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Purpose: The purpose of this study is to suggest a new approach to identifying patterns of comorbidity and multimorbidity. Design and Methods: A random sample of 1,039 rural community-resident American Indian elders aged 60 years and older was surveyed. Comorbidity was investigated with four standard approaches, and with cluster analysis. Results: Most respondents (57%) reported 3 or more of 11 chronic conditions. Cluster analysis revealed a four-cluster comorbidity structure: cardiopulmonary, sensory-motor, depression, and arthritis. When the impact of comorbidity on four health-related quality of life outcomes was tested, the use of the clusters offered more explanatory power than the other approaches. Implications: Our study improves understanding of comorbidity within an understudied and underserved population by characterizing comorbidity in conventional and novel ways. The cluster approach has four advantages over previous approaches. In particular, cluster analysis identifies specific health problems that have to be addressed to alter American Indian elders' health-related quality of life. Key Words: Chronic illness, Health-related quality of life, Functional impairment

A study of a long-term care program's multidisciplinary case management team evaluated the risk of long-term nursing home placement and chose a care plan for a hypothetical client underlines a need for further research and standards in decision making. In evaluating the risk of institutionalization, the highly professional case management team was thorough in considering the medical and physical aspects, somewhat overstressed the economic factors and program capacities and ignored geriatric case management.

Purpose: The purpose of this study was to evaluate burden experienced by a group of American Indian primary family caregivers and to determine if caregiver burden is a multidimensional concept. Design and Methods: This analysis is based on the results of a survey questionnaire administered to 169 Pueblo primary family caregivers in New Mexico. Results: Analysis of the items composing the Caregiver Burden scale indicated that caregiver burden is multidimensional and consists of several types of burden. Caregiver burden, as identified in this sample, is composed of four dimensions: role conflict, negative feelings, lack of caregiver efficacy, and guilt. Investigations of caregiver burden should consider the multidimensionality of this experience and evaluate burden accordingly. Implications: By identifying the specific type of burden that a caregiver experiences, interventions can be targeted more accurately to support family caregiving. Key Words: Family caregiving, American Indians, Caregiver burden

The chronically ill aged patient often has restrictions placed upon his or her autonomy due to the symptoms of the illness. Adding to this burden are restrictions placed upon patients by caregivers and caregiving institutions. But evidence suggests that a sense of personal control may be crucial to the well-being of the patient and may maximize the medical outcome, making this dilemma particularly important. Long-term community-based services are increasingly becoming the standard in the care and treatment of the frail elderly. Thus, a community-based long-term care program was chosen to study issues of autonomy and the risk of loss of autonomy in providing services for the elderly. Assessment of needs, care planning, and delivery of services are all performed on-site. The totality and intensity of care in this setting creates potential for clients to achieve maximal autonomy because their needs can be intimately known by the staff. On the other hand, such total control by staff can be abused, leading to little autonomy for patients. Detailed notes regarding 360 clients were made in the staff's comments at weekly team meetings over a three-month period to identify the criteria used to make decisions about the clients' care. It was found that choice of treatment, and hence autonomy, was directly related to the staff's perception of the risk a client presented, or the client's ability to be maintained easily. Low-risk patients encountered greater flexibility on the staff's part whereas higher risk patients (noncompliant patients, for example) required a more controlling response by staff. In all cases, there was often incongruence between a client's wishes and the staff's allocation of resources. The staff attempted to minimize risk for clients while controlling costs. Sometimes this required a temporary loss of autonomy in the interests of improving overall long-term functioning and delivering cost-effective care. The issues raised underscore the complexity of ethics, rights and responsibilities in balancing clients' wishes and needs against available resources. (Consumer Summary produced by Reliance Medical Information, Inc.)