Testing the Measurement Properties of the Short Form-36 Health Survey in a Frail Elderly Population

doi:10.1016/S0895-4356(98)00061-4

Journal of Clinical Epidemiology

Volume 51, Issue 10, October 1998, Pages 827-835

https://doi.org/10.1016/S0895-4356(98)00061-4 Get rights and content

Abstract

The Short Form-36 Health Survey (SF-36) is a widely used measure of health-related quality of life, however, its suitability for frail older persons is not well documented. This study examines the measurement properties of the SF-36 in a frail older patient population. Patients consecutively admitted to two geriatric services (n = 146) were administered the SF-36 and comparative measures on admission and discharge. Internal consistency (0.75–0.91) and test-retest reliability (0.24–0.80) did not meet standards for clinical application of the tool. Four subscales were moderately correlated with comparative measures (Physical Function 0.53 to −0.76; Bodily Pain −0.61; Vitality −0.58; Mental Health −0.63). The results of effect size, standardized response mean, and relative efficiency statistics were consistent in documenting only minimal change for the SF-36 subscales. The SF-36 appears to be reliable and valid, although its ability to monitor clinical change for frail older patients is questionable.

Introduction

The evaluation of interventions targeted to the frail elderly is challenging, given that their problems are multiple and complex, and that few health outcomes are important for all patients 1, 2, 3. The traditional health outcomes of mortality and morbidity reduction often fail to capture all of the issues that are important for preserving dignity and maintaining independence of this group [3]. Consequently, measures that address these health-related factors are needed when evaluating specialized geriatric interventions 4, 5.

Although a number of instruments are available to tap health-related quality of life (HRQL) in general 6, 7, to address specific health dimensions 8, 9, 10 and to examine HRQL in distinct populations 11, 12, no “gold standard” exists. The generic Short Form-36 Health Survey (SF-36) [13], has, however, gained rapid acceptance as a HRQL measure, because of its brevity and favorable psychometric properties [14]. While there is extensive experience with the SF-36 in general populations across age groups and health conditions 15, 16, 17, there is a paucity of data to support its use with the frail elderly. Many studies incorporate the elderly, but fail to describe its measurement properties for the oldest old (>75 years) 16, 17, 18, 19, in whom frailty is a common occurrence [3]. Studies often exclude persons with multiple health problems or chronic conditions 20, 21, 22, and when older persons are included is often not evident that they are frail 20, 23, 24, 25, 26.

It has been suggested that the SF-36 may be the optimum outcome measure [27], and to have surpassed the Nottingham Health Profile [7], a long-standing generic assessment of HRQL, as the instrument of choice for outcomes research [14]. This project was designed to test these claims by assessing the feasibility, scaling properties, reliability, validity, and responsiveness of the SF-36 in a frail elderly patient population, using standardized instructions for administration and scoring.

Section snippets

Design, Setting, and Subjects

This study was conducted between September 1995 and November 1996, on the Geriatric Restorative Care (GRC) and the Geriatric Day Hospital (GDH) services, at the Queen Elizabeth II Health Sciences Centre (QEII HSC), Halifax, Nova Scotia, Canada. The GRC and GDH programs provide inpatient and outpatient rehabilitation respectively, to elderly people who require rehabilitation following surgery, acute illness, or chronic health problems. All persons 65 years and older were eligible for inclusion;

Patients

Two hundred patients with first admissions were screened for the study. Eight persons (4.0%) refused to participate, 41 (20.5%) were ineligible, and five (2.5%) could not be contacted in time (four missed, one quarantined). The patients who completed the interview battery differed from those who did not complete the tests. The ineligible/refused group had fewer years of education, were less likely to reside in their own home, were more cognitively impaired, and more limited in IADL prior to

Discussion

This study examined the measurement properties of the SF-36 for frail elderly individuals admitted to an inpatient rehabilitative service and outpatient hospital program. Although the measurement properties of the SF-36 are well documented in general populations 19, 32, 36, 40, this is the first study to evaluate comprehensively the performance of the instrument in a cohort of frail elderly people.

Recruitment of a well defined cohort of frail elderly persons represents an important strength of

Conclusion

This study set out to address two assertions, that the SF-36 represents the “optimum outcome measure” [27] and that the instrument displays superior measurement properties for subsequent application with the frail elderly. In conclusion, the results of this study do not support these broad claims.

