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Adjustment to hemodialysis : a relationship study with demographic variables Sawatzky, Dale James 1987

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ADJUSTMENT TO HEMODIALYSIS: A RELATIONSHIP STUDY WITH DEMOGRAPHIC VARIABLES BY DALE JAMES SAWATZKY B.A. T r i n i t y Western College, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN THE FACULTY- OF GRADUATE STUDIES Department of Counselling Psychology We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA JUNE, 1987 © D A L E JAMES SAWATZKY, 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia 1956 Main Mall Vancouver, Canada Department V6T 1Y3 DE-6(3/81) ABSTRACT T h i s study examines the r e l a t i o n s h i p s between three aspects of adjustment t o hemodialysis ( i . e . a c t i v i t y l e v e l s , mood s t a t e s and s e v e r i t y of symptoms) and four demographic v a r i a b l e s ( i . e . age, occupation, education and length of time on d i a l y s i s ) . The sample c o n s i s t e d of 37 p a t i e n t s on hem o d i a l y s i s . A c t i v i t y l e v e l s , mood s t a t e s and s e v e r i t y of symptoms were measured by the a c t i v i t y i n v e n t o r y , p r o f i l e of mood s t a t e s and symptom q u e s t i o n n a i r e , r e s p e c t i v e l y . A p e r s o n a l h i s t o r y q u e s t i o n n a i r e was employed t o assess the demographic v a r i a b l e s . The data was analyzed u s i n g the Pearson Product-Moment C o r r e l a t i o n Method with a o n e - t a i l e d t e s t of s i g n i f i c a n c e . A c t i v i t y l e v e l s were found t o be n e g a t i v e l y c o r r e l a t e d with age a t a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l , but were not s i g n i f i c a n t l y c o r r e l a t e d with occupation, education or le n g t h of time on d i a l y s i s . T o t a l mood d i s t u r b a n c e was not s i g n i f i c a n t l y c o r r e l a t e d with any of the demographic v a r i a b l e s . T o t a l s e v e r i t y of symptoms were n e g a t i v e l y c o r r e l a t e d with education a t a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l , but no s i g n i f i c a n t c o r r e l a t i o n s were d i s c o v e r e d between t h i s aspect of adjustment and the other demographic v a r i a b l e s . i i i . A few supplemental findings were also deemed important. Total severity of symptoms were both negatively correlated with a c t i v i t y levels and p o s i t i v e l y correlated with mood states at s t a t i s t i c a l l y s i g n i f i c a n t l e v e l s . However, mood states and a c t i v i t y levels were not s i g n i f i c a n t l y correlated. F i n a l l y , a s i g n i f i c a n t positive correlation was found between education and occupational l e v e l . i v . TABLE OF CONTENTS Page Abstract i i . Table of Contents i v . L i s t of Tables ix . CHAPTER I INTRODUCTION TO THE STUDY 1 . Stresses of Hemodialysis 2. Psychological Problems 4. Rehabilitation Problems 6. Compliance Problems 8. The Problem Situation 9. Purpose of the Study 10. Speci f i c Objectives of the Study 11. Hypotheses Tested 12. Significance of the Study 13. De f i n i t i o n of Terms 15. CHAPTER II REVIEW OF THE LITERATURE 20. Age 21. Age and Severity of Symptoms 23. Age and A c t i v i t y Levels 24. Age and Mood States 27. Page Occupation . 29 Occupation and Severity of Symptoms 29 Occupation and A c t i v i t y Levels... 30 Occupation and Mood States 31 Education 31 Education and Severity of Symptoms 3 2 Education and A c t i v i t y Levels 32 Education and Mood States 33 Length of Time 35 Length of Time and Severity of Symptoms. 35 Length of Time and A c t i v i t y Levels 36 Length of Time and Mood States 37 CHAPTER III METHODOLOGY 39 Subjects 39 Instruments 40 Personal History Questionnaire 41 P r o f i l e of Mood States 42 POMS Internal Consistency 43 POMS Test-Retest R e l i a b i l i t y 43 POMS V a l i d i t y 4 4 Use of the POMS in other C l i n i c a l Studies 46 v i . Page Symptom Questionnaire 47 SQ V a l i d i t y and R e l i a b i l i t y 49 Use of the SQ.in other C l i n i c a l Studies 49 A c t i v i t y Inventory 50 A c t i v i t y Inventory and the Standardization Issue 51 S t a t i s t i c a l Analysis 51 CHAPTER IV RESULTS 5 3 A c t i v i t y Levels and Demographic Variables 53 Mood States and Demographic Variables... 56 Severity of Symptoms and Demographic Variables 5 7 Supplemental Findings. 60 CHAPTER V DISCUSSION OF RESULTS 6 2 A c t i v i t y Levels and Demographic Variables 62 A c t i v i t y Levels and Age 62 A c t i v i t y Levels and Occupation 64 A c t i v i t y Levels and Education 67 v i i . Page A c t i v i t y Levels and Length of Time on D i a l y s i s 69 Mood States and Demographic Variables.. 70 Mood States and Age. 7 0 Mood States and Occupation 7 3 Mood States and Education 7 3 Mood States and Length of Time on D i a l y s i s 75 Severity of Symptoms and Demographic Variables 76 Severity of Symptoms and Age 7 6 Severity of Symptoms and Occupation.... 77 Severity of Symptoms and Educational Level 78 Severity of Symptoms and Length of Time on D i a l y s i s 80 Supplemental Findings 81 Total Severity of Symptoms and A c t i v i t y Levels 81 Total Severity of Symptoms and Mood States 81 Mood States and A c t i v i t y Level 82 Education and Occupation. . . 8 2 Education and Age . 83 v i i i . Page Methodological Limitations 83 Limitations Associated with the Instrumentation 83 Limitations Associated with the Sample 8 6 Limitations Associated with Data C o l l e c t i o n 87 Limitations Associated with Correlational Method 89 J u s t i f i c a t i o n of the Study 91 J u s t i f i c a t i o n of the Methodology.. 92 Conclusions and Discussion 94 Suggestions for Additional Research.... 98 EPILOGUE Counselling and Adjustment to Hemodialysis 100 REFERENCES 102 APPENDIX A Personal History Questionnaire 118 A c t i v i t y Inventory 123 APPENDIX B P r o f i l e of Mood States 124 APPENDIX C Symptom Questionnaire 126 ix. LIST OF TABLES PAGE T A B L E ' 4-1 5 4 TABLE 4-2 55 TABLE 4-3 • 61 1 CHAPTER I  INTRODUCTION TO THE STUDY More than 50,000 persons in the United States are a f f l i c t e d with some form of renal disease (Department of Health, Education, and Welfare, 1979) and t h i s number i s expected to increase to 70,000 by 1990 (Kolata, 1980). Each year renal f a i l u r e affects approximately 150 to 200 people per m i l l i o n , worldwide (Levy, 1981). Over half of these patients have d i s -eases of a generalized nature in which a r t i f i c a l substitution of kidney function .would only minimally prolong l i f e , and would not materially change i t s quality (Levy, 1981). Those individuals whose condi-ti o n has deteriorated to the i r r e v e r s i b l e or end state (known as end stage renal disease or ESRD) require some form of d i a l y s i s as an alternative to renal trans-plantation for l i f e maintenance. As of 1979, approxi-mately 42,000 persons in the United States were receiv-ing such treatment annually (DHEW, 1979). In Canada, the number of patients on d i a l y s i s i s over 3,500 (Canadian Renal Failure Register Report, 1983). Of this dialyzed population in Canada, more than 80% are being maintained on hemodialysis, while the remainder are treated with peritoneal d i a l y s i s (Canadian Renal Failure Register Report, 1983). Although approxi-2 . mately 40% of ESRD patients undergoing hemodialysis treatment were dialyzed through home and self-care hemodialysis, the majority (about 60%) of these patients were treated in a c l i n i c or hospital (Canadian Renal Failure Register Report, 1983). The technology of hemodialysis has advanced greatly over the years. This form of treatment i s now a safe and ef f e c t i v e means for managing end state renal disease. The d i a l y s i s process i s smoother,- the patients spend less time on d i a l y s i s ; they are in better physical condition; and, there are fewer compli-cations (Czaczkes and De-Nour, 1978). In addition, hemodialysis allows for a modest l i f e span and may give access to the opportunity of a transplant. STRESSES OF HEMODIALYSIS Despite the technical improvements with t h i s type of d i a l y s i s , these patients are faced with numerous stressors that are not a l l e v i a t e d by the new advances in technology (Czaczkes and De-Nour, 1978). These stressors include: problems of dependency upon a proce-dure, a machine, and a group of professional people (Shea, E.J., Bogdan, D.F., Freeman, R.B. and Schreiner, G.E. 1965; Wright, R.G., Sand, P. and Livingston, G. 1966; Crammond , W.A., Knight, P.R. and Lawrence, J.R. 1967; De-Nour, A.K., S h a l t i e l , J . and Czaczkes, J.W. 1968; De-Nour and Czaczkes 1969; De-Nour, 1970; Curtis et a l . 1969; Short and Alexander 1969; Short and Wilson 1969; Abram 1970, 1974; Halper 1971; Reichsman and Levy 1972; De-Nour and Czaczkes 1974; and Levy 1976, 1978, 1981); the threat of death (Sand, P., Livingston, G. and Wright, R.G. 1966; Beard 1969; Wijsenbeck and Munitz 1970; Levy 1977, 1984); the medical regimen and the r e s t r i c t i o n s on t r a v e l l i n g and in planning of d a i l y a c t i v i t i e s (Wright et a l . 1966; Crammond et a l . 1967; De-Nour et a l . 1968; Wijsenbeck and Munitz 1970; Crammond, 1970; Goldstein and Reznikoff 1971; Levy 1974, 1976); multiple losses (Wright et a l . 1966; Crammond et a l . 1967; Levy 1977, 1981, 1984; and Gutman, R.A., Stead, W.A. and Robinson, R.R. 1981); increased aggression (Wright et a l . 1966; De-Nour et a l . 1968; De-Nour, and Czaczkes, 1969, 1974,1976; Wijsenbeck and Munitz 19 70; Halper 1971; Tourkow 1974); problems with body image (Shea et a l . 19 65; Cooper 1967; De-Nour et a l . 1968; De-Nour and Czaczkes 1969; Short and Wilson 4 . 1969; Abram 1970; Wijsenbeck and Munitz 1 970; Lefebvre, P., Norbert, A. and Crombez, J.C. 1 9 72; Basch 1974; Tourkow 1974; Pinney 1976; Czaczkes and De-Nour 1978; Levy 1984); and various physical problems (Armstrong 1978; De-Nour and Shanan 1980; and Nichols and Springford 1984). As a r e s u l t of these multiple stresses, patients have a range of problems in adjusting to hemodialysis treatment. PSYCHOLOGICAL PROBLEMS Many patients on hemodialysis experience psycho-l o g i c a l and emotional problems (Abram 1969, 1972, 1974; Anderson 1975; Levy 1977, 1978, 1981, 1984; Armstrong 1978; Nichols and Springford 1984). The most common psychological problem seen in them i s depression (Gonzalez et a l . 1963; Shea et a l . 1965; Retan and Lewis 1966; Wright et a l . 1966; Crammond et a l . 1967; Beard 1969; Friedman, E.A., Goodwin, N.J. and Chandhry, L. 1970; Daly 1970; Lefebvre et a l . 1972; Reichsman and Levy 1972; Fishman and Schneider 1972; Holcomb and MacDonald 1973; Pierce D.M., Freeman, R., Lawton, R. and Fearing, M. 1973; Shulman, R., Pacey, I. and Diewold, P. 1974; Mlott and Mason 1975; Levy and Wynbrandt 1975; Levy 1976, 1977 1981; 5 . De-Nour 1976; De-Nour and Czaczkes 1976). S u i c i d a l behaviour i s another frequently observed problem among patients on hemodialysis (Abram, H.S., Moore, G.L. and Westervelt, F.B. J r . 1971; Foster, F.G., Cohn, G.L. and McKegney, F.P. 1973; Holcomb and MacDonald 1973; Shulman et a l . 1974. These patients also experience varying degrees of anxiety (Cazzullo, C.L., Invernizzi, G., Ventura, R. and Sostero, M. 1973; Czaczkes and De-Nour 1978; Wright 1981). Sexual dysfunction among t h i s population i s also exceedingly common (De-Nour 1969; Phadke, A.G., MacKinnon, K.J. and Dossetor, J.B. 1970; Levy 1973, 1976, 1977, 1979, 1981, 1984; Levy and Wynbrandt 1975; Abram, H.S., Hester, L.R., Sheridan, W.F. and Epstein, G.M. 1975; Lim, V.S., Auletta, F. and Kathpalia, S. 1978; Chopp and Mendez 1978; Procci 1982, 1983). One of the greatest problems encountered by d i a l y s i s s t a f f i s what might be referred to as the "uncooperativeness" of these patients (Levy 1980, 1981). F i n a l l y , there are some reports of psychosis among them (Gonzalez, F.M., Pabico, R.C., Brown, W.H., Maker, J.F. and Schreiner, G.E. 1963; Shea et a l . 1965; Cooper 1967; Wijsenbeck and Munitz 1970; Taylor 1972; M e r r i l l and Co l l i n s 1974), but i t seems to be a r e l a t i v e l y uncommon reaction to the stresses of hemodialysis (Levy 1 976). 