension, Chronic Illness Severity Score, No. Physician Visits, Perceived Adequacy of Financial Resources, Amount of Social Support Score, No. Physician Visits, Perceived Adequacy of Financial Resources, Amount of Social Support Given, Cognitive Status, and Functional Impairment.Given, Cognitive Status, and Functional Impairment.

* p<.05, ** p<.01, *** p<.001* p<.05, ** p<.01, *** p<.001

Odds RatiosOdds Ratios

Table 3Table 3

Significant Baseline Predictors of DEPRESSION Trajectories Using Significant Baseline Predictors of DEPRESSION Trajectories Using Logistic RegressionLogistic Regressionaa , with “High Stable” (N=338) as reference group , with “High Stable” (N=338) as reference group

******

**

****

**

**

******

Table 4Table 4

Significant Baseline Predictors of COGNITIVE FUNCTION TrajectoriesSignificant Baseline Predictors of COGNITIVE FUNCTION TrajectoriesUsing Logistic RegressionUsing Logistic Regressionaa , with “High Stable” (N=300) as reference group , with “High Stable” (N=300) as reference group

ImprovingImprovingN=87N=87

FluctuatingFluctuatingN=73N=73

DecliningDecliningN=141N=141

Low StableLow StableN=156N=156

Age (4 categories)Age (4 categories) 1.111.11 **** 1.131.13 ******

Race (black=1)Race (black=1) 2.302.30 ** 3.203.20 **** 2.002.00 ** 4.744.74 ******

Years of Educ. (4 categories) Years of Educ. (4 categories) .77.77 ****** .87.87 **** .88.88 ****** .68.68 ******

Income (4 categories)Income (4 categories) 1.011.01 **

Freq. of Church Attendance (4 categories)Freq. of Church Attendance (4 categories) .79.79 ** .75.75 **

Social Support Received (4 categories)Social Support Received (4 categories) 1.151.15 **

Self-Rated Health (4 categories)Self-Rated Health (4 categories) 1.011.01 **

Functional Status (3 categories)Functional Status (3 categories) 2.902.90 **

a Also controlling on Marital and Working Statuses, Rural/Urban Residence, Veteran Status, Service ConnectedDisability, History of Stroke, Diabetes, Heart Attack, Hypertension, Chronic Illness Severity Score, NeglectOwn Health, No. Physician Visits, Current Smoker, Perceived Adequacy of Financial Resources, Amount ofSocial Support Given, No. People Interact With, Adequacy of Social Support, No. Negative Life Events, andDepression.

b b * p<.05, ** p<.01, *** p<.001* p<.05, ** p<.01, *** p<.001

PredictorsPredictors Odds RatiosOdds Ratios

Table 5Table 5

Significant Baseline Predictors of PHYSICAL FUNCTION TrajectoriesSignificant Baseline Predictors of PHYSICAL FUNCTION TrajectoriesUsing Logistic RegressionUsing Logistic Regressionaa , with “High Stable” (N=500) as reference group , with “High Stable” (N=500) as reference group

ImprovingImprovingN=29N=29

FluctuatingFluctuatingN=32N=32

DecliningDecliningN=120N=120

Age (4 categories)Age (4 categories) 1.101.10 ** 1.101.10 ****** 1.301.30 ******

Low StableLow StableN=45N=45

Race (black=1)Race (black=1) .28.28 **

Currently married (0-1)Currently married (0-1) .36.36 **

Veteran (0-1)Veteran (0-1) .65.65 **

Dx: Stroke (0-1)Dx: Stroke (0-1) 7.007.00 **

Perceived Adeq., Finances (3 categories)Perceived Adeq., Finances (3 categories) 2.102.10 **

Social Support Given (4 categories)Social Support Given (4 categories) .81.81 ** .91.91 ** .58.58 ******

Social Support Received (4 categories)Social Support Received (4 categories) 1.201.20 ** 1.381.38 ****

Self-Rated Health (4 categories)Self-Rated Health (4 categories) .63.63 ****

Cognitive Status (4 categories)Cognitive Status (4 categories) 1.901.90 ****

Depression (4 categories)Depression (4 categories)

a Also controlling on Education, Income, Working Status, Rural/Urban Residence, Service Connected

Disability, History of Diabetes, Heart Attack, Hypertension, Chronic Illness Severity Score, Neglect Own Health, No. Physician Visits, Current Smoker, Freq. of Church Attendance, Perceived Adequacy of Social Support, No. of People Interact With, No. Negative Life Events, Cognitive Impairment, and Self-Rated Health.