Although the SF-36 can be administered to frail elderly in a timely fashion and with limited missing data, a substantial proportion of the responses to items are inconsistent. It is not clear, at this

Acknowledgements

This study was supported with a grant from the Camp Hill Medical Centre Research Fund. The National Health Research Development Program (NHRDP) supported this research through a National Health Scholar award to Kenneth Rockwood and through a National Health graduate award to Karen Stadnyk.

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Cited by (90)

Sedentary Time in Older Adults With Acute Cardiovascular Disease
2022, CJC Open
Citation Excerpt :
The SF-36 Health Survey is a 36-item health-related quality of life (HRQOL) survey self-reported by patients. It is the most widely used HRQOL instrument, is feasible to administer in-person and by phone, and has been validated in older patient populations.14 Covariates of interest included age, sex, primary admission diagnosis, length of unit stay and LOF scores at 3 intervals (prehospital, admission, and unit discharge).
Older adults may be subject to prolonged bedrest during hospitalization for acute cardiovascular disease, which can contribute to poor functional outcomes posthospitalization. Our objective was to describe mobility status in hospitalized older adults with acute cardiovascular disease.
Patients aged ≥ 60 years old in the cardiac intensive care unit and cardiovascular ward at a tertiary care academic centre in Montréal, Québec were prospectively enrolled from April 2019 to March 2020. Activity levels were measured with the ActiGraph GT9X Link 3-axis accelerometer (ActiGraph, Pensacola, FL). Sedentary was defined as lying in bed or in a sitting position. Health-related quality of life (HRQOL) was measured with the Short-Form 36 (SF-36) questionnaire by telephone at 1 month posthospitalization. The primary outcome was percentage of sedentary time during hospitalization.
There were 35 patients included in the analysis (75.7 ± 6.9 years old; 45.7% female; 22.9% ischemic heart disease; 20.0% heart failure). Patients spent 91.2% ± 5.5 in a sedentary position during their hospital stay. Mean steps per minute were 1.0 ± 1.2, and mean kcals consumed per day were 116.6 ± 124.5. In the multivariable analysis, a higher percentage of sedentary time and lower steps per minute were each associated with lower total SF-36 scores at 1-month posthospitalization (both P < 0.05).
Older adults with acute cardiovascular disease may be sedentary for a large part of their hospital stay. Increased sedentary time is associated with worse self-reported posthospital HRQOL. Future studies are needed to determine whether interventions to increase activity during hospitalization improve posthospital HRQOL and functional outcomes.
Les personnes âgées hospitalisées en raison d’une maladie cardiovasculaire en phase aiguë peuvent être sujettes à un alitement prolongé qui peut contribuer à des résultats fonctionnels médiocres après l’hospitalisation. Notre objectif était de décrire l’état de mobilité des personnes âgées hospitalisées en raison d’une maladie cardiovasculaire en phase aiguë.
Nous avons inscrit de façon prospective les patients de ≥ 60 ans de l’unité des soins intensifs cardiaques et de l’unité de cardiologie d’un centre universitaire de soins tertiaires à Montréal, au Québec, d’avril 2019 à mars 2020. Nous avons mesuré les niveaux d’activité physique à l’aide de l’accéléromètre ActiGraph GT9X Link 3-axis (ActiGraph, Pensacola, Floride, É.-U.). Nous avons défini la sédentarité par le fait d’être couché au lit ou en position assise. Nous avons mesuré la qualité de vie liée à la santé (QVLS) à l’aide du questionnaire SF-36 (Short Form-36) par téléphone un mois après l’hospitalisation. Le critère de jugement principal était le pourcentage de temps sédentaire durant l’hospitalisation.
Dans l’analyse, on comptait 35 patients (75,7 ± 6,9 ans; 45,7 % de femmes; 22,9 % atteints d’une cardiopathie ischémique; 20,0 % atteints d’insuffisance cardiaque). Les patients passaient 91,2 % ± 5,5 en position sédentaire durant leur séjour à l’hôpital. Les pas moyens par minute étaient de 1,0 ± 1,2, et les kcal moyennes consommées par jour étaient de 116,6 ± 124,5. Dans l’analyse multivariée, un pourcentage plus élevé de temps sédentaire et un nombre inférieur de pas par minute étaient chacun associés à des scores totaux plus faibles au SF-36 un mois après l’hospitalisation (P < 0,05, pour les deux).
Les personnes âgées atteintes d’une maladie cardiovasculaire en phase aiguë se retrouvent sédentaires pendant une grande partie de leur séjour à l’hôpital. L’augmentation du temps sédentaire est associée à une plus mauvaise QVLS après l’hospitalisation selon les personnes âgées interrogées. Des études ultérieures sont nécessaires pour déterminer si les interventions pour accroître l’activité physique durant l’hospitalisation améliorent la QVLS et les résultats fonctionnels après l’hospitalisation.
Health-Related Quality of Life in Older Adults With Acute Cardiovascular Disease Undergoing Early Mobilization
2021, CJC Open
Citation Excerpt :