6 . REHABILITATION PROBLEMS D i f f i c u l t i e s in adjustment to hemodialysis are also common in various aspects of r e h a b i l i t a t i o n . Vocational r e h a b i l i t a t i o n i s generally quite poor among patients on hemodialysis (Cameron, J.S., E l l i s , F.G., Ogg, C.S., Bewick, M., Boulton-Jones, J.M., Robinson, R.D. and Harrison, J.A. 1970; Pendras and Pollard 1970; Strauch, M., Huber, W., Rahauser, G., Werner, J . , Walzer, P. and Hafner, H. 1971; Reichsman and Levy 1972; Freyberger 1973; Malmquist 1973; Foster, F.G.', Cohn, G.L. and McKegney, F.P. 1 973; Parsons, F.M., Brunner, F.P., Burck, H.C., Graser, W., Gurland, H.J., Harlen, H., Scharer, K. and Spies, G.W. 1974; Disney and Row 1974; Cadnapaphornchai, P., Chakko Kuruvila, K., Holmes, J . and Schrier, R. 1974; Dubernard, C , Cognet, J.B., Maret, J . , M a i l l i e , J.P., Favre-Bulle, S., C a n a r e l l i , G. , Moskovtchenko, J.P. and Traeger, J . 1975; De-Nour and Czaczkes 1975; Levy and Wynbrandt 1975; De-Nour and Czaczkes 1976; Brunner, F.P., Giesecke, B., Gurland, H.J., Jacobs, C , Parsons, F.M., Scharer, K., Seyffart, G. and Wing, W.J. 1976; De-Nour and Shanan 1980; and Gutman, R.A., Stead, W.W. and Robinson, R.R. 1981). They t y p i c a l l y have a marked decrease in s o c i a l a c t i v i t i e s (Short 7 . and Alexander 1969; Glassman and Siegal 1970; Friedman, E.A., Goodwin, N.J. and Chaudhry, L. 1970; Strauch et- a l . 1971; and Shulman, R. , Pacey, I. and Diewold, P. 1974; Czaczkes and De-Nour 1978; De-Nour, and Shannan 19 80; Procci 1981; and De-Nour 1982) recreational a c t i v i t i e s (Strauch et a l . 1971; Shulman et a l . 1974; and De-Nour 1982), and physical a c t i v i t i e s (Strauch et a l . 1971 and Gutman et a l . 1981). Another component of r e h a b i l i t a t i o n in which these patients tend to not atta i n ideal adjustment i s in family l i f e (Shambaugh, P.W., Hampers, C.L., Bailey, G.L., Snyder, D. and M e r r i l , J.P. 1 967 ; B a i l l o d , R.A., Crockett, R.E. and Ross, A. 1969; Short and Wilson 1969; Smith, E.K.M., Curtis, J.R., McDonald, S.J. and De Wardener, H.E. 1969; De-Nour and Czaczkes 1970; Friedman et a l . 1970; Heale, W.F., Leisegang, J. and N i a l l , J.F. 1970; Strauch et a l . 1971; Holcomb and MacDonald 1973; Shulman et a l . 1974; Mass and De-Nour 1975; Maurin and Schenkel 1976; Steele, T.E., Finkelstein, S.H. and Finkelstein, F.O. 1976; and Tsaltas 1976). 8 . C O M P L I A N C E P R O B L E M S Compliance with the medical treatment i s an additional area in which patients often have adjust-ment problems. Poor compliance with the die t i s common among these patients (Shea et a l . 19 65; Friedman et a l . 1970; Abram, H.S., Moore, G.L. and Westervelt, F.B. 1971; Brunner, F.P., Gurland, H.J., Harlen, H., Scharer, K. and Parsons, F.M. 1972; De-Nour and Czaczkes 1972; and Brunner et a l . 1976). Some patients choose to completely withdraw from hemodialysis treatment, which i s the most extreme form of non-compliance (Abram et a l . 1971; and Cadnapaphornchai et a l . 1974). 9 . THE PROBLEM SITUATION Although many studies have been published about adjustment to hemodialysis, a review of the l i t e r a t u r e reveals that a very limited number of investigations have examined how t h i s adjustment i s related to demo-graphic variables. More s p e c i f i c a l l y , few studies have examined how the severity of symptoms, a c t i v i t y l e v e l s , and psychological (mood) states of these patients are correlated with the demographic variables of age, education, occupation and length of time on d i a l y s i s . Some of these areas of concern have had the attention of either only one study or no studies. Furthermore, in the categories which have had the attention of more than one study, primarily contradic-tory findings have t y p i c a l l y been reported. The shortage of information in t h i s area i s p a r t i c u l a r l y surprising in l i g h t of the widely held b e l i e f s in the medical profession that such factors as age (De-Nour and Czaczkes 1974, Blodgett 1981-82), education (De-Nour and Czaczkes 1974, Olsen 1983), and occupa-t i o n a l l e v e l (Strauch, M., Huber, W., Rahauser, G., Werner, J., Walzer, P. and Hafner, H. 1971; Levy 1976) and length of time on d i a l y s i s (Blodgett 1981-82) 1 0 . tend to influence a patient's adjustment to hemo-d i a l y s i s . Because there i s i n s u f f i c i e n t information and knowledge about the influence of such demographic variables on the physical symptoms, a c t i v i t y l e v e l s , and psychological problems of patients undergoing hemodialysis treatment, there i s an inadequate under-standing of the s u s c e p t i b i l i t y to impairment and the potential needs of patients in these various demo-graphic categories. In addition, the d e f i c i t of information in t h i s area may i n h i b i t appropriate planning of services and deploying of resources for meeting the various needs of these patients. PURPOSE OF THE STUDY The general purpose of t h i s study i s to examine how the psychological and physiological problems of hemodialysis patients are related to various demographic variables. 11 . SPECIFIC OBJECTIVES OF THE STUDY I n l i n e w i t h t h e g e n e r a l p u r p o s e o f t h i s s t u d y , t h e s p e c i f i c q u e s t i o n s t o be a n s w e r e d a r e : 1. What a r e t h e r e l a t i o n s h i p s b e t w e e n t h e s e l f - r e p o r t e d a c t i v i t y l e v e l s ( a s m e a s u r e d b y t h e a c t i v i t y i n v e n t o r y ) o f p a t i e n t s u n d e r g o i n g h e m o d i a l y s i s t r e a t m e n t a n d t h e d e m o g r a p h i c v a r i a b l e s o f a g e , o c c u p a t i o n , e d u c a t i o n a n d l e n g t h o f t i m e on d i a l y s i s ? 2. What a r e t h e r e l a t i o n s h i p s b e t w e e n t h e mood s t a t e s ( a s m e a s u r e d b y t h e P r o f i l e o f Mood S t a t e s ) e x p e r i e n c e d by p a t i e n t s u n d e r g o i n g h e m o d i a l y s i s t r e a t m e n t and t h e d e m o g r a p h i c v a r i a b l e s o f a g e , o c c u p a t i o n , e d u c a t i o n a n d l e n g t h o f t i m e on d i a l y s i s ? 3. What a r e t h e r e l a t i o n s h i p s b e t w e e n t h e s e v e r i t y o f symptoms ( a s m e a s u r e d by t h e Symptom Q u e s t i o n n a i r e ) e x p e r i e n c e d by p a t i e n t s u n d e r g o i n g h e m o d i a l y s i s t r e a t -ment and t h e d e m o g r a p h i c v a r i a b l e s o f a g e , o c c u p a t i o n , e d u c a t i o n a n d l e n g t h o f t i m e on d i a l y s i s ? 1 2 . HYPOTHESES TEST  Hypothesis 1 : There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a -t ions between the se l f - repor ted a c t i v i t y leve l s (as measured by the a c t i v i t y inventory) of pat ients undergoing hemodialysis treatment and the demographic var iab les of age, occupation, education and length of time on d i a l y s i s . Hypothesis 2: There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a -t ions between the mood states (as measured by the P r o f i l e of Mood States) experienced by pat ients undergoing hemodialysis treatment and the demographic var iab les of age, occupation, education and length of time on d i a l y s i s . Hypothesis 3: There w i l l be no s t a t i s t i c a l l y s i gn i f i c an t c o r r e l a -t ions between the sever i ty of symptoms (as measured by the Symptom Questionnaire) experienced by pat ients undergoing hemodialysis treatment and the demographic var iables of age, occupation, education and length of time on d i a l y s i s . 1 3 . SIGNIFICANCE OF THE STUDY The independent variables ( i . e . age, occupation, education and length of time on d i a l y s i s ) selected for th i s study were chosen because of the commonly held b e l i e f s among health professionals (Blodgett 1981-82, De-Nour and Czaczkes 1974, Levy 1976, Olsen 1983 and Strauch et a l . 1971) that they influence a patient's adjustment to hemodialysis treatment. It seems worth-while, therefore, to investigate the rel a t i o n s h i p of these demographic variables to the independent v a r i -ables of t h i s study which represent various aspects of adjustment to hemodialysis. Information gathered in th i s study w i l l not only be of the o r e t i c a l interest, but may also have a role in leading to research of p r a c t i c a l importance. Future research may bu i l d on information generated by t h i s and other studies and may provide greater understanding of adjustment to hemodialysis and factors predictive of such adjust-ment. This kind of knowledge could perhaps then prove useful in helping to determine the potential needs and the most ef f e c t i v e treatment interventions that may be employed with each patient undergoing maintenance 1 4 . hemodialysis. Possibly such data may make a small step in pointing to the need for new and d i f f e r e n t treatment approaches in order to lessen the various aspects of d i s a b i l i t y and maladjustment of these patients. These findings may also a s s i s t future health professionals in targeting high r i s k patients for intervention before or at the onset of hemodial-y s i s treatment. Furthermore, organ substitution has opened up a new phase of medicine in which such fac-tors need to be better understood (Levy, 1981). It has been asserted (Levy, 1981) that t h i s kind of understanding i s p o t e n t i a l l y available through studies on the f i r s t and largest group of these patients, those on hemodialysis. Abram (1977) wrote "Chronic d i a l y s i s serves as a paradigm not only of man's res-ponse to a chronic i l l n e s s , but to a treatment which requires dependence upon an a r t i f i c a l device for sur v i v a l . " 1 5 . DEFINITION OF TERMS ACTIVITY LEVEL: The extent to which the physical a c t i v i t i e s that were engaged in pr i o r to kidney f a i l u r e are s t i l l done recently, as measured by the a c t i v i t y inventory. ADJUSTMENT TO HEMODIALYSIS: Those behaviours which are consistent with the broad goals of b i o l o g i c a l s u r v i v a l , responsible conduct and competent behaviour (Weissman, 1972). It involves the following general areas: (1) psychological and emotional adjustment, (2) r e h a b i l i t a t i o n (including vocational r e h a b i l i t a t i o n , s o c i a l a c t i v i t i e s , recreational a c t i v i t i e s , physical a c t i v i t i e s , and family l i f e ) , and (3) compliance with the medical treatment for the purposes of t h i s study adjustment to hemodialysis w i l l be defined as a c t i v i t y l e v e l , mood states and severity of symptoms as measured by the a c t i v i t y inventory, p r o f i l e of mood states and symptom questionnaire, respectively. ADJUSTMENT TO HEMODIALYSIS TREATMENT: A c t i v i t y l e v e l , mood states and severity of symptoms as measured by the a c t i v i t y inventory, p r o f i l e of mood states and symptom questionnaire, respectively. 1 6 . AGE: Chronological age as measured by the personal history questionnaire. ARTIFICIAL KIDNEY: A slang term which refers to the kidney machine, the connecting tubes and the dialyzer through which the patient's blood passes in order to maintain the f l u i d and chemical balance of the body. ARTIFICIAL KIDNEY TREATMENT: The process of maintaining the chemical and f l u i d balance of the blood when the patient's kidneys have f a i l e d . May refer to either hemodialysis or peritoneal d i a l y s i s treatment. CHRONIC: A medical term meaning prolonged, l a s t i n g for years. The word also t y p i c a l l y implies that the condition w i l l not be reversed. chronic renal or peritoneal CHRONIC DIALYSIS: The treatment of f a i l u r e through either hemodialysis d i a l y s i s . CHRONIC IN—CENTRE HEMODIALYSIS: Thrice weekly hemodialysis treatment in a health care f a c i l i t y . 1 7 . CHRONIC RENAL FAILURE: A c o n d i t i o n i n which t h e ki d n e y s have been d e s t r o y e d by d i s e a s e and cannot f u n c t i o n a d e q u a t e l y any l o n g e r . The term end stage r e n a l d i s e a s e has t h e same meaning as v e r y advanced c h r o n i c r e n a l f a i l u r e . DIALYSIS: The p r o c e s s of which waste p r o d u c t s are removed from the b l o o d . The waste p r o d u c t s a r e d i f f u s e d a c r o s s a semipermeable membrane i n t o t h e d i a l y s a t e . DIALYZER: The p a r t of t h e h e m o d i a l y s i s machine t h a t c o n t a i n s t h e semipermeable membrane t h r o u g h which b l o o d passes d u r i n g h e m o d i a l y s i s . DIET: A person's food i n t a k e . K i d n e y p a t i e n t s a re u s u a l l y recommended t o adhere t o a s p e c i a l d i e t i n or d e r t o reduce t h e amount of waste p r o d u c t s t h a t accumulate i n p a t i e n t s w i t h r e n a l f a i l u r e . EDUCATIONAL e d u c a t i o n as q u e s t i o n n a i r e . LEVEL: H e i g h t a s s e s s e d by of th e achievement i n p e r s o n a l h i s t o r y 1 8 . END-STAGE RENAL DISEASE: "Terminal, i r r e v e r s i b l e kidney f a i l u r e in which conservative management would not support l i f e " (Reichsman and Levy, 1974). HEMO: Blood. HEMODIALYSIS: The process of using an a r t i f i c i a l kidney to remove waste products from the blood. The blood i s cir c u l a t e d through a semipermeable membrane with exposure to a suitable s a l t solution. HOME DIALYSIS: Self-care d i a l y s i s treatment of chronic renal f a i l u r e at the patient's home. Usually a spouse as s i s t s the patient in th i s process. KIDNEY: One of two such organs which are located in the middle of the back, one on each side cf the spine. They function to maintain the chemical balance of the body. KIDNEY TRANSPLANTATION: The removal of a kidney from either an unrelated deceased person or from a l i v i n g r e l a t i v e of the patient, and s u r g i c a l l y placing t h i s new kidney into the patient with kidney f a i l u r e . 