1.201.20 **

* p<.05, ** p<.01, *** p<.001

PredictorsPredictors Odds RatiosOdds Ratios

Table 1a: Summary of ANOVAsTable 1a: Summary of ANOVAs

Health DomainsHealth Domains

1985 Baseline Predictors1985 Baseline Predictors Self-RatedSelf-RatedHealthHealth

DepressionDepression CognitiveCognitiveFunctionFunction

PhysicalPhysicalFunctionFunction

A. Demographic & SocialA. Demographic & SocialAge (4 categories)Age (4 categories) ****** ****** ******

Race (black=1)Race (black=1) **** **** ****** ******

Years of Educ. (4 categories) Years of Educ. (4 categories) ****** ****** ****** ******

Income (4 categories)Income (4 categories) ****** ****** ****** ******

Urban vs. Rural (Rural=1)Urban vs. Rural (Rural=1) **** **

Currently married (0-1)Currently married (0-1) **** ****** ******

Currently working (0-1)Currently working (0-1) ** ****** ** ******

Veteran (0-1)Veteran (0-1) ****** ******

Freq. of Church Attendance (4 categories)Freq. of Church Attendance (4 categories) ****** ****** ****** ******

Perceived Adeq., Finances (3 categories)Perceived Adeq., Finances (3 categories) ****** ****** ****** ******

No. Negative Life Events (3 categories)No. Negative Life Events (3 categories) ****** ****** ** **

No. People Interact with (4 categories)No. People Interact with (4 categories) ** ****

Social Support Received (4 categories)Social Support Received (4 categories) ** **

Per. Avail. of Social Support (3 categories)Per. Avail. of Social Support (3 categories) ****** ****** ******

Social Support Given (4 categories)Social Support Given (4 categories) ** **** ****** ******

Predictor significantly discriminates among trajectories in that domain at .05 Predictor significantly discriminates among trajectories in that domain at .05 **, .01, .01 **** ,or .001 ,or .001 ****** levelslevels

Table 1b: Summary of ANOVAsTable 1b: Summary of ANOVAs

Health DomainsHealth DomainsSelf-RatedSelf-Rated

HealthHealthDepressionDepression CognitiveCognitive

FunctionFunctionPhysicalPhysicalFunctionFunction

1985 Baseline Predictors1985 Baseline Predictors

B. Medical & Health Services UseB. Medical & Health Services Use

** **** **Service connected disability (0-1)Service connected disability (0-1)

** ** ******Dx: Stroke (0-1)Dx: Stroke (0-1)

******Dx: Diabetes (0-1)Dx: Diabetes (0-1)

****** ****Dx: Heart Attack (0-1)Dx: Heart Attack (0-1)

**** ****Dx: Hypertension (0-1)Dx: Hypertension (0-1)

****** **Chronic Illness Sev. Score (3 categories) Chronic Illness Sev. Score (3 categories)

****** ******Neglect Going to Doctor (0-1)Neglect Going to Doctor (0-1)

****** ****No. Doctor Visits (1-4+)No. Doctor Visits (1-4+)

****Current Smoker (0-1)Current Smoker (0-1)

C. Baseline Domain MeasuresC. Baseline Domain Measures

NANA ****** ****** ******Self-Rated Health (4 categories)Self-Rated Health (4 categories)

