Instrumental Autonomy Research Articles

The impact of self-care behaviour on health-related quality of life across functional dependency phenotipes: insights from a real-world cohort of 1120 patients with chronic heart failure

Abstract Background Poor self-care is associated with higher risk in heart failure (HF). Self-care may influence patient-reported outcomes (PROMs) such as health-realted quality of life (QoL). Functional and instrumental autonomy are determinants of QoL. Literature has shown instrumental and/or functional dependency are associated with worse QoL. Purpose Describe the effect of self-care on QoL across to different levels of dependency and explore the potencial interaction between self-care and autonomy. Methods 1120 patients with chronic HF from DAMOCLES study were analyzed. We used modified European Heart Failure Self-care Behavior Scale 9-item version (EHFSCBS-9) to measure self-care, scores were inverted. To assess QoL, we used Minnesota Living with Heart Failure Questionnaire (MLHFQ). Functional dependency for basic activities of daily living (BADL) was evaluated using Barthel index (BI). Dependency for instrumental activities (IA) was evaluated using Lawton and Brody questionnaire (LBQ). Regarding dependency, patients were grouped in 3 phenotypes: independent (normal BI and LBQ, phenotype 1), dependency for IA (abnormal LBQ, phenotype 2) and dependency for BADL and IA (abnormal BI ± abnormal LBT, phenotype 3). General linear models (GLM) were constructed to explore interaction between dependency phenotypes and poor self-care (defined as EHFSCBS-9 ≤lower tertile) on adjusted MLHFQ scores and to obtain the estimated marginal means of QoL scores across phenotypes and levels of self-care. All models were adjusted by determinants of HF severity. Results Mean age was 72±11 years, 43% were women and mean LVEF was 45±17%. Mean MLHFQ scores were 45±24. Mean EHFSCBS-9 scores were 69±28. There was a significant inverse correlation between EHFScBS-9 and MLHFQ scores (r=−0.158; p-value <0.0001). Unadjusted MLHFQ scores were consistenly higher in the phenotype 3 (51.5±21.3) compared to phenotype 2 (41.8±25.4, p-value<0.001) or phenotype 1 (41.6±25.6, p-value <0.001). In adjusted GLM, poor global self-care (F=15.7; p-value <0.001) was an independent predictor of higher adjusted scores in MLHFQ. Interaction term dependency phenotypes by poor self-care was not significantly associated with MLHFQ scores (F=0.297; p-value = 0.743; Figure 1): the gap in terms of QoL between self-care strata was observed across dependency phenotypes. Estimated adjusted marginal means of MLHFQ scores stratified according to dependency phenotypes and levels of self-care are displayed in Table 1. In phenotypes 2 or 3, MLHFQ scores were lower in patients with preserved self-care. In phenotype 1 differences in QoL across self-care strata were present but not significant. Conclusions Self-care behaviour is an independent predictor of health-related QoL in HF regardless of the level of patient's autonomy. Better self-care was associated with better QoL particularly in patients with dependendecy to IA and/or BADL. Impact of self-care on QoL was attenuated in patients with normal autonomy. Funding Acknowledgement Type of funding sources: None.

Technological Solutions for Diagnosis, Management and Treatment of Alzheimer's Disease-Related Symptoms: A Structured Review of the Recent Scientific Literature.

In people with Alzheimer’s disease (PwAD), there is a need for specific tools for the timely diagnosis, management, and treatment of symptoms. New technological solutions, including digital devices, application programs (apps), sensors and virtual reality, represent promising possibilities for objective and reliable assessment, monitoring and intervention strategies in this field. Our structured review presents an up-to-date summary of the technological solutions for the (i) diagnosis, (ii) management and (iii) treatment of AD-related symptoms. To this end, we searched electronic databases (i.e., PubMed, Web of Science, and Cochrane Library) for studies published over the last 10 years. Two authors of the review extracted data of interest. A total of eight manuscripts were included. In the last decade, a series of technological solutions across AD stages have been proposed. These include: (i) innovative strategies for the early detection of deficits in finger dexterity, visuo-spatial abilities (including spatial navigation), divided attention and instrumental autonomy; (ii) tools to activate the patient’s responsiveness in terms of alertness and mood improvement; and (iii) useful interventions for retrieving memories, increasing body movements and improving spatial cognition. Methodological limitations, mainly pertaining to the paucity of randomized controlled trials and comprehensive assessments, were observed. Advances in technology currently provide the potential for designing innovative methods for evaluating, controlling and handling AD-related symptoms. The co-creation of technological solutions with all stakeholders represents the best way to design effective strategies for PwAD.