1 9 • LENGTH OF TIME ON DIALYSIS: Number of months on d i a l y s i s . MOOD STATES: Aff e c t i v e states as measured by the p r o f i l e of mood states. OCCUPATIONAL LEVEL: Rank of occupation as assessed by the personal history questionnaire. PERITONEAL DIALYSIS: A form of d i a l y s i s in which, instead of using a dialyzer as in hemodialysis, the l i n i n g of the patient's abdomenal cavity, or the peritoneum i s used as the semipermeable membrane. RENAL: Having to do with the kidneys. SEMIPERMEABLE MEMBRANE: A thin layer of material which has many very small pores or gaps. Waste products are able to pass out from the blood through these pores, but blood c e l l s are too large to escape. SEVERITY OF SYMPTOMS: The severity of various symptoms common among d i a l y s i s patients, as measured by the symptom questionnaire. UREMIA: A condition associated with kidney f a i l u r e and the buildup of waste products in the blood. CHAPTER II REVIEW OF THE LITERATURE In spite of the large body of research concerning adjustment to hemodialysis, there i s limited informa-tion as to the relat i o n s h i p of demographic variables to t h i s adjustment. Even less research has examined how the demographic variables of age, occupation, education and length of time on d i a l y s i s are related to the a c t i v i t y l e v e l s , mood states and physical symptoms of these patients. Not only have very few studies focused s p e c i f i c a l l y on these relationships, but l i t t l e research i s even p a r t i a l l y relevant to these areas of concern. As scarce as the pertinent research on these relationships has been, a review of the available l i t e r a t u r e i s helpful in showing the need for t h i s study. 21 AGE Research on the factors predictive of adjustment to d i a l y s i s began i n i t i a l l y in order to establish ob-jective c r i t e r i a for patient selection, an unfortunate r e a l i t y in the early years of hemodialysis when the demand for treatment far exceeded the resources available (Maher et a l . 1983). Although i t seems that none of the demographic variables of t h i s study have been the subject of more than a small number of investigations, age as a factor in adjustment has perhaps been of more interest because of i t s use as a primary selection c r i t e r i o n (Blodgett, 1981-82). It was generally assumed that older patients would have p o t e n t i a l l y greater adjustment d i f f i c u l t i e s and poorer survival rates than younger patients (Blodgett, 1981-82). Older patients were also consid-ered to be poorer candidates than younger patients for subsequent renal transplantation (Cohen et a l . 1970). Such views were r e f l e c t e d in the fact that, prior to 1972, patients under 18 and over 50 were t y p i c a l l y excluded from d i a l y s i s treatment (Kutner and Cardenas, 1981). 22 . The limited information concerning the influence of age on adjustment to hemodialysis and survival rates, however, seems to be of a contradictory nature. For instance, a number of studies (Lewis , E.J., Foster, D.M., De La Puete, J. and Scurlock, C. 1969; Samuels, S., Charra, B., Olheiser, K. and Blagg, C, 1974; Henari, F.Z., Gower, P.E., Curtis, J.R., Eastwood, J.B., P h i l l i p s , M.E., Greatbatch, M.L., Williams, G.B., Gordon, E.M., Boyd, P.J.R., Stubbs, R.K.T. and De Wardener, H.E. 1971; Gurland, H.J., Wing, A.J., Jacobs, C. and Brunner, F.P. 1978; Kutner and Cardenas 1981) have reported that age was inversely related with s u r v i v a l . In contrast, other investigations (Cohen et a l . 1970; Foster et a l . 1973; and Adler. 1975) have found that age i s not s i g n i f i c a n t l y correlated with s u r v i v a l . Walker, P.J., Ginn, H.E., Johnson, H.K., Stone, W.J., Teschan, P.E., Latos, D., Stouder, D., Lamberth, E.L. and O'Brien, K. (1976) discovered that patients over 50 had approximately the same rate of survival as younger persons for the f i r s t three years. After the i n i t i a l three years, however, the older patients had a s i g n i f i c a n t l y higher mortality rate than the younger ones. 23 . AGE AND SEVERITY OF SYMPTOMS The limited amount of data related to the influence of age on the severity of symptoms experienced by these patients appears to be in disagreement. Two studies seem to support the view that older patients experience more physical symptoms of d i a l y s i s than younger patients. Meldrum, M.W. , Wolfram, J.G. and Rubini, M.E. (1968) did an early study of 24 veteran patients in the United States. Employing a scale of 3.0 (1 = suboptimum, 2 = average, 3 = exemplary), a rating team consisting of a psy c h i a t r i s t , two physicians, the d i a l y s i s nurse in charge, and a s o c i a l worker, re-evaluated the source materials on each patient. They reported that the medical results not limited to symptoms common in chronic renal f a i l u r e were poorer in the older group of patients (40 or above) than in the younger group (20 to 39). Sim i l a r l y , an investigation involving 85 patients in Scotland (Livesley, 1981) revealed that somatic symptoms (somatic concomitants of anxiety) occurred more frequently in old patients. However, contrary r e s u l t s were obtained by two other studies. No s i g n i f i c a n t c o rrelation was found between age category and the medical outomes of 137 American patients in an investigation by Kutner and Cardenas (1981). The patients medical outcomes were evaluated through a semi-structured interview (in which they were asked about t h e i r average weight gain between treatments; the usual amount of time required to "recover" following d i a l y s i s ; d a i l y hours spent in sleep, rest and sedentary le i s u r e ; and how they f e l t on a r i s i n g , at midday and on r e t i r i n g ) , a s e l f - r a t i n g scale (which was partly concerned with t h e i r present medical situation) a subset of the Hester Evaluation System (used to investigate cognitive motor func-tioning of the patients) and through muscle strength te s t grades assigned by a physical therapist. Procci (1981), employing the Ruesch Social D i s a b i l i t y Scale, which provides a subscore for physical impairment (determined by an assessment of a l l physical diagnosis and affected organ systems and the physical functions altered), found that among the 21 patients in his investigation, age was not s i g n i f i c a n t l y correlated with s o c i a l d i s a b i l i t y . AGE AND ACTIVITY LEVELS The information relevant to the relationship between age and the a c t i v i t y levels of hemodialysis patients i s contradictory. The r e s u l t s of some reports tend to support the b e l i e f that older patients have decreased a c t i v i t y l e v e l s . One study (Meldrum et a l . 1968) indicated that older patients did more poorly in s o c i o l o g i c a l and vocational r e h a b i l i t a t i o n than younger patients. Huber, W. , Strauch-Rahauser, G., Werner, J., Hafner, H. and Strauch, M. (1972), in t h e i r study of 179 patients in Germany through the use of a standardized questionnaire, and Kutner and Cardenas (1981) also reported an inverse relationship between age and vocational r e h a b i l i t a t i o n . Even more noteworthy perhaps, a survey of 2,481 patients by Gutman et a l . (1981) revealed that older patients engaged in less physical a c t i v i t y . De-Nour (1982) in a study of 102 patients observed that age appeared to influence the maintenance of involvement in s o c i a l a c t i v i t i e s . Although, De-Nour and Czaczkes (1974) discovered that low functioning was the most frequent in the youngest group (under 20) i t was also common in the oldest age group (50 years and over). In addi-ti o n , they noted that patients had s i g n i f i c a n t l y more problems in t h e i r s o c i a l l i v e s than those between ages 3 0 and 49. Other investigations have found no s i g n i f i c a n t c o r r e l a t i o n between age and a c t i v i t y l e v e l s . A number of studies (Cohen et a l . 1970, De-Nour and Czaczkes 1975, De-Nour et a l . 1977-78) discovered l i t t l e correspondence between age and vocational r e h a b i l i -t a t i o n . O'Brien (1980), in a study of 126 patients, and Procci (1981) in his examination of 21 patients, indicated that s o c i a l functioning and s o c i a l d i s -a b i l i t y , respectively, were not s i g n i f i c a n t l y influenc-ed by age. S t i l l other studies (Sviland 1972, Malmquist 1973, Adler 1975, and Olsen 1983) have reported no s i g n i f i c a n t r elationship between age and adjustment in general. In stark contrast to the data which corroborates the view that older patients have decreased a c t i v i t y , one study (Csaczkes and De-Nour, 1978) actually found that vocational r e h a b i l i t a t i o n improved with age. Such a finding seems to underscore the contradictory nature of the existing l i t e r a t u r e in t h i s area. AGE AND MOOD STATES There i s , again, considerable disagreement among studies related to the cor r e l a t i o n between age and mood states. On the one hand, several studies found no s i g n i f i c a n t c o rrelation between psychological prob-lems and age. In a study of 12 patients, Fishman and Schneider (1972) discovered that age did not influence " f i r s t year emotional adjustment". De-Nour and Czaczkes (1974), reported that depression among the 83 patients in t h e i r study increased with age, but not at a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l . They also observed no clear-cut relationship between anxiety and age. In one study (Foster et a l . 19 73), 14 survivors on hemo-d i a l y s i s were compared with 7 patients who had died and no psychological difference according to age was observed. S t a t i s t i c a l l y i n s i g n i f i c a n t c o e f f i c i e n t s were also obtained by Procci (1981) when he correlated age with the s o c i a l d i s a b i l i t y scores of the 21 pa-ti e n t s in his study. (The Reusch Social D i s a b i l i t y Scale used by Procci in t h i s study provides a subscore for an assessment of a l l psychiatric diagnosis and the type and degree of psychopathology). In her meta-analysis of 40 empirical studies related to variables 28 . predictive, of adjustment to hemodialysis, Olsen (1983) found that age was not s i g n i f i c a n t l y correlated with adjustment. On the other hand, data generated by other studies suggests that older patients tend to have more psychological problems than younger patients. Czaczkes and De-Nour (1978), in t h e i r study of 47 patients in I s r a e l , found that psychiatric compli-cations were more common among older patients. In p a r t i c u l a r , they discovered that s u i c i d a l tendencies among these patients increased with age. S i m i l a r l y , Kutner and Cardenas (1981) reported that patients age 55 and older were more l i k e l y than other age groups to evidence depressive symptoms. They also noted that of the 137 patients in t h e i r study those between ages 25 and 34 had the best o v e r a l l adjustment to hemodialysis treatment. F i n a l l y , Livesley (1981), through c o r r e l a -t i n g the ages and psychiatric symptoms of the 85 patients in his study, discovered that somatic symp-toms occurred more frequently in older patients. 29 . CCCLTPATION As mentioned e a r l i e r , a widespread assumption exists within the medical community that patients of higher occupational levels tend to adjust better to hemodialysis treatment than patients with lower job status (Strauch et a l . 