****** NANA ****** ******Depression (4 categories)Depression (4 categories)

**** ****** NANA ******Cognitive Status (4 categories)Cognitive Status (4 categories)

** **** NANAFunctional Impairment (3 categories)Functional Impairment (3 categories)

Predictor significantly discriminates among trajectories in that domain at .05 Predictor significantly discriminates among trajectories in that domain at .05 **, .01, .01 **** ,or .001 ,or .001 ****** levelslevels

Findings (7-year window)Findings (7-year window) What at baseline predicts a vulnerability trajectory of What at baseline predicts a vulnerability trajectory of self-self-

rated healthrated health??• In contrast with the men having high stable ratings of self-

rated health, men with low stable ratings were more likely, at baseline, to be white, to live in urban areas, to have higher chronic illness severity scores, to smoke regularly, to have symptoms of depression, and to perceive their finances as inadequate for meeting their needs.

• In contrast with high stable men, men with low stable trajectories of self-rated health report significantly more visits to the doctor, yet also are more likely to report that they neglect going when they need to go.

• Overall: Older men who, over the 7-year trajectory window, rate their health consistently low are the highest users of health services but, at the same time, report high levels of unmet need.

Findings (7-year window)Findings (7-year window) What at baseline predicts a vulnerability trajectory of What at baseline predicts a vulnerability trajectory of

depressiondepression? ?

• Two key predictors of depression trajectories: # of negative life events that the men experienced at baseline, and baseline measures of health service need. – For every category increase in number of negative life events

experienced at baseline, the odds of exhibiting an increasing or stable high depression symptom trajectory rise nearly two fold.

– The predictor “Neglect going to the doctor when I need to go” is positively associated with the odds of exhibiting increasing, fluctuating, or stable high depression trajectories.

Findings (7-year window)Findings (7-year window) What at baseline predicts a vulnerability trajectory What at baseline predicts a vulnerability trajectory

of of cognitive functioningcognitive functioning??

– The literature suggests that higher levels of cognitive impairment are associated with increased receipt of assistance. We found this to be true, but only among men with low stable trajectories of cognitive function. These men need assistance and they are more likely to receive it.

– However, among older men whose cognitive functioning is changing -- either in patterns of decline, improvement, or fluctuation – these men receive no more social support on average than men with high functioning trajectories. This begs the question, “how long do symptoms of cognitive impairment typically exist before support is mobilized?

Findings (7-year window)Findings (7-year window) What predicts a vulnerability trajectory What predicts a vulnerability trajectory

of of physical functioningphysical functioning??

• In comparison to physically high functioning men, men with low stable physical functioning were more likely to be older, white, with histories of stroke, giving less but receiving greater amounts of social support, more cognitively impaired and more depressed.

• However, men with greater levels of physical dependency who undoubtedly need support do appear to be receiving it.

“Overall, we are encouraged by the precision gained in using trajectories rather than measures of central tendency to chart

health processes over time” – GSA 2003.

EPESE Data -- after thoughts…EPESE Data -- after thoughts…• Most community-dwelling older people are functioning Most community-dwelling older people are functioning

well across health domains. But many others are not - yet well across health domains. But many others are not - yet their vulnerabilities (illness pathways) are masked in their vulnerabilities (illness pathways) are masked in traditional analytic approaches. traditional analytic approaches.

• Nurse scientists need to consider both traditional (central Nurse scientists need to consider both traditional (central tendency) and trajectory approaches (identification of tendency) and trajectory approaches (identification of clinically-meaningful groups) when measuring clinical clinically-meaningful groups) when measuring clinical phenomena over time.phenomena over time.

• The clinically relevant categories can be identified best by The clinically relevant categories can be identified best by nurse scientists.nurse scientists.

• Future studies need to focus on the interaction of multiple Future studies need to focus on the interaction of multiple health trajectories within patients. This will allow nurses health trajectories within patients. This will allow nurses to design interventions that build on one’s strengths while to design interventions that build on one’s strengths while targeting areas of vulnerability. targeting areas of vulnerability.