Effects of domotics on cognitive, social and personal functioning in patients with Parkinson’s disease: A pilot study

ABSTRACT Home automation (HA) is either a “smart” house or a supportive environment, which enables the patients to regain an active role in daily life. HA could allow people affected by Parkinson Disease (PD) to better manage their daily lives. This study aims to evaluate the effects of domotics on quality of life, and personal/social autonomy in PD patients. We enrolled 40 with PD undergoing neurorehabilitation, who were randomized into either the control (CG) or the experimental group (EG). Two different rehabilitative approaches were used: the CG was submitted to a traditional training, whilst the EG underwent HA training, in which the activities were carried out through the use of assistive technologies. In both the training, the exercises were performed in small samples of 3–5 patients. Results showed that both CG and EG had a significant improvement in global cognitive functioning, executive functions, and instrumental autonomy. However, only in the EG, we observed a significant increase in social adaptation, activities of daily living and quality of life. This pilot study suggests that HA training could be a useful tool for the rehabilitation of patients with PD, improving social and cognitive functioning, personal autonomy and quality of life.

Multidimensional approach usefulness in early Alzheimer's disease: Advances in clinical practice.

Background and aim: Improving quality of life of patients with early Alzheimer’s Disease (AD) is a primary concern of health professionals involved in dementia treatment. The aim of this study is to reveal associations among psychiatric symptoms and wellbeing aspects, dysfunctional lifestyles and stress-related behaviors, illness perception, personality traits, and life quality satisfaction, in order to offer a comprehensive evaluation of psychological and behavioral aspects characterizing patients with early AD. Methods: This is a cross-sectional study in which all the outpatients included were evaluated at the Dementia Clinic in Parma (Italy). 21 patients with probable AD were assessed by an overall cognitive screening (Milan Overall Dementia Assessment), the evaluation of personal and instrumental autonomy (Activities of Daily Living and Instrumental Activities of Daily Living), and of dementia severity (Clinical Dementia Rating Scale). After the neurocognitive assessment, a wide battery of clinical and psychological measures (Symptom Questionnaire, Pisa Stress Questionnaire, Illness Behavior Questionnaire, Sixteen Personality Factor Questionnaire and Satisfaction Profile) was administered to the patients. Spearman’s rho correlations between clinical and psychological measures were performed. Results: A tendency to deny anxiety, depressive and somatic symptoms might be present in patients with early AD. They also present with hypochondriasis, resulting in higher level of anxiety and depression. Reduced liveliness and self-reliance as personality traits may influence the intensity of such symptoms. Conclusions: A comprehensive assessment including psychological and clinical measures should be routinely integrated in clinical practice for the evaluation of patients with early AD. (www.actabiomedica.it)

The End of Democracy and the Modes of Resistance in Education

Our scope is to show how democracy has been trivialized as a concept and, more worryingly, as a mystified practice of consented servitude, which supposedly would bring to its very end. In fact, for the emblematic occidental societies, democracy has, at the best, been reduced to a consumerist way of life, under the capitalist liberal order, and the facade of a 'spectacularized' electoral process. Overall, the word 'democracy' is currently used to mask different forms of authoritarianism, from which nor even western societies escape. In such context, as to the promises of democracy for schools' systems, we see nothing but a bureaucratic centralization, allowing no more than an instrumental autonomy of power of execution through which the players only enjoy a 'voluntary servitude' to the neoliberal naturalized ideology of efficiency, competitiveness and pseudo meritocracy. We thus conclude by suggesting possibilities of resistance and the empowerment of the subject.