Data on patient physical and mental health is stratified across 8 domains: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health.11 The SF-36 is the most widely used HRQOL instrument, is easy to administer in person and by telephone, and has been shown to be valid and reliable in elderly populations.13 For each subject, the following data were obtained from the electronic medical record: age, sex, primary admission diagnosis, length of CICU and hospital stay, discharge location, vital status at discharge, mobility assessments (LOF scores, contraindications, activities completed, and adverse events).
Early mobilization (EM) is safe and feasible in older adults with acute cardiovascular disease (CVD) and may improve posthospitalization patient-centred outcomes. Our objective was to assess posthospitalization health-related quality of life (HRQOL) in older adults with acute CVD undergoing EM.
Patients aged ≥ 60 years with acute CVD undergoing EM at an academic tertiary centre in Montreal, Quebec were prospectively enrolled from January 2018 to January 2020. Functional status was measured using the validated Level of Function Mobility Scale. HRQOL was measured using the Short-Form 36 questionnaire at 1 and 12 months posthospitalization. The primary outcome was the questionnaire’s physical component summary (PCS) score at 1 month posthospitalization.
There were 147 patients included in the analysis (aged 75.0 ± 8.7 years; 44.6% female; 48.6% with ischemic heart disease). The mean 1-month PCS score was 34.7 ± 9.7, which was 11.5 points and 8.4 points lower compared to age-matched Canadian normative data for people ages 65-74 years and ≥ 75 years, respectively. The mean PCS score at 12 months (36.5 ± 9.2) and the mean mental component summary scores at 1 and 12 months (36.9 ± 11.1; 40.5 ± 11.5) were lower than those of the age-matched population (all P < 0.0001). In the multivariable analysis, increased age and worse prehospitalization function were associated with lower PCS score at 1 month.
Older adults with acute CVD had lower HRQOL at 1 and 12 months posthospitalization than age-matched Canadian norms. Prehospitalization functional status was predictive of poor posthospitalization HRQOL. The EM program was safe and feasible in this patient population. Further studies are needed to determine whether EM can improve posthospitalization patient-centred outcomes in older adults, particularly those with poor prehospitalization functional status.
La mobilisation précoce (MP) est sécuritaire et réalisable chez les personnes âgées atteintes d’une maladie cardiovasculaire (MCV) aiguë et peut permettre d’améliorer les résultats axés sur les patients après l’hospitalisation. Notre objectif était d’évaluer la qualité de vie liée à la santé (QVLS) après l’hospitalisation chez les personnes âgées atteintes d’une MCV aiguë se soumettant à la MP.
Les patients ≥ 60 ans atteints d’une MCV aiguë se soumettant à la MP dans un centre universitaire de soins tertiaires à Montréal, au Québec, ont été inscrits de façon prospective de janvier 2018 à janvier 2020. Nous avons mesuré l’état fonctionnel au moyen de l’échelle de mobilité fonctionnelle validée. Nous avons mesuré la QVLS à l’aide du questionnaire d’évaluation de la santé en version abrégée (SF-36, de l’anglais Short-Form 36 questionnaire) un mois et 12 mois après l’hospitalisation. Le principal critère d’évaluation était les scores du sommaire de la composante physique (SCP) du questionnaire un mois après l’hospitalisation.
Cent quarante-sept patients ont fait l’objet de l’analyse (âgés de 75,0 ± 8,7 ans; 44,6 % de femmes; 48,6 % atteints d’une cardiopathie ischémique). Les scores moyens du SCP après un mois étaient de 34,7 ± 9,7, soit 11,5 points et 8,4 points plus bas que les données normatives canadiennes appariées selon l’âge pour les personnes de 65 à 74 ans et ≥ 75 ans, et ce, respectivement. Les scores moyens du SCP après 12 mois (36,5 ± 9,2) et les scores moyens du sommaire de la composante mentale après un mois et après 12 mois (36,9 ± 11,1; 40,5 ± 11,5) étaient plus bas que les scores de la population appariée selon l’âge (toutes les P < 0,0001). Dans l’analyse multivariée, l’âge avancé et le plus mauvais fonctionnement avant l’hospitalisation ont été associés à un score plus bas du SCP après un mois.
Les personnes âgées atteintes d’une MCV aiguë avaient un mois et 12 mois après l’hospitalisation une QVLS inférieure aux normes canadiennes appariées selon l’âge. L’état fonctionnel avant l’hospitalisation permettait de prédire une QVLS médiocre après l’hospitalisation. Le programme de MP était sécuritaire et réalisable pour ces patients. D’autres études sont nécessaires pour déterminer si la MP peut contribuer à l’amélioration des résultats axés sur les patients après l’hospitalisation chez les personnes âgées, particulièrement chez celles qui ont un état fonctionnel médiocre avant l’hospitalisation.
Classification of quality of life subscales within the ICF framework in burn research: Identifying overlaps and gaps
2014, Burns
Quality of life (QOL) is one of the leading outcomes in burn care research. This study classifies subscales of common QOL measures within the International Classification of Functioning disability and health (ICF) framework to determine to which extent the measures are complementary or overlapping and to investigate whether the instruments are able to describe the full spectrum of patients’ functioning.