1971, and Levy 1976). Despite t h i s commonly held opinion, there i s a conspicuous dearth of research documenting the influence of occupa-tion upon adjustment to hemodialysis. OCCUPATION AND SEVERITY OF SYMPTOMS A review of the l i t e r a t u r e turned up only two studies which have obtained information relevant to the relationship between occupation and the severity of symptoms experienced by hemodialysis patients. Both investigations appear to suggest that severity of symptoms i s not s i g n i f i c a n t l y related to occupational l e v e l . Huber et a l . (1972), in t h e i r questionnaire study of 179 patients in Germany found that "severity of symptoms did not d i f f e r s i g n i f i c a n t l y between so c i a l ranks " (which were determined on the basis of occupation). Also, using a questionnaire p a r t i a l l y designed to measure somatic concomitants of anxiety, Livesley (1981) discovered that occupation was not s i g n i f i c a n t l y related to questionnaire scores. OCCUPATION AND ACTIVITY LEVELS There seems to be a consensus among the pertinent studies in support of the b e l i e f that patients of higher job status tend to have greater a c t i v i t y levels than patients of lower occupational l e v e l . Walker et a l . (1976) discovered that professionals, white-collar workers, and the self-employed had excellent voca-t i o n a l r e h a b i l i t a t i o n , while blue-collar workers tended to have poor levels of vocational r e h a b i l i t a t i o n . Short and Alexander (1969) noted that patients who had been employed in sedentary jobs did better in maintaining employment than those with manual jobs. A questionnaire study of 179 patients by Huber et a l . (1972) revealed that the higher the s o c i a l rank, the lower the degree of professional disablement and vice versa. S i m i l a r l y , O'Brien (1980) observed that u n s k i l l e d workers generally reported the lowest s o c i a l functioning and those at the professional l e v e l the highest. 31 OCCUPATION AND MOOD STATES Information relevant to the correlation between the mood states of hemodialysis patients and occupa-t i o n a l l e v e l appears to have been generated by only one study. Livesley (1981) employed a questionnaire which contained subscales r e l a t i n g to various neurotic syndromes and found that " s o c i a l class, coded from occupation, was not s i g n i f i c a n t l y related to question-naire scores." This finding would seem to suggest that a s i g n i f i c a n t r elationship between occupational l e v e l and mood states does not exist. EDUCATION Just a handful of studies has attempted to document the corr e l a t i o n between education and adjustment to hemodialysis. When one considers the broadly maintained view in the medical profession, as previously indicated, that education (De-Nour and Czaczkes 1974, and Olsen 1983) tends to influence adjustment to hemodialysis, the sca r c i t y of i n f o r -mation in t h i s area i s somewhat bewildering. Further-more, the small number of pertinent studies that do exist seem to be at odds. 32 . EDUCATION AND SEVERITY OF SYMPTOMS It seems that- no e f f o r t s have been made to investigate the relationship between the severity of symptoms experienced by hemodialysis patients and education. EDUCATION AND ACTIVITY LEVELS Data relevant to the influence of education on the a c t i v i t y levels of patients undergoing hemo-d i a l y s i s have been gathered by a few studies. Although some of these investigations are contra-dictory, the majority of them appear to substantiate the impression that education i s p o s i t i v e l y correlated with a c t i v i t y l e v e l s . The f i r s t study to seemingly support t h i s view was conducted by Meldrum et a l . in 1968. They found a s i g n i f i c a n t positive correlation between education and the vocational and s o c i a l adjustment. Several other researchers (Short and Alexander 1969, Huber et a l . 1972, De-Nour and Czaczkes 1974, De-Nour et a l . 1977-78, and Gutman et a l . 1981) discovered that patients with higher education had a greater degree of vocational reha-b i l i t a t i o n than patients with less education. Education was also found to be p o s i t i v e l y correlated at a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l with successful adaptation to hemodialysis in a study by Alder (1975). This researcher studied 62 male chronic hemodialysis patients, 33 of whom were successfully adapted and 29 of whom were unsuccessfully adapted. In order to be considered successful, the patients in t h i s study had to meet one of the following c r i t e r i a : i) be on home d i a l y s i s , i i ) be presently employed, or i i i ) be p a r t i c i p a t i n g in an a c t i v i t y outside the home. Most recently, O'Brien (1980) discovered that patients with more education had higher levels of so c i a l functioning. Two studies, however, appear to suggest that the a c t i v i t y levels may not be s i g n i f i c a n t l y correlated with education. In 1975, De-Nour and Czaczkes gathered information on 50 male patients in Israel and found that education did not influence vocational r e h a b i l i t a t i o n s i g n i f i c a n t l y . In addition, Olsen (1983) discovered that education was not a s t a t i s t -i c a l l y s i g n i f i c a n t predictor of adjustment to hemodialysis. EDUCATION AND MOOD STATES There appears to be only a scanty number of investigations which have generated information 34 . pertinent to the relationship between mood states and education. The majority of t h i s research seems to indicate that a s i g n i f i c a n t c o r r e l a t i o n between education and the mood states of these patients does not exist. I t was observed by Fishman and Schneider(1972) that education did not influence " f i r s t year emotional adjustment". Foster et a l . (1973) compared 14 survivors on hemodialysis with 7 patients who died on t h i s treatment and found no psychological differences between these two groups with respect to age. Additionally, r e s u l t s consistent with these findings, as mentioned before, were documented by Olsen (1983), who reported that education was not s i g n i f i c a n t l y correlated with overall adjustment to hemodialysis (even though i t did approach s t a t i s t i c a l s i g n i f i c a n c e ) . The single investigation which p a r t i a l l y f a i l e d to corroborate the above studies was conducted by De-Nour and Czaczkes (1974). They found that patients with higher education suffered from anxiety more often than patients with less education. Interestingly, they also discovered that frequency of depression and other psychiatric complications was not influenced by education. LENGTH OF TIME Blodgett (1981-82) has asserted that on c l i n i c a l grounds, length of time on d i a l y s i s i s a powerful influence on adjustment. Yet, very l i t t l e attention has been given to t h i s issue. The shortage of informa-ti o n in t h i s area, Blodgett (1981-82) believes, stems par t l y from the limited research methodology employed in most investigations of adjustment to d i a l y s i s and to a certain extent from an assumption that, in general, adjustment i s more a s t a t i c than dynamic process. Moreover, the few studies that have been done, report contradictory findings. LENGTH OF TIME AND SEVERITY OF SYMPTOMS The only apparent study of the relationship between length of time on d i a l y s i s and the severity of symptoms experienced by patients on hemodialysis was conducted by Procci (1981). He discovered "no s i g n i f i c a n t increase in the degree of physical impairment with the chronicity of i l l n e s s " . These results seem to suggest that severity of symptoms i s not s i g n i f i c a n t l y correlated with the length of time on d i a l y s i s . 36. LENGTH OF TIME AND ACTIVITY LEVELS There i s disagreement among the relevant invest-igations as to the influence of length of time in treatment upon the a c t i v i t y levels of hemodialysis patients. Two studies seem to suggest that there i s not a s i g n i f i c a n t c o r r e l a t i o n between these variables. Length of time on d i a l y s i s was found to be not s i g n i f i -cantly related to s o c i a l functioning (O'Brien 1980) or ove r a l l adjustment to hemodialysis (Olsen 1983). Another two investigations appear to support the view that patients reach a stable l e v e l of a c t i v i t y after a period of time. Huber et a l . (1972) witnessed an increasing degree of vocational disablement p a r t i c u -l a r l y among subjects in t h e i r second and t h i r d year of hemodialysis. However, there was no additional increase of disablement in the subjects dialyzed for more than three years. Somewhat d i f f e r e n t l y , De-Nour and Czaczkes (1975) noted that after approximately six months, the 50 male patients in t h e i r study reached stable levels of vocational r e h a b i l i t a t i o n and medical compliance, with l i t t l e subsequent change to that l e v e l . 37 . Inconsistent with the above findings, a study by Procci (1981) appears to denote an inverse r e l a t i o n -ship between length of time on d i a l y s i s and the a c t i v i t y levels of these patients. His investigation indicated that in spite of the l i t t l e apparent r e l a -tionship between chronicity of i l l n e s s and s o c i a l d i s a b i l i t y for patients with f i v e or fewer years of hemodialysis, there was a s i g n i f i c a n t increase in over-a l l d i s a b i l i t y scores for patients with more than fiv e years of treatment. This data suggests, as Procci pointed out, that as the length of time on hemo-d i a l y s i s increases, the patient gradually experiences more and more psychosocial disablement. LENGTH OF TIME AND MOOD STATES With the apparent exception of one study, the available, and again limited, data seems to indicate that the psychological problems among these patients tend to increase with the length of time on hemo-d i a l y s i s . In 1965, Shea and her associates discovered that the longer the 13 patients in her study were undergoing treatment, the less tolerance (on a psychological level) they had for the treatment. 38 . Blakely's (1977) study suggested that anxiety among these patients increased with the amount of time in d i a l y s i s treatment. A more compelling finding was generated by Maher et a l . (1983) who reported that shorter time on d i a l y s i s was associated with lower depression and hysteria scores on the MMPI. Contrary to the above r e s u l t s , Procci (1981) found no s i g n i f i c a n t r e l a t i o n s h i p between psychiatric d i f f i c u l t i e s and chronicity of i l l n e s s . I t i s note-worthy, however, that he did observe (as previously discussed) a relationship between chronicity of i l l -ness and the degree of psychosocial impairment experienced by these patients. 39 . CHAPTER III METHODOLOGY SUBJECTS The sample for t h i s research consisted of 37 patients who were undergoing hemodialysis treatment at two separate medical centres in the Los Angeles area: the Long Beach Veteran's Administration Medical Centre and the Sky Park Medical Centre. The 46 patients at the two centres who had been on hemodialysis a minimum of 6 months were approached for p a r t i c i p a t i o n in the study. Four .patients declined to participate for per-sonal reasons and data col l e c t e d on 5 other patients was incomplete. The age range of the patients was from 30 to over 70 years, with the mean age in the 50's. Twenty-nine of the subjects were male, 8 were female. There were caucasion, black, asian and hispanic subjects in the sample. The levels of education attained by the subjects varied from less than 7 to 16 or more years with a mean of approximately 12 years. Their occupational levels spanned from career o f f i c e r , career enlisted or unskilled worker to administrative personnel, owners of concerns and professionals. The mean length of time on d i a l y s i s was 42.55 months, although the rage was from 6 months to over 144 months (over 12 years). INSTRUMENTS The measurements of the a c t i v i t y l e v e l s , mood states and severity of symptoms of the subjects were based on information col l e c t e d from the a c t i v i t y inventory (Al), p r o f i l e of mood states (POMS) and the symptom questionnaire (SQ). Data gathered by the personal history questionnaire were used to assess the subjects on the demographic variables of age, occupa-t i o n a l l e v e l , educational l e v e l and length of time on d i a l y s i s . A psychologist with experience in working with the d i a l y s i s population administered these meas-ures o r a l l y over 3 or 4 sessions while the.subjects were undergoing the hemodialysis procedure. With the majority of the subjects, one instrument was admin-istered per session (some subjects, however, were