Relevant Factors on Cognitive Evaluation of the Portuguese Population

Aging is an inevitable process that has a social impact in the forecoming decades, and it will present a great challenge regarding public health. An efficient health system requires a reflection on the preventive measures to be implemented. The study population comprised a total number of 2672 individuals of both genders, aged 55 years and over, residents in continental Portugal, to whom a questionnaire was applied that included the following sections: Social network; Locomotion; Physical autonomy; Instrumental autonomy; Cognitive assessment; Physical activity. The study of aging in the Portuguese population found that physical autonomy for tasks related to daily life are associated with better cognitive evaluation. A statistically significant association was found between performance in cognitive assessment and gender, age, schooling, the fact of living alone, the number of hours being alone, autonomy to walk in the street, washing, dressing, eating, preparing meals, doing shopping, managing money and taking medications and washer / treat clothing. Cognitive evaluation is negatively influenced by the number of hours that an individual is alone. Activities of daily life must be valued, since they require the ability to plan and carry out tasks and their preservation is a key component in successful aging.

Vulnerabilities in Older Patients when Cancer Treatment is Initiated: Does a Cognitive Impairment Impact the Two-Year Survival?

IntroductionDementia is a known predictor of shorter survival times in older cancer patients. However, no empirical evidence is available to determine how much a cognitive impairment shortens survival in older patients when cancer treatment is initiated.PurposeTo longitudinally investigate how much a cognitive impairment detected at the initiation of cancer treatment influences survival of older patients during a two-year follow-up duration and to compare the predictive value of a cognitive impairment on patients survival with the predictive value of other vulnerabilities associated with older age.MethodsThree hundred and fifty-seven consecutive patients (≥65 years old) admitted for breast, prostate, or colorectal cancer surgeries were prospectively recruited. A cognitive impairment was assessed with the Montreal Cognitive Assessment (MoCA<26). Socio-demographic, disease-related, and geriatric vulnerabilities were assessed using validated tools. Univariate and subsequent multivariate Cox proportional hazards models stratified for diagnosis (breast/prostate cancer versus colorectal cancer) and disease status (metastatic versus non-metastatic) were used.ResultsA cognitive impairment was detected in 46% (n = 163) of patients. Survival was significantly influenced by a cognitive impairment (HR = 6.13; 95% confidence interval [CI] = 2.07–18.09; p = 0.001), a loss in instrumental autonomy (IADL ≤7) (HR = 3.06; 95% CI = 1.31–7.11; p = 0.009) and fatigue (Mob-T<5) (HR = 5.98; 95% CI = 2.47–14.44; p <0.001).ConclusionsDuring the two years following cancer treatment initiation, older patients with a cognitive impairment were up to six times more likely to die than patients without. Older patients should be screened for cognitive impairments at cancer treatment initiation to enable interventions to reduce morbidity and mortality. Further studies should address processes underlying the relationship between cognitive impairments and an increased risk of dying in older cancer patients.

Best interests and the raison d’être of health care

The report of the expert group on the review of the Mental Health Act has recommended that the requirement to consider the best interests of the person be replaced by a list of guiding principles, which focus on the autonomy of the individual. The implied rationale for this is that acting in our patients’ best interests may be a violation of their human rights. Dignity is being proposed as an alternative way of capturing ‘the positive aspects associated with best interests’, but it is not clear how dignity is preferable to best interests. Both approaches may help protect the most vulnerable from exploitation. However, unlike best interests, dignity can be used as a synonym for autonomy. Valuing autonomy as a means to an end (instrumental value) should be distinguished from valuing autonomy as an end in itself (intrinsic value). As the ultimate end of instrumental autonomy is invariably the person’s best interests, abandoning that principle renders instrumental autonomy obsolete, leaving intrinsic autonomy as the supreme value. As best interest, dignity and autonomy rarely conflict, the proposed changes may appear minor, but they are not. When such values do conflict, acting against our patients’ interests may become inevitable.