A literature search was performed to determine the most frequently used questionnaires in burn research. The subscales of the three mostly used questionnaires were classified within the ICF framework.
Two generic measures, the Short Form-36 items (SF-36) and the European Quality of Life 5 Dimensions (EQ-5D), and a disease specific measure, the Burn Specific Health Scale-Brief (BSHS-B), were analyzed. The BSHS-B covered most domains and was the only scale that included personal factors. The SF-36 included only one domain in the activity limitations and similar to the EQ-5D no contextual factors were included. Environmental factors were not addressed in the questionnaires, even though these may have an impact on the quality of life in patients with burns.
To capture the full spectrum of dysfunctioning a combination of the BSHS-B with a generic questionnaire seems obligatory. However still some domains of functioning remain uncovered.
Inclusion of frail elderly patients in clinical trials: Solutions to the problems
2013, Journal of Geriatric Oncology
Citation Excerpt :
Studies have shown that frail older adults have difficulty with self-administered questionnaires. For example, the Short Form-36 (SF-36) [12] has proven to be reliable and valid in a frail elderly population only when used in an interview setting [19,20]. The interview setting used made it difficult to strictly adhere to the content of the questionnaires due to the addition of personal comments and questions leading the patients to disclose tangential information.
With the aging of the population, the interest in clinical trials concerning frail elderly patients has increased. Evidence-based practice for the elderly patient is difficult because elderly patients, especially the frail, are often excluded from clinical trials. To facilitate the participation of frail elderly patients in clinical trials, investigators should be more aware of possible barriers when setting up research. While conducting a trial entitled ‘A randomized controlled trial of geriatric liaison intervention in frail surgical oncology patients’ (LIFE) the main problem was low inclusion rates. This was due to: 1) limited physical and cognitive reserve of frail elderly patients making participation and extra visits to the hospital a burden for patients; 2) difficulty with understanding written information and information given by telephone; and 3) insufficient awareness of the study by health care professionals. To increase inclusion rates, follow-up measurements were taken at a home visit. To overcome barriers to understanding written information and information given over the phone, patients were informed face to face and questionnaires were filled in an interview format. To increase awareness, posters, pencil and sweets with the logo of the study were distributed and the study protocol was repeatedly explained to new staff. Moreover, it was checked if possible eligible patients coming to the hospital were indeed screened for participation. The mentioned measures, increased inclusion rates but also caused an increased time investment and consequently extra financial resources for staff costs.
Measuring Outcomes of Multidimensional Interventions
2010, Brocklehurst's Textbook of Geriatric Medicine and Gerontology
Self-reported Physical Function Decline and Mortality in Older Adults Receiving Hemodialysis
2019, Kidney Medicine
Timely recognition of functional decline in older adults receiving dialysis will allow clinicians to pursue interventions to prevent further disability and/or lead patient-centered goals of care discussions. Annual change in the 12-Item Short Form Health Survey (SF-12) physical component score (PCS) could identify patients with functional decline. Our objectives were to assess SF-12 PCS change over a year, risk factors associated with SF-12 PCS change, and the association of SF-12 PCS change with mortality in a survivor cohort of older adults receiving dialysis.
Retrospective study.
1,371 adults 65 years or older receiving hemodialysis for 6 or more months who completed SF-12 PCSs 300 or more days apart from 2012 to 2013.
Serum albumin level; hemodialysis access type; SF-12 PCS change (for mortality analyses).
SF-12 PCS change and mortality.
Multivariable-adjusted linear regression model; Cox proportional hazards model.
We excluded 24% (n = 801) of our cohort for death before the second SF-12 PCS. Among the 1,371 with sufficient SF-12 PCS data, mean age was 79.9 ± 4.5 years. Average SF-12 PCS change in 1 year was minimal (−0.9 ± 9.6), but 39.3% (n = 539) and 32.2% (n = 442) had clinically relevant SF-12 PCS decline and improvement, respectively. Albumin level and access type were not statistically associated with SF-12 PCS change. SF-12 PCS change was not associated with mortality (adjusted HR, 0.98; 95% CI, 0.96-1.00).
2 time points to assess SF-12 PCS change; covariate assessment only at baseline; survivor bias.
In this cohort of older adults receiving hemodialysis, nearly one-fourth died, while among survivors, it was more common for SF-12 PCS to decline than improve in a year. Annual SF-12 PCS change was not associated with traditional risk factors for functional impairment or mortality risk. Additional research is needed to identify appropriate measures and frequency of assessment for functional decline.