unable, for various reasons, to complete a measure in 41 a single session). The instruments were administered in the following order: (1) the personal history questionnaire, (2) the p r o f i l e of mood states, and (3) the symptom questionnaire. PERSONAL HISTORY QUESTIONNAIRE The Personal History Questionnaire (Appendix A) was constructed to obtain the demographic information on the subjects as well as gather data on t h e i r per-sonal h i s t o r i e s and present situations. The coding for age, occupational l e v e l , educational l e v e l and length of time on d i a l y s i s was designed to provide a quantitative measurement of the subjects on these variables. Age was coded as follows: 1 = 20-29; 2 = 30-39; 3= 40-49; 4 = 50-59; and 6 = 70+. Occupational le v e l had the following coding: 1 = administrative personnel, owners of concerns and professionals; 2 = owners of small business, sales, c l e r i c a l and tech-n i c a l positions; 3 = s k i l l e d workers; 4 = semi-skilled workers; 5 = unsk i l l e d workers; 6 = career enlisted; and 7 = career o f f i c e r . Educational l e v e l was coded in t h i s manner: 1 = less than 7 years; 2 = 7-9 years; 3 = p a r t i a l highschool or trade school; 4 = highschool or trade school; 5 = p a r t i a l college or university; 6 = college or university graduate; and 7 =16+ years. F i n a l l y , length of time on d i a l y s i s was coded in number of months. PROFILE OF MOOD STATES The POMS (Appendix B) was developed to indentify and assess transient, fluctuating a f f e c t i v e states. This instrument measures six i n d e n t i f i a b l e mood or a f f e c t i v e states: tension-anxiety; depression-dejection; anger-hostility; v i g o r - a c t i v i t y ; fatigue-i n e r t i a ; and confusion-bewilderment. The question-naire contains 65. items, each an adjective or a phrase which describes a f e e l i n g or mood. The subjects were asked to rate the degree to which each item described t h e i r feelings over the past week (including the day they f i l l e d out the question-naire) on a 5-point scale (0 = not at a l l , 1 = a l i t t l e ; 2 = moderately; 3 = quite a b i t ; 4 = extremely). Thus, the higher the scores for the six mood or a f f e c t i v e states the more they are experienced by the subject. Because mood or a f f e c t i v e states actually exist on a continuous scale, there i s a certain amount of error implied in using discrete measurements. However, l i k e other questionnaires of 43 . t h i s type, the POMS has b u i l t in a degree of redundancy among the 65 items in an attempt to overcome t h i s error. POMS INTERNAL CONSISTENCY Data from the patient normative samples in a study of 350 male psychiatric outpatients and in a study of 650 female psychiatric outpatients, revealed internal consistency r e l i a b i l i t y c o e f f i c i e n t s (K-R20) ranging from .84 to .95 in the various factors (McNair et a l . 1971). A l l these indices are near .90 or above and are therefore highly s a t i s f a c t o r y . POMS TEST-RETEST RELIABILITY Approximately 60% of the 1,000 patients from the normative samples were accepted for treatment at a university medical psychiatric c l i n i c . The patients who entered treatment were reassessed on the POMS immediately prior to t h e i r f i r s t therapy session after having received s i x weeks of treatment. In order to estimate t e s t - r e t e s t s t a b i l i t y , the f i r s t 100 patients who remained in treatment at least six weeks were selected. This sample was composed of 44 . approximately two-thirds female and one t h i r d male. Product-moment correlations among t h e i r POMS scores were computed and revealed s t a b i l i t y c o e f f i c i e n t s (rtt) for the six POMS factors scores ranging from .43 to .74. It should be noted that the correlations between the POMS scores at intake and at pretreatment intake, (which ranged from .65 to .74), provide a rough estimate of s t a b i l i t y without the intervention of treatment. Although the obtained s t a b i l i t y c o e f f i -cients are considerably lower than the .80 to .90 levels expected of measures of stable personality t r a i t s , such levels would hardly be expected of a fluctuating a f f e c t i v e state l i k e mood. These t e s t - r e t e s t c o e f f i c i e n t s are consistent with those reported for an e a r l i e r version of the POMS. McNair and Lorr (1964) studied 150 VA outpatients who were tested at intake and after four weeks of treatment. The te s t - r e t e s t r e l i a b i l i t y for the six factors ranged from .61 to .69. POMS VALIDITY The six factor analytic r e p l i c a t i o n s (McNair et a l . 1971) done in the development of the POMS give support to the f a c t o r i a l v a l i d i t y of the six mood factors. Remarkably congruent results were reported for the di f f e r e n t patient and normal samples for the 4-point and 5-point scales and for the d i f f e r e n t rating time periods. A study by Lorr, Daston, and Smith (1967) also i d e n t i f i e d eight mood factors in the POMS. The face or content v a l i d i t y of the factor scores i s supported by an examination of the individual items defining each mood scale. Additionally, evidence for the predictive and construct v a i l i d i t y of the POMS has been provided by four areas of research: (1) short-term psychotherapy; (2) controlled c l i n i c a l drug t r i a l s ; (3) investigations of response to emotion-inducing conditions; and (4) research on concurrent v a l i d i t y c o e f f i c i e n t s and other POMS correlates. A number of reports (Lorr, McNair, Weinstein, Michaux and Raskin, 1961; Lorr, McNair and Weinstein, 1964; Haskell, Pugatch and McNair, 1969) have shown one or more of the POMS factor scores to be sensitive to change associated with psychotherapy. Several studies of controlled c l i n i c a l drug t r i a l s (Lorr, McNair and Weinstein, 1964; McNair, Goldstein, Lorr, C i b e l l i , and Roth, 1865; McNair, Kann, Droppleman and Fisher, 1967, 1968; McNair, Fisher, Sussman, 46 . Droppleman and Kahn, 19 70; and McNair, Fisher, Kahn and Droppleman, 1970) suggest that the factors in the POMS are sensitive to short-term change associated with mild t r a n q u i l i z e r s . The s e n s i t i v i t y of the POMS factor scores to mood changes has been demonstrated in a number of studies of emotion-inducing conditions ( P i l l a r d and Fisher, 1967; P i l l a r d , Atkinson, and Fisher, 1967; Fisher, P i l l a r d , and Yamada, 1968; P i l l a r d and Fisher, 1970;Nathan, Zare, Ferneau, and Lowenstein, 1970; Nathan, T i t l e r , Lowenstein, Solomon, and Rossi, 1970; and Mirin, Shapiro, Meyer, P i l l a r d , and Fisher, 1971). F i n a l l y , evidence for the predictive and construct v a l i d i t y of the POMS has been generated by studies of concurrent v a l i d i t y c o e f f i c i e n t s and other POMS correlates (McNair, Lorr, and Droppleman, 1971). USE OF THE POMS IN OTHER CLINICAL STUDIES Although i t seems that the POMS has not been previously used with the d i a l y s i s population, i t has 47 . been u t i l i z e d successfully with other groups of patients. S t i t t , Frane and Frane (1977) used the POMS to investigate mood change in rheumatoid a r t h r i t i s patients. I t was found that, although the POMS was developed to measure the mood states of other populations, i t i s useful with patients suffering from chronic disease. In another study the POMS was u t i l i z e d with medically i l l patients (Soloff and Bartel 1979). In t h e i r investigation t h i s instrument proved successful in assessing the moods of patients with coronary artery disease. These studies and the apparent face v a l i d i t y that the POMS has for the d i a l y s i s population suggest that the POMS could be effe c t i v e in measuring the moods of patients under-going hemodialysis treatment. SYMPTOM QUESTIONNAIRE The SQ (Appendix C) i s designed to semi-quantitatively assess the severity of various symptoms common among d i a l y s i s patients. Thirteen such symptoms were examined by the questionnaire. Of these symptoms, 9 were related to 48 . the nervous system: sleep, concentration, fatigue, restlessness, a c t i v i t y , appetite, neuropathic symptoms (for example, numbness, burning sensations), headache and pruritus. The remaining 4 symptoms are associated with body f l u i d volume, blood coagulation, cardiac compensation or c a p i l l a r y i n t e g r i t y : muscle cramps, bruising or bleeding, edema and dypsnea. For each symptom four short statements were presented indicating a range from minimal (1) to severe (4). These statements appeared in 65 pairs on a six-page questionnaire. Five pairs of statements (1 vs. 2, 1 vs. 3, 2 vs. 3, 2 vs. 4, and 3 vs 4) repre-sent each symptom and are printed in random order in the questionnaire. The subjects were asked to select the member of each pair that most suitably described his or her perception of the symptom. Each symptom was represented by a score (0 to 5) indicating the number of times the subject chose the more severe statement of the pairs r e l a t i n g to a given symptom. Therefore, the higher the scores for each symptom the greater the severity of the symptom. 49 . SQ VALIDITY AND RELIABILITY A review of the l i t e r a t u r e revealed no apparent studies on the v a l i d i t y or r e l i a b i l i t y of the SQ. However, an examination of the individual items de-fi n i n g the symptom scales in the measure supports i t s face or content v a l i d i t y . USE OF THE SQ IN OTHER CLINCAL STUDIES Other c l i n i c a l studies have reported the product-ive use of the SQ in measuring the severity of sympt-oms common to d i a l y s i s patients. A study by Maher et a l . (1983) employed the SQ as part of t h e i r investiga-tion of the psychosocial aspects of chronic hemodial-y s i s . They asserted that t h i s measure provided a maximally objective estimate of the severity of the symptoms which i t i s designed to assess. The SQ was also u t i l i z e d as one of the four assessment tools in a study of Ele c t r o p h y s i o l g i c a l and neurobehavioural responses to therapy reported by Teschan et a l . (1983). The SQ, they indicated, was one of the devices selected by the National Cooperative D i a l y s i s Study to be used in providing quantitative measure-ments of abnormality among d i a l y s i s patients. 50 . ACTIVITY INVENTORY The Activity ' Inventory (Appendix A) is part of the personal history questionnaire developed as a means of assessing the extent to which the subject's present activity levels differ from their activity levels prior to kidney failure. The l i s t of activities by which the subjects indicate their past and present activity levels includes: pleasure walking, lawn care, gardening, housecleaning, swimming, dancing, bicycling, bowling, golf and tennis. Accompanying this l i s t are two columns, one in which they are asked to indicate which of the listed items they did in the past, and the other in which they are requested to record which of these activities they have been engaged in recently (over the last 3 months). On the basis of this data, the percentage of former activities that each subject s t i l l does wi l l be calculated. These percentages wi l l then be assigend to the subjects as their activity level scores. 51 ACTIVITY INVENTORY AND THE STANDARDIZATION ISSUE This assessment tool was designed s p e c i f i c a l l y for t h i s study. No attempt was made to standardize t h i s instrument. It was developed simply to provide a rough estimate of the past and present a c t i v i t y levels of the subjects. Although no research has been done on the v a l i d i t y and r e l i a b i l i t y of t h i s measure, i t does contain some face v a l i d i t y . STATISTICAL ANALYSIS The data w i l l be analyzed using the Pearson Product-Moment Correlation method. This s t a t i s t i c a l technique was selected because i t has a smaller standard of error than the other bivariate analysis methods. In order to determine the s t a t i s t i c a l s i g n i f i -cance of the obtained correlation c o e f f i c i e n t s , and ultimately to establish a basis for rejecting the n u l l hypothesis, a 1-tailed t e s t of s t a t i s t i c a l s i g n i f i -cance was employed (this l e v e l of significance i s 52 . expressed as a pr o b a b i l i t y value p). The n u l l hypothesis w i l l be rejected at the .05 l e v e l of significance. 