The Aging Profile of the Portuguese Population: A Principal Component Analysis

In the last 5 years the resident population of Portugal has increased 2.3%, along with a progressive ageing. This study aims assessing the social dependence and frailty, as well as social and familial support needs of the elderly. In an observational, cross-sectional community based study (EPEPP study), a total of 2,672 people, aged 55 or more, were submitted to an enquiry and several variables were studied among three age groups: 55-64 years old (37%), 65-74 years old (37%) and ≥ 75 years old (26%), encompassing a total of 57% women and 43% men. A questionnaire including items such as physical autonomy, locomotion, falls, health/medical complaints, instrumental autonomy, physical activity, health self-evaluation and emotional status was applied. The strong correlations among the studied scores allowed the identification of people groups with common characteristics when a principal component analysis was used: "autonomy" (scores of instrumental autonomy, locomotion and physical autonomy) and "perception of health and emotional status" (scores of health self-evaluation and emotional status), were present in the three age groups. The component analysis evidences that a good autonomy, a good perception of health and emotional status are determinant to a good quality of life in elderly. Although health status and self-rated health have a propensity to deteriorate with aging, older Portuguese consider their state of health satisfactory and tend to underestimate their decline. In what concerns the analysis of gender with the same age and in contrast to what has been reported, older women alike to men, experience a good mobility and health self-evaluation.

Antecedents of Role Stress Among Correctional Staff

Role stress is an important aspect of the prison workplace that impairs organizational functioning and can have negative effects for correctional staff. While the effects of role stress on correctional workers are largely known, few studies have examined the causes of role stress. The current study explores potential antecedents of role stress among 160 correctional staff at a private Midwestern prison. Multivariate OLS (ordinary least squares) regression analysis identified five statistically significant predictors of role stress: instrumental communication, supervisory support, formalization, job autonomy, and race. The results suggest that correctional managers and supervisors can reduce role stress substantially by clarifying the roles, responsibilities, and expectations of employees, creating a supportive atmosphere for workers, and identifying areas where staff can have greater control over their jobs.

Effects of a College Adventure Orientation Program on Student Development Behaviors

This study examined the effects of an adventure orientation program on the student development behaviors of incoming first-year students at Hartwick College in Oneonta, New York. Student development was measured by a condensed version of the Student Development Task Inventory-2 (CSDTI-2; Gass, 1986; Winston, Miller, &amp; Prince, 1979). Data analysis showed overall positive significant gains for adventure orientation program participants on certain measures of developmental tasks (i.e., developing autonomy, developing purpose) and subtasks (i.e., emotional autonomy, instrumental autonomy, appropriate educational plans). Changes in this study differed from those found by Gass (1986) and Hansen (1982) at their respective institutions. The different outcomes highlight that adventure orientation courses' variability in curricular design may have a strong impact on student developmental task and subtask outcomes. This finding demonstrates the importance of selecting program activities and processing techniques based on a program's intent, objectives, philosophy, experiences, and focus.