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^☆: Accepted for publication on 28 April 1998.

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Original ArticlesTesting the Measurement Properties of the Short Form-36 Health Survey in a Frail Elderly Population☆

Abstract

Introduction

Section snippets

Design, Setting, and Subjects

Patients

Discussion

Conclusion

Acknowledgements

Pain

J Chronic Dis

Chest

J Psychiatr Res

Illness presentation in elderly patients

Arch Intern Med

Preventing frail health

Clin Geriatr Med

Frailty in elderly peopleAn evolving concept

Can Med Assoc J

A multidimensional view of quality of life in frail elders

Measurement of quality of life in the frail elderly

The Sickness Impact ProfileDevelopment and final revision of a health status measure

Med Care

Measuring Health Status

Outcome of comprehensive medical rehabilitationMeasurement by PULSES Profile and the Barthel Index

Arch Phys Med Rehabil

The development, validity, and reliability of the OARS multidimensional functional assessment questionnaire

J Gerontol

Development of a health questionnaire specific for end-stage renal disease

Nephron

The MOS 36-item short form health survey (SF-36). I. Conceptual framework and item selection

Med Care

Measuring HealthA Guide to Rating Scales and Questionnaires

SF-36 Health Survey Manual and Interpretation Guide

Short form 36 (SF36) health survey questionnaireNormative data for adults of working age

Br Med J

Patient-based health status measures in outpatient dialysis

Med Care

Ongoing assessment of health status in patients with diabetes mellitus

Med Care

Validating the SF-36 health survey questionnaireNew outcome measure for primary care

Br Med J

Methods for assessing condition-specific and generic functional status outcomes after total knee replacement

Med Care

Longitudinal sensitivity of generic and specific health measures in chronic sinusitis

Qual Life Res

Measuring physical function in community-dwelling older personsA comparison of self-administered, interview-administered, and performance-based measures

J Am Geriatr Soc

Original Articles
Testing the Measurement Properties of the Short Form-36 Health Survey in a Frail Elderly Population☆