53 . CHAPTER 4  RESULTS ACTIVITY LEVELS AND DEMOGRAPHIC VARIABLES Hypothesis 1: There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n s between the s e l f - r e p o r t e d a c t i v i t y l e v e l s (as measured by the a c t i v i t y inventory) of p a t i e n t s undergoing hemodialysis treatment and the demographic v a r i a b l e s of age, occupation, education and len g t h of time on d i a l y s i s . The c o r r e l a t i o n c o e f f i c i e n t between the a c t i v i t y l e v e l s and age was r = -.3531, p = .016. Because t h i s c o r r e l a t i o n i s s i g n i f i c a n t , we may r e j e c t the n u l l hypothesis as i t p e r t a i n s t o t h i s p a r t i c u l a r s e t of v a r i a b l e s . The remaining demographic v a r i a b l e s ( i . e . occupation, education and length of time on d i a l y s i s ) , however, were not s i g n i f i c a n t l y c o r r e l a t e d with a c t i v i t y l e v e l ( t a b l e 4-1). Thus, f o r these p a i r s of v a r i a b l e s , we accept the n u l l h y p o t h e s i s . TABLE 4-1 CORRELATIONS BETWEEN DEMOGRAPHIC VARIABLES AND VARIOUS ASPECTS OF ADJUSTMENT TO HEMODIALYSIS MONTHS ON AGE OCCUPATION EDUCATION DIALYSIS ACTIVITY -.3531 .0708 .1386 .1239 INVENTORY P= .016 P = .339 P= .207 P = .232 TENSION/ -.0874 -.2033 .0468 .2143 ANXIETY P= .303 P=. .'114 P= .392 P= .101 DEPRESSION/ -.2533 -.0744 .0134 .0247 DEJECTION P= .065 P= .331 P= .469 P= .442 ANGER/ -.2577 -.0614 .0799 .1868 HOSTILITY P= .062 P= .359 P= .319 P= .134 VIGOR/ -.2161 -.0059 .1770 .0194 ACTIVITY P= .099 P= .486 P= .147 P= .455 FATIGUE/ .0512 -.0009 -.0369 -.0941 INERTIA P= .382 P= .498 P= .414 P= .290 CONFUSION/ -.2892 -.0778 .0170 .2466 BEWILDERMENT P= .041 P= .324 P= .460 P= .071 TOTAL MOOD -.1290 -.0889 -.0154 .0960 DISTURBANCE P= .223 P= .300 P= .464 P= .286 APPETITE .2541 .0184 -.0491 -.0390 P= .065 P= .457 P= .387 P= .409 BRUISING OR .1578 -.0084 -.3723 .0373 BLEEDING P= .175 P= .480 P= .012 P= .413 SHORTNESS .1226 -.0184 -.3326 .0056 OF BREATH P= .235 P= .457 P= .022 P= .487 FATIGUE .4104 .2102 -.4954 -.3255 P= .006 P= .106 P= .001 P= .025 PEARSON PRODUCT-MOMENT CORRELATION COEFFICIENTS 37 CASES 1 - TAILED TEST OF SIGNIFICANCE TABLE 4-2 CORRELATIONS BETWEEN DEMOGRAPHIC VARIABLES AND  VARIOUS ASPECTS OF ADJUSTMENT TO HEMODIALYSIS AGE OCCUPATION MONTHS ON EDUCATION DIALYSIS MUSCLE CRAMPS .0050 .1284 P= .488 P= .224 -.2591 -.3524 P= .061 P= .016 HEADACHES .0996 .3787 P= .279 P= .010 -.2935 .0117 P= .039 P= .473 SLEEP PROBLEMS .1457 .2585 P= .195 P= .061 -.2977 -.0663 P= .037 P= .348 ITCHING . 1 342 .1 1 1 5 P= .214 P= .256 -.2731 -.1981 P= .051 P= .120 DEPRESSION .0197 -.0431 p= . 4 5 4 p= .400 -.3053 -.2114 P= .033 P= .105 ACTIVITY LEVEL .3358 .1643 P= .021 P= .166 -.4532 -.1263 P= .002 P= .228 RESTLESSNESS -.1273 .0852 P= .226 P= .308 -.1434 -.1319 P= .199 P= .218 CONCENTRATION .0782 -.0868 P= .323 P= .305 .3157 .3897 P= .029 P= .009 NUMBNESS .0607 .1576 P= .361 P= .176 -.2189 -.0565 P= .097 P= .370 SEX ,=.2205 .1624 P= .095 P= .168 -.3876 -.2579 P= .009 P= .062 TOTAL SEVERITY .2600 .2198 OF SYMPTOMS P= .060 P= .096 -.5150 -.2148 P= .001 P= .101 PEARSON PRODUCT-MOMENT CORRELATION COEFFICIENTS 3 7 CASES 1 - TAILED TEST OF SIGNIFICANCE MOOD STATES AND DEMOGRAPHIC VARIABLES Hypothesis 2: There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t correlations between the mood states (as measured by the P r o f i l e of Mood states) experienced by patients undergoing hemodialysis treatment and the demographic variables of age, occupation, education and length of time on d i a l y s i s . A s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n c o e f f i c i e n t (r = -.2892, p = .041) was found between the scores on the confusion/bewilderment mood factor and age. Therefore, with respect to t h i s c o r r e l a t i o n c o e f f i c i e n t , we re j e c t the n u l l hypothesis. As can be seen on table 4-1, a l l other correlation c o e f f i c i e n t s between the mood states (on the six mood factors and the t o t a l mood disturbance) and the demographic v a r i -ables were s t a t i s t i c a l l y i n s i g n i f i c a n t . We must conse-quently accept the n u l l hypothesis regarding these sets of variables. I t should be noted however, that three of these co r r e l a t i o n c o e f f i c i e n t s approached s t a t i s t i c a l s ignificance. The correlation c o e f f i c i e n t between age and the depression/dejection factor was discovered to be -.2533, p = .065. A similar correlation c o e f f i c i e n t of -.2577, p = .062 was also found to exist between age and the anger/hostility factor. The t h i r d correlation c o e f f i c i e n t to approach s t a t i s t i c a l l y significance was between length of time on d i a l y s i s and the confusion/bewilderment. SEVERITY OF SYMPTOMS AND DEMOGRAPHIC VARIABLES Hypothesis 3 : There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t correlations between the severity of symptoms (as measured by the Symptom Questionnaire) experienced by patients undergoing hemodialysis treatment and the demographic .variables of age, occupation, education and length of time on d i a l y s i s . Education was found to have a correlation coefficent of r = -.5150, p = .001 with t o t a l severity of symptoms. As a re s u l t , we rej e c t the n u l l hypo-thesis concerning t h i s correlation c o e f f i c i e n t . Conversely, because the correlation c o e f f i c i e n t s between t o t a l severity of symptoms and the remaining demographic variables were s t a t i s t i c a l l y i n s i g n i f i -cant, (table 4-2) we must accept the n u l l hypothesis in reference to these sets of variables. S t a t i s t i c a l significance was approached however, in the cor-r e l a t i o n c o e f f i c i e n t of r = .2600, p = .060 between 58 . age and t o t a l severity of symptoms. The correlations between t o t a l severity of symptoms and the demographical variables i s r e f l e c t i v e of the correlation c o e f f i c i e n t s found between the individual symptoms and the demographic variables. Tables 4-1 and 4-2 show that education was s i g -n i f i c a n t l y correlated with bruising or bleeding (r = -.3723, p = .012), shortness of breath (r = -.3326, p = .022), fatigue (r = .4954, p = .001), headaches (r= -.2935, p = .039), sleep problems (r = -.2977, p = .037), depression (r = -.3053, p = .033), lowered a c t i v i t y levels (r = -.4532, p = .002), concentration d i f f i c u l t i e s (r = .3157, p = .029) and decreased sex drive ( r = -.3876, p = .009). We therefore, r e j e c t the n u l l hypothesis concerning these correlations c o e f f i c i e n t s . Appetite, muscle cramps, itching, restlessness and numbness were found not to be s i g n i f i c a n t l y correlated with education. Thus, for these sets of variables we are compelled to accept the n u l l hypo-thesis. Muscle cramps and itching, however, approached s t a t i s t i c a l significance in t h e i r correlation c o e f f i c i e n t s with education with correlation c o e f f i c i e n t s of r = -.2591, p = .061 and r = -.2731, p = .051, respectively). One can observe on tables 4-1 and 4-2 that length of time on d i a l y s i s was s i g n i f i c a n t l y correlated with fatigue (r = -.3255, p = .025), muscle cramps (r = -.3524, p = .016 and concentration problems (r = .3897, p = .009). As a consequence, we r e j e c t the n u l l hypothesis with regard to these co r r e l a t i o n c o e f f i c i e n t s . In contrast, the n u l l hypothesis must be accepted as i t pertains to the cor r e l a t i o n c o e f f i -cients between length of time on d i a l y s i s and the remaining symptoms. It should be noted that a c o r r e l a -t i o n of r = -.2579, p = .062, which approaches s t a t i s -t i c a l significance, was found between decreased sex drive and length of time on d i a l y s i s . Age was found to be s i g n i f i c a n t l y correlated with fatigue (r = .4104, p = .006) and lowered a c t i v i t y l e v e l (r = .3358, p = .021). The n u l l hypothesis i s therefore rejected with respect to these co r r e l a t i o n c o e f f i c i e n t s . Regarding the cor r e l a t i o n c o e f f i c i e n t s between age and the remainder of the symptoms, for which s t a t i s t i c a l l y s i g n i f i c a n t correlations were not discovered, we accept the n u l l hypothesis. Stat-i s t i c a l significance was approached by one of the symptoms, appetite, in i t s correlation (r = .2541, p = .065) with age. Only headaches (table 4-2) were s i g n i f i c a n t l y correlated with occupation (r = .3787, p = .010). While we rej e c t the n u l l hypothesis in reference to this correlation c o e f f i c i e n t , we are obliged to accept the n u l l hypothesis concerning the correlation c o e f f i c i e n t s between occupation and a l l of the other symptoms. Mention should also be made of the correlation c o e f f i c i e n t between sleep problems and occupation, which approached s t a t i s t i c a l significance r = .2585, p = .061). S U P P L E M E N T A L F I N D I N G S Total severity of symptoms was found to be s i g n i f i c a n t l y correlated with a c t i v i t y l e v e l (r = -.3266, p = .024) and t o t a l mood disturbance (r = .3717, p = .012). A s i g n i f i c a n t correlation of r = -.5227, p = .000 was discovered between education and occupation. F i n a l l y , i t i s noteworthy that a correlation of r = -.2597, p = .060, which approaches significance was found to exist between education and age. 6 1 TABLE 4-3 SUPPLEMENTAL CORRELATIONS ACT INV TMD SEV AGE OCC ED DIAL ACTIVITY 1.0000 .0481 -.3266 -.3531 .0708 INVENTORY P= . P= .389 P= .024 P= .016 P= .339 .1386 .1239 P= .207 P= .232 TOTAL MOOD DISTURBANCE .0481 1.0000 .3717 P= .389 P= . P= .012 -.1290 -.0889 P= .223 P= .300 -.0154 .0960 P= .464 P= .286 TOTAL SEVERITY OF SYMPTOMS -.3266 .3717 1.0000 P= .024 P= .012 P= . .2600 .2198 -.5150 -.2148 P= .060 P= .096 P= .001 P= .101 AGE -.3531 -.1290 .2600 P= .016 P= .223 P= .060 1.0000 • .1453 P= . P= .195 -.2597 -.1963 P= .060 P= .122 OCCUPATION .0708 P= .339 -.0889 P= .300 .2198 P= .096 . 1 453 P= .195 1 .0000 P= . -.5227 P= .000 -.0676 P= .240 EDUCATION .1386 P= .207 -.0154 P= .464 -.5150 P= .001 -.2597 P= .060 -.5227 P= .000 1.0000 P= . .1 196 P= .345 MONTHS ON .1239 .0960 -.2148 -.1963 -.0676 DIALYSIS P= .232 P = .286 P= .101 P= .122 P= .345 .1196 1.000 P= .240 P= . PEARSON PRODUCT-MOMENT CORRELATION COEFFICIENTS 37 CASES 1 - TAILED TEST OF SIGNIFICANCE CHAPTER 5  DISCUSSION OF RESULTS ACTIVITY LEVELS AND DEMOGRAPHIC VARIABLES ACTIVITY LEVELS AND AGE The s t a t i s t i c a l l y s i g n i f i c a n t negative c o r r e l a -t i o n found between age and a c t i v i t y levels (table 4-1) is consistent with the res u l t s reported by Meldrum et a l . (1968), Huber et a l . (1972), De-Nour and Czaczkes (1974), Kutner and Cardenas (1981), Gutman et a l . (1981), and De-Nour (1982). This finding i s also compatible with the commonly held assumption within the medical community (Blodgett, 1981-82) that older patients have p o t e n t i a l l y greater d i f f i c u l t y in adjust-ing to hemodialysis than younger patients. Also noteworthy, a similar negative correlation of r = .3358, p = .021 (note that scores on t h i s symptom of the SQ were coded inversely of the scores on the Al) was discovered between age and the a c t i v i t y l e v e l symptom on the SQ. The results of t h i s study, however, are at odds with those investigations which seem to suggest no s i g n i f i c a n t c orrelation between a c t i v i t y levels and age (Cohen et a l . 1970, Sviland 1972, Malmquist 1973, Alder 1975, De-Nour and Czaczkes 1975, De-Nour and Czaczkes 1975, De-Nour et a l . 1977-78, O'Brien 1980, Procci 1981 and Olsen 1983). One Study (Czaczkes and De-Nour, 1978) even discovered that the vocational r e h a b i l i t a t i o n of these patients improved with age. Several factors may account for the discrepancy among these studies. An important consideration i s that none of the previous research pertinent to the relationships between a c t i v i t y l e v e l and the demo-graphic variables of t h i s study ( i . e . age, occupation, education and length of time on d i a l y s i s ) have employ-ed the a c t i v i t y inventory. Because the a c t i v i t y inventory might well be measuring something d i f f e r e n t from these other studies, a s i g n i f i c a n t negative correlation may indeed exist between age and a c t i v i t y levels, even though age does not seem to be s i g n i f i -cantly correlated with, for example, vocational rehabi-l i t a t i o n . One might also point to the fact that the a c t i v i t y inventory i s a crude instrument on which no v a l i d i t y or r e l i a b i l i t y studies have been done. In addition, i t could be that the c o r r e l a t i o n c o e f f i c i e n t observed between a c t i v i t y levels and age in t h i s study is the function of a c o r r e l a t i o n with one or more extraneous variables. Because the sample size for t h i s investigation i s r e l a t i v e l y small (although i t i s above the t y p i c a l l y suggested minimum of 30 cases for a c o r r e l a t i o n a l study), extraneous variables may have been able to systematically a f f e c t the findings. Moreover, because d i a l y s i s units are not homogeneous settings (Yanagida and S t r e l t z e r , 1979), s p e c i f i c aspects of the testing si t u a t i o n in which the data for t h i s study were gathered might have influenced the r e s u l t s . F i n a l l y , another explanation for the incongruity in question could be that the obtained correlation c o e f f i c i e n t in the present study i s simply greater than the population c o e f f i c i e n t . ACTIVITY LEVELS AND OCCUPATION Contrary to a l l apparent relevant studies (Short and Alexander 1969, Huber et a l . 