Co-morbidity and functionality: observational study of a cohort of patients

Hypertension, Diabetes Mellitus, Cardiac Ischemic Disease and Asthma are chronic diseases that often coexist. Studies on consequences of co-morbidity conclude that the competition of illnesses can be associated with physical and social disability and a higher request of Health services. This study intends to describe the alterations in co-morbidity of a cohort of sick people between 2003 and 2007, to relate it with functionality and to characterise their impact on health resources. The study is observational. A random sample of 110 sick people, stratified by age and gender, was obtained from the database COMORB4DC. Variables were studied on specific domains: demographic, social, morbid-mortality, health resources and functionality. Health problems are classified according to ICPC2. The test of marginal homogeneity, the test of the signals, the test of Mann-Whitney and the test of Kruskal-Wallis were used for statistically analysis. The majority of the sample has 65 or more years. The most frequent comorbidities between the four chronic index diseases, in the years of 2003 and 2007, are hypertension with diabetes and the hypertension with ischemic cardiac disease. In the set of the locomotion tasks, physical and instrumental autonomy, only 8% of the sick people are totally independent and 47% are autonomous, these mainly had to use ways of support. Between 2003 and 2007, it is verified a difference (p < 0.001) in the average of identified health problems and in the number of problems grouped in classes. The dependence in locomotion is only associated with a superior number of illnesses (p = 0.033), of used resources of health (p = 0.005) and prescribed drugs (p = 0.001). It is verified to exist a correlation among the number of chronic diseases and the number of contacts with the health centre (r = 0.434, p < 0.001). The collected data on co-morbidity, functionality, resource to social assistance activities and medication allow us to better know the complex network of co-morbidity. This can help us make earlier diagnosis, more accurate prognosis and creating health quality and management plans. The repetition of the study with another interval of time can give us more knowledge on this net of relations. It is essential to effectively provide population with specific health resources and to link primary, secondary and tertiary care.

Moral Orientation and Psychosocial Development: Gender and Class-Standing Differences

Effects of gender and class standing on college students' moral orientation (Liddell, 1990) and psychosocial development (Winston, Miller, & Prince, 1995) were investigated. Women had significantly greater ethic of care, tolerance, educational involvement, instrumental autonomy, lifestyle planning, salubrious lifestyle, and interdependence scores than men. Upperclassmen possessed greater educational involvement, career planning, lifestyle planning, emotional autonomy, and peer relationships than freshmen.

Moral Orientation and Psychosocial Development: Gender and Class-Standing Differences

Effects of gender and class standing on college students' moral orientation (Liddell, 1990) and psychosocial development (Winston, Miller, &amp; Prince, 1995) were investigated. Women had significantly greater ethic of care, tolerance, educational involvement, instrumental autonomy, lifestyle planning, salubrious lifestyle, and interdependence scores than men. Upperclassmen possessed greater educational involvement, career planning, lifestyle planning, emotional autonomy, and peer relationships than freshmen.

What’s the relationship between psychosocial development and moral voice? Spotlight on Carla E. Jones and John D. Watt

Jones and Watt studied the relationship between psychosocial development and moral voice among first-year students. Specifically they were interested in examining the effect of moral voice on development, hypothesizing that former would significantly affect psychosocial development and task achievement. The study was conducted using the Student Developmental Task Life & Lifestyle Assessment (SDTLA), and the Measure of Moral Orientation (MMO). Their results indicated that students who describe themselves as more “justice oriented” scored higher on certain tasks on the SDTLA (career planning, lifestyle planning, peer relationships, salubrious lifestyle, instrumental autonomy, interdependence, emotional autonomy and academic autonomy). In addition, women in the study scored higher than men did on the tolerance scale of the SDTLA. There were no significant gender differences on care or justice scores. What might this mean? While these findings are strictly preliminary, they might indicate that first-year students who describe themselves with a high-justice orientation might be more likely to develop psychosocially – at least in ways measurable by the SDTLA. Professionals who work with students are encouraged to help them facilitate both moral voices – care and justice – in order to balance their commitments to people with their commitments to principles. Results of the study are published in the March/April 1999 issue of the Journal of College Student Development. Dr. Jones was interviewed about this study.

Boredom Proneness and Psychosocial Development

The effect of boredom proneness as measured by the Boredom Proneness Scale (R. F. Farmer & N. D. Sundberg, 1986) on college students' psychosocial development was investigated via the Student Developmental Task and Lifestyle Assessment (SDTLA; R. B. Winston, T. K. Miller, & J. S. Prince, 1995). Low boredom-prone students had significantly higher scores on the following SDTLA measures: career planning, lifestyle planning, peer relationships, educational involvement, instrumental autonomy, emotional autonomy, interdependence, academic autonomy, and salubrious lifestyle. Gender differences on boredom proneness and psychosocial development measures are discussed.