Example 3Example 3National Longitudinal Caregiving StudyNational Longitudinal Caregiving Study

• Funded by the VA HSR&D National Nurses’ Funded by the VA HSR&D National Nurses’ Research Initiative (1997-2001) Research Initiative (1997-2001)

• Goal: to examine comprehensively the Goal: to examine comprehensively the informalinformal disease burden on families caring for disease burden on families caring for elderly with dementing disorderselderly with dementing disorders

National Longitudinal Caregiver Study (NLCS)

4-year longitudinal study (4 annual surveys) 2,278 informal primary caregivers at baseline Patients are elderly (60+) veterans followed in the VA

Hospital system, nationwide Identified using VA administrative databases (formal

diagnoses -- ICD-9 codes for AD or VAD Mail surveys in 1998 (baseline), 1999, 2000, 2001 Unit of analysis is the caregiver, but data include

caregiver and patient information

Informal Caregivers of Elderly with Dementia:Informal Caregivers of Elderly with Dementia:Latent Class Analysis using M-PlusLatent Class Analysis using M-Plus

very new materialvery new material

• Cross-sectional (Pre-trajectory work)– Clinical phenomena (class membership) – Service Use Patterns (class membership)– “Drivers” of service use pattern (class

membership)

• Longitudinal Trajectories of caregiver depression

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Depression Aggression Vegetative Inertia Dysregulation Psychotic

Class 1 (4%)

Class 2 (18%)

Class 3 (36%)

Class 4 (41%)

Dementia Problem Behavior Classes at BaselineDementia Problem Behavior Classes at Baseline (what caregivers are dealing with now) – M-Plus (what caregivers are dealing with now) – M-Plus

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Informal Help Support Groups Home Health Adult Day Care Respite

Class 1 (17%)

Class 2 (26%)

Class 3 (57%)

“Low-Users”

“In-Home Users”

“Out of Home Users”

Caregiver Classes of Support Service UseCaregiver Classes of Support Service UseBaselineBaseline

Greater Patient Disability

“Low-Users”

“In-Home Users”

Probability of Caregiver User Class by Probability of Caregiver User Class by Patient DisabilityPatient Disability

Looking for “drivers” of service useLooking for “drivers” of service use

“Out of home users”

• Goal: To identify distinct trajectories of depressive symptoms within a large national sample of informal caregivers of older individuals with clinically diagnosed with dementia.

• Using LCA (M-Plus) - Three trajectories were identified: High Declining, Moderate Stable, Low Increasing.

• This suggests that measures of central tendency in caregiver depressive symptoms mask important sources of clinically-relevant variation within the caregiver population that may be important for tailoring interventions to reach the neediest caregivers with maximum cost benefit.

Informal Caregiver DepressionInformal Caregiver DepressionWho to target for resources and referral?Who to target for resources and referral?

3-Year3-Year Trajectories of Depression Trajectories of DepressionNational Longitudinal Caregiver Study (2300+ at baseline)National Longitudinal Caregiver Study (2300+ at baseline)

3 classes using M-Plus3 classes using M-Plus

Continued -Continued -• A series of measures significantly differentiated the three

trajectories of depressive symptomotology. – Subjective measures of caregiver burden differed more

consistently across the trajectories than did objective measures such as tasks completed.

– For example, caregivers in the “high declining trajectory” had lower life satisfaction and reported needing more help from family and friends compared to the other two trajectories.

• Nursing implications: Screening elderly persons for their caregiver status during annual physical exams is warranted given the prevalence of depression

• Simple subjective questions related to the caregiver’s life satisfaction and perceived need for help in the caregiving role may offer an efficient yet powerful means of identifying caregivers most at risk for adverse emotional health consequences.

In SumIn Sum• Latent class analysis is a way to classify individuals into

meaningful groups• Cross-sectionally or longitudinally

– Clinical phenomena (e.g., dementia Behavior Problems, caregiver depression)

– Behaviors (e.g., health services use)

• These groups suggest intervention targets at the cross-sectional level (e.g., are “low users” most vulnerable?)