1972, Walker et a l . 1976 and O'Brien), which substantiate the view that patients of higher job status tend to have greater a c t i v i t y levels than patients of lower occupational lev e l s , the present investigations found that these variables were not s i g n i f i c a n t l y correlated (r = .0708, p = .339). I t was also discovered that occupation was not correlated at a s i g n i f i c a n t l e v e l (r= .1643, p= .166) with the a c t i v i t y symptom on the symptom questionnaire. Not only are these f i n d -ings in disagreement with those of the existing research, they also c o n f l i c t with the broadly maintained b e l i e f among health professionals that patients of higher occupations have a tendency to adjust better to hemodialysis treatment than patients with lower job status (Strauch et a l . 1971 and Levy 1 976 ) . This interesting c o n f l i c t may be explained in a variety of ways. As already indicated, the a c t i v i t y inventory was not used by any of these e a r l i e r studies. Furthermore, none of the previous research relevant to t h i s area of concern focused s p e c i f i c a l l y on a c t i v i t y l e v e l s . Instead, they have centered t h e i r investigations on vocational r e h a b i l i t a t i o n or s o c i a l functioning. Thus, although occupational l e v e l seems to be s i g n i f i c a n t l y correlated with vocational rehabi-l i t a t i o n or s o c i a l functioning, i t may not be s i g n i f i -cantly correlated with a c t i v i t y l e v e l s . The variance at issue may also be accounted for by drawing atten-tion to the lack of v a l i d i t y and r e l i a b i l i t y informa-tion on the a c t i v i t y inventory. Borg and G a l l (1983) point out that an obtained co r r e l a t i o n c o e f f i c i e n t may be lower than the true c o e f f i c i e n t to the extent that a measure i s not perfectly r e l i a b l e . The c o r r e l a t i o n c o e f f i c i e n t noted in the present study may have been systematically influenced by some uncontrolled factors due to the small sample size. It should also be remembered that a small sample requires a greater c o r r e l a t i o n c o e f f i c i e n t than a larger sample in order to be s t a t i s t i c a l l y s i g n i f i -cant. Another factor which may have confounded the findings of t h i s study with respect to the c o r r e l a t i o n c o e f f i c i e n t between a c t i v i t y l e v e l and occupation i s that occupation was coded somewhat poorly. There were neither clear d e f i n i t i o n s to help the subjects discern the difference among s k i l l e d , semi-skilled and un-s k i l l e d workers, nor clear c r i t e r i a to help the subjects determine occupational l e v e l s . For example, i t i s unclear as to whether a career o f f i c e r (coded as the lowest occupational level) i s of a lower occupa-t i o n a l l e v e l than an unskilled or semi-skilled worker. Moreover, given t h i s apparent vagueness in the coding, i t i s conceivable that some of the sub-jects may have given themselves a higher occupational rating than was r e a l l y the case, in order to show themselves in a better l i g h t . Thus, occupational le v e l might not have been accurately measured in the present investigation, and in turn the obtained 67 . correlation c o e f f i c i e n t may not be t r u l y represen-t a t i v e of the relationship between occupational status and a c t i v i t y l e v e l s . ACTIVITY LEVELS AND EDUCATION There seems to be only two reports (De-Nour and Czaczkes 1975 and Olsen 1983) which are congruent with the finding of t h i s study that a c t i v i t y levels were not s i g n i f i c a n t l y correlated with educational l e v e l (r = .1386, p = .207). Most of the previous research (Meldrum et a l . 1968, Short and Alexander 1969, Huber et a l . 1 972, De-Nour and Czaczkes 1 974 , Alder 1 975 , De-Nour et a l . 1977-78, O'Brien 1980 and Gutman et a l . 1981), however, supports the b e l i e f that a c t i v i t y levels are p o s i t i v e l y correlated with educational l e v e l . Furthermore, in l i n e with the majority of investigations relevant to t h i s area of concern, there i s a widespread assumption within the medical profes-sion that education tends to influence a patient's adjustment to hemodialysis treatment. The inconsistency between the bulk of the related research and the results of the present study may be ascribed to a few previously mentioned possible 68 . explanations. Again, as with age and occupation, none of these previous investigations have u t i l i z e d the a c t i v i t y inventory. Moreover, a c t i v i t y levels were not s p e c i f i c a l l y studied in any of them. They have focused rather on vocational r e h a b i l i t a t i o n , s o c i a l adjustment, s o c i a l functioning and successful adapta-tion to hemodialysis treatment. Hence, i t would be that although s i g n i f i c a n t positive correlations seem to exist between education and such variables as voca-t i o n a l r e h a b i l i t a t i o n , s o c i a l adjustment and s o c i a l functioning, there may be not s i g n i f i c a n t c o r r e l a t i o n between education and a c t i v i t y l e v e l s . Another factor which may have influenced the findings of t h i s study i s that due to a lack of v a l i d i t y or r e l i a b i l i t y i n f o r -mation on the a c t i v i t y instrument, i t i s possible that t h i s instrument has somewhat poor v a l i d i t y or r e l i -a b i l i t y . Also, the sample size of the present investigation necessitates the results be viewed with some caution. It i s noteworthy that, in stark contrast to the i n s i g n i f i c a n t correlation c o e f f i c i e n t between the a c t i v i t y inventory scores and educational l e v e l , a s t a t i s t i c a l l y s i g n i f i c a n t negative correlation c o e f f i c i e n t (r= -.4532, p= .002) was found between educational l e v e l and the a c t i v i t y symptom on the symptom questionnaire. This discrepancy i s d i f f i c u l t to understand. One way to account for i t i s to draw attention to what seems to be a subtle difference between the two instruments in what i s being measured. The a c t i v i t y inventory i s assessing a c t i v i t y l e v e l on the basis of ten s p e c i f i c a c t i v -i t i e s , whereas the a c t i v i t y symptom on the symptom questionnaire measures d a i l y a c t i v i t y levels in general. ACTIVITY LEVELS AND LENGTH OF TIME ON DIALYSIS The correlation c o e f f i c i e n t between the subjects' a c t i v i t y levels and t h e i r length of time on d i a l y s i s was s t a t i s t i c a l l y i n s i g n i f i c a n t (table 4-1). Simi-l a r l y , length of time on d i a l y s i s was not s i g n i f i -cantly correlated with the a c t i v i t y symptom on the symptom questionnaire (table 4-2). While some previous investigations (O'Brien 1980 and Olsen 1983) have reported results compatible with these findings, other studies (Huber et a l . 1972 and De-Nour and Czaczkes 1975) have suggested that after a period of time patients attain a stable l e v e l of a c t i v i t y . S t i l l another investigation has supported a view that a c t i v i t y levels are negatively correlated with length of time on d i a l y s i s . Although these incongruities are puzzling, a number of factors may help explain them. These factors, which have been discussed, include: (1) the lack of s p e c i f i c attention to a c t i v i t y levels in re l a t i o n to length of time on d i a l y s i s in the previous research; (2) the fact that the a c t i v i t y inventory has not been employed previously; (3) the lack of v a l i d i t y and r e l i a b i l i t y information on the a c t i v i t y inventory; and, (4) the small sample size in the present study. MOOD STATES AND DEMOGRAPHIC VARIABLES MOOD STATES AND AGE The t o t a l mood disturbance of the subjects in th i s study was not s i g n i f i c a n t l y correlated with age (table 4-1). This i s r e f l e c t i v e of the fact that f i v e of the six mood state factors were not s i g n i f i c a n t l y correlated with age. It i s also worth noting that a si m i l a r l y i n s i g n i f i c a n t c o r r e l a t i o n c o e f f i c i e n t was discovered between age and the depression symptom of the symptom questionnaire (table 4-2). These findings are congruent with the majority of the pertinent investigations (Fishman and Schneider 1972, Foster et a l . 1973, De-Nour and Czaczkes 1974, Procci 1981 and 71 Olsen 1983). Some other studies (Czaczkes~and De-Nour 1978, Livesley 1981 and Kutner and Cardenas 1981) however, seem to suggest that older patients have mood d i f f i c u l t i e s more often than younger patients. Also, in p a r t i a l support of t h i s view i s the s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n c o e f f i c i e n t between the confusion/bewilderment mood factor and age (along with the observation that both the depression/ dejection and anger/hostility mood factors approached s t a t i s t i c a l significance in t h e i r c o r r e l a t i o n c o e f f i c i e n t s with age). A few factors may explain why the s t a t i s t i c a l l y i n s i g n i f i c a n t c o r r e l a t i o n between t o t a l mood disturb-ance and age in t h i s study i s discordant with the minority of studies just c i t e d . F i r s t of a l l , attention should be drawn to the fact that none of the previous studies which have gathered data relevant to the relationships between mood states and the demo-graphic variables of age, occupation, education and length of time on d i a l y s i s have either u t i l i z e d the POMS or investigated moods s p e c i f i c a l l y . Second, because moods are transient a f f e c t i v e states subject to diverse influences, i t could be contended that since the moods of the subjects were only measured once, an accurate picture of th e i r mood states was not captured. The many extraneous uncon-t r o l l e d variables that could p o t e n t i a l l y influence the moods of patients undergoing hemodialysis treatment, during which the data for t h i s investigation was collected, might have affected the r e l i a b i l i t y of subject's scores on the POMS. If indeed the POMS scores were not r e l i a b l e , then the obtained correlation c o e f f i c i e n t may be lower than the true correlation c o e f f i c i e n t to the extent that the obtained mood scores do not represent the subjects true mood states. F i n a l l y , not only i s there a lack of information on the v a l i d i t y of the POMS with respect to the d i a l y s i s population, but i t appears that i t has not been previously employed with t h i s population. Although i t has proven useful in other populations, i t would be incorrect to assume that t h i s instrument i s equally applicable to the d i a l y s i s population (Yanagida and St r e l t z e r , 1979). MOOD STATES AND OCCUPATION A study by Livesley (1981) i s the only evident study relevant to t h i s area of interest. His findings were consistent with the results of the present investigation which indicated that moods states were not s i g n i f i c a n t l y correlated with occupa-t i o n a l status (table 4-1). The obtained r e s u l t should nonetheless be interpreted with a certain degree of caution, p a r t i c u l a r l y because of the previously i n d i -cated concerns regarding the manner in which occupa-t i o n a l l e v e l was coded and the use of the POMS in t h i s study. MOOD STATES AND EDUCATION Educational l e v e l was not s i g n i f i c a n t l y correlated with mood states in th i s study (table 4-1). Most of the pertinent investigations (Fishman and Schneider 1972, Foster et a l . 