• Longitudinal trajectories will provide natural histories which inform timing of interventions.

How and when can nurses attempt to reorient?

Nursing Science Example Nursing Science Example P20 Pilot / Feasibility StudyP20 Pilot / Feasibility Study

• Cross-sectional data show high rates of illness-related Cross-sectional data show high rates of illness-related uncertainty (IRC) in Hep C patients under watchful uncertainty (IRC) in Hep C patients under watchful waiting tx plans.waiting tx plans.

• How and when to intervene with Hep C pts in WW to How and when to intervene with Hep C pts in WW to improve overall functioning and QOL?improve overall functioning and QOL?

• 18-month repeated measures study on 200 Hep C pts 18-month repeated measures study on 200 Hep C pts in WW to establish patterns of physical and in WW to establish patterns of physical and psychological functioning.psychological functioning.

• The timing of an intervention to reduce uncertainty The timing of an intervention to reduce uncertainty will be applied will be applied whenwhen most needed (for greatest impact) most needed (for greatest impact)

C Bailey, 2006C Bailey, 2006

Nursing Science Example 2Nursing Science Example 2Work in progress (Clipp & George, April 2006)Work in progress (Clipp & George, April 2006)

• Question: How can nursing interventions aimed at community-dwelling individuals with major depressive disorder (MDD) be more effectively targeted to neediest patients?

• Goal: To examine long-term trajectories of recovery, chronicity, and relapse post MDD event

• Method: 125 psychiatric inpatients with MDD followed over 4 years w/ interviews q 6mo scoring the CES-D 16+ for D

Stable D 22.4% (28)

D continuously non-D 43% (54)

D non-D D Non-D 14.4% (18)

D extreme fluctuation 6.4% (8)

•

GSA abstract (2006)GSA abstract (2006) • ““This work illustrates the potential payoff of using a This work illustrates the potential payoff of using a

trajectory approach to studying the course of illness. trajectory approach to studying the course of illness. • We can examine We can examine heterogeneityheterogeneity in illness course and in illness course and

outcome without losing the ability to relate patterns of outcome without losing the ability to relate patterns of change to variables of interest (e.g., social support, change to variables of interest (e.g., social support, treatment plans). treatment plans).

• These clinically relevant trajectories will generate These clinically relevant trajectories will generate information information unobservableunobservable with group-oriented with group-oriented statistics”.statistics”.

ConclusionsConclusions

• A trajectory approach A trajectory approach – moves from group level analysis to an intermediate level moves from group level analysis to an intermediate level

of complexity by focusing on intra-individual variation of complexity by focusing on intra-individual variation in health dynamicsin health dynamics

– blends together the efficiency of sample statistics and blends together the efficiency of sample statistics and the richness and diversity of clinical patterns the richness and diversity of clinical patterns

– will help nurses identify clinically-relevant subgroups will help nurses identify clinically-relevant subgroups – is a natural “nursing perspective” and the key to is a natural “nursing perspective” and the key to

improving the effectiveness of nursing interventions. improving the effectiveness of nursing interventions.

Nursing is not the only discipline moving in this directionNursing is not the only discipline moving in this direction

Institute of Medicine Institute of Medicine (IOM; Spring 2005)(IOM; Spring 2005)

• ““Contextual and longitudinal research is needed if Contextual and longitudinal research is needed if there is any hope of there is any hope of understandingunderstanding priority health priority health problems and designing effective problems and designing effective actionsactions to resolving to resolving or eliminating them”.or eliminating them”.

From a nursing perspective…From a nursing perspective…• Understanding priority health problemsUnderstanding priority health problems: charting : charting

trajectories of clinically-relevant phenomenatrajectories of clinically-relevant phenomena• ActionsActions: Based on knowledge of health trajectories, : Based on knowledge of health trajectories,

designing tailored and well-timed nursing designing tailored and well-timed nursing interventions for greatest impact.interventions for greatest impact.

Discussion