1973 and Olsen 1983) have reported findings which are in l i n e with t h i s discovery. The one study (De-Nour and Czaczkes 1974) which was p a r t i a l l y contradictory to the results of the present investigation reported that educational l e v e l was p o s i t i v e l y correlated with anxiety. At the 74 . same time, however, they also noted that frequency of depression and other psychiatric complications were not s i g n i f i c a n t l y correlated with education. Interest-ingly, in the present study, a s i g n i f i c a n t c orrelation c o e f f i c i e n t (r = -.3053, p = .033) was observed between the educational l e v e l and scores on the depression symptom of the symptom questionnaire. Although t h i s i s a surprising discrepancy with the correlation c o e f f i c i e n t s between scores on the POMS and education, some observations may help account for i t . An important point to consider i s that there seems to be a subtle difference between these two instruments in what they are measuring. In the symptom questionnaire, the subjects respond to the depression symptom questions according to th e i r own de f i n i t i o n s of depression. No mention of depression i s made, however, in the POMS. Instead, the POMS has used several scales based on d i f f e r e n t adjectives or phrases which describe d i f f e r e n t feelings or moods that help to define depression. Because of the differences between these instruments, one might also speculate that, considering the high degree of denial exercised by d i a l y s i s patients (Wright et a l . 1966, Menzies and Stewart 1968, Beard 19679, Short and Wilson 1969 and Fishman and Schneider 1972), the subjects with higher levels of education in t h i s study were more able to deny depression on the depression symptom of the symptom questionnaire than they were on the POMS (in which the intent to measure depression i s disguised). MOOD STATES AND LENGTH OF TIME ON DIALYSIS Mood states were not s i g n i f i c a n t l y correlated with length of time on d i a l y s i s (table 4-1). This finding was pa r a l l e l e d by the cor r e l a t i o n between length of time on d i a l y s i s and t h e i r scores on the depression symptom of the symptom questionnare (table 4-2). Although one investigation (Procci 1981) reported no s i g n i f i c a n t relationship between psychiatric d i f f i c u l t i e s and chronicity of i l l n e s s , the majority of the relevant studies (Shea et a l . 1965, Blakely 1977 and Maher et a l . 1983) suggest that mood disturbance i s p o s i t i v e l y correlated with length of time on d i a l y s i s . The disagreement between the present study and Procci's findings may be accounted for by the explanations discussed in the previous section on relationship between mood states and age. 76 . SEVERITY OF SYMPTOMS AND DEMOGRAPHIC VARIABLES SEVERITY OF SYMPTOMS AND AGE The correlation c o e f f i c i e n t between t o t a l severity of symptoms in the present study and age was not s t a t i s t i c a l l y s i g n i f i c a n t , although i t did ap-proach significance (r = .2600, p = .060). Two previous investigations (Kutner and Cardenas 1981 and Procci 1981) produced si m i l a r r e s u l t s . Another two studies (Meldrum et a l . 1968 and Livesley 1981), however, substantiate the b e l i e f held by many health professionals that older patients tend to suffer from more physical symptoms of d i a l y s i s than younger patients. A few considerations may help explain the con-f l i c t i n g r e sults between the present investigation and the studies by Meldrum et a l . (1968) and Livesley (1981). F i r s t of a l l , severity of symptoms was measured in d i f f e r e n t ways. The SQ was not used by any of the proceeding studies which have obtained information relevant to the relationship between severity of symptoms and the demographic variables of age, occupation, education and length of time on d i a l y s i s . One should also bear in mind the fact that severity of symptoms was only measured once in the 77 . present study and that there i s no apparent i n f o r -mation on the v a l i d i t y or r e l i a b i l i t y of the POMS. Also, because of r e l a t i v e l y homogeneous nature of the subjects in t h i s study with respect to age, a smaller correlation c o e f f i c i e n t would be expected. In turn, the somewhat small sample size might have had an exacerbating e f f e c t because smaller sample sizes require higher correlation c o e f f i c i e n t s to be sta t -i s t i c a l l y s i g n i f i c a n t . I t should also be emphasized that, although the resu l t s of t h i s study are inconsis-tent with the reports by Meldrum et a l . (1968) and Livesley (1981), the obtained co r r e l a t i o n c o e f f i c i e n t was a positive one which did approach s t a t i s t i c a l s i gnificance. SEVERITY OF SYMPTOMS AND OCCUPATION The relevant available research (Huber et a l . 1972 and Livesley 1981) i s consistent with the finding of the present study that occupation l e v e l i s not s i g n i f i c a n t l y related to the t o t a l severity of symptoms (r = .2198, p = .096). While one must bear in mind that occupation was coded somewhat poorly in thi s investigation and that there have been no apparent attempts to standardize the SQ, the existing 78 . information (including the present study) does seem to disconfirm the broadly maintained view that patients of higher job status tend to adjust better to hemo-d i a l y s i s than patients wiht lower occupational levels (Strauch et a l . 1971 and Levy 1 976).. It i s i n t e r e s t -ing, however, that the one symptom on the SQ, which was s i g n i f i c a n t l y correlated with occupation (r = .3787, p = .010), was headaches. This suggests that the higher the occupational l e v e l of a d i a l y s i s paitent, the more l i k e l y that he or she i s to suffer from headaches. SEVERITY OF SYMPTOMS AND EDUCATIONAL LEVEL A large correlation c o e f f i c i e n t which has a s t r i k i n g l y high l e v e l of s t a t i s t i c a l significance, was observed between t o t a l severity of symptoms and educa-t i o n a l l e v e l (r = -.5150, p = .001). This discovery, therefore, supports the view that patients with higher levels of education tend to experience less severity of symptoms common to d i a l y s i s than patients with lower levels of education. Such a finding also corrob-orates the widespread assumption among professionals in the medical f i e l d (De-Nour and Czaczkes 1974 and Olsen 1983) that adjustment to hemodialysis tends to be influenced by education. It i s surprising, in l i g h t of t h i s common c l i n i c a l impression, that there appears to be no previous research documented in t h i s area. As to possible reasons for the prominent c o r r e l -ation c o e f f i c i e n t between the educational levels of the subjects in t h i s study and t h e i r t o t a l severity of symptom scores, a certain amount of speculation can be offered. One explanation might be that patients with higher levels of education may tend to inform them-selves more about how to most e f f e c t i v e l y manage t h e i r i l l n e s s , (for example, with respect to such things as the i r dietary and f l u i d control requirements). Another factor may be that the SQ i s an instrument which measures the patient's subjective perception of the extent to which he or she i s experiencing the various symptoms common to d i a l y s i s patients. It could be argued that more educated patients tend to have cultivated, through t h e i r more extended educa-t i o n a l experience, a greater degree of internal locus of control, which in turn may help them fe e l more in control of th e i r sickess than patients with less educa-t i o n . This greater sense of control may consequently enable them to perceive the symptoms as less severe, more tolerable or even more manageable. 80 . SEVERITY OF SYMPTOMS AND LENGTH OF TIME ON DIALYSIS It appears that only one e a r l i e r study (Procci 1981) has gathered information on the relat i o n s h i p between length of time on d i a l y s i s and severity of symptoms. His results were consistent with the f i n d -ing of the present study that severity of symptoms were not s i g n i f i c a n t l y correlated (r = -.2148, p = .101) with length of time on d i a l y s i s . Three symptoms of the SQ, however, were correlated with length of time on d i a l y s i s at a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l . Negative correlations of r = -.3255, p = .025 between length of time on d i a l y s i s and fatigue, and r = -.3524, p = .016 between length of time on d i a l y s i s and muscle cramps were found. These res u l t s suggest that the longer a patient has been on d i a l y s i s , the less severe his or her d i f f i c u l t i e s with fatigue and muscle cramps w i l l tend to be. Conversely, concen-t r a t i o n was discovered to be p o s i t i v e l y correlated (r = .3897, p = .009) with length of time on d i a l y s i s . In other words, patients who have been on d i a l y s i s for longer periods of time tend to have more problems with concentration than those who received d i a l y s i s t r e a t -ment for shorter periods of time. The contradictory nature of these findings on the SQ seems rather enigmatic. No interpretations w i l l be put forward. 81 SUPPLEMENTAL FINDINGS TOTAL SEVERITY OF SYMPTOMS AND ACTIVITY LEVEL A s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n coef-f i c i e n t of r = -.3266, p = .024 was observed between the t o t a l severity of symptoms and the a c t i v i t y inven-tory scores. This finding seems to suggest that the more severe a patient's symptoms are, the lower his or her a c t i v i t y l e v e l w i l l tend to be. TOTAL SEVERITY OF SYMPTOMS AND MOOD STATES The t o t a l severity of symptom scores of the subjects in the present study were found to be posi-t i v e l y correlated with t o t a l mood disturbance (r= .3717, p= .012). It would appear then, that patients with greater severity of symptoms have a tendency to experience more mood disturbance. Again, one might expect such an association. 82 . MOOD STATES AND ACTIVITY LEVEL Although t o t a l severity of symptoms was s i g n i f i -cantly correlated with both the a c t i v i t y inventory and t o t a l mood disturbance, i t i s surprising that the a c t i v i t y inventory scores and t o t a l mood disturbance were not s i g n i f i c a n t l y correlated (r = .0481, p = .389). Apparently, a c t i v i t y levels and mood states are independently correlated with t o t a l severity of symptoms, but not s i g n i f i c a n t l y correlated with each other. EDUCATION AND OCCUPATION The educational l e v e l and occupational status of the subjects in t h i s study were discovered to be c o r r e l a t -ed at a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l (r= -.5227, p = .000). This i s a negative c o r r e l a t i o n because educa-ti o n and occupation were coded inversely of each other. A s i g n i f i c a n t c orrelation between these two variables i s consistent with the common observation that people with higher job status tend to have more education. 83. EDUCATION AND AGE Interestingly, a negative co r r e l a t i o n c o e f f i c i e n t which approached s t a t i s t i c a l significance (r = -.2597, p = .060) was noted between educational l e v e l and age. Perhaps educational opportunity has gradually increased over the years and has resulted in the tendency of the older subjects in t h i s study to have lower levels of education than those who were younger. METHODOLOGICAL LIMITATIONS The present study has a number of methodological limi t a t i o n s or weaknesses which may have influenced the results and which consequently l i m i t the generalization of the findings. The l i m i t a t i o n s or weaknesses are primarily associated with the instrumentation, the sample, the data c o l l e c t i o n and co r r e l a t i o n a l method. LIMITATIONS ASSOCIATED WITH THE INSTRUMENTATION The a c t i v i t y inventory presents some problems. This i s a crude instrument which was designed spec-i f i c a l l y for the present study. No attempt was made 84 . to e s t a b l i s h - i t s v a l i d i t y or r e l i a b i l i t y . F u r t h e r -more, i t s s e n s i t i v i t y i n measur ing the a c t i v i t y l e v e l of the s u b j e c t s seems somewhat l e s s than i d e a l . The accuracy w i th which i t a s ses sed a c t i v i t y l e v e l c o u l d p robab ly have been improved i f a more comprehensive l i s t of a c t i v i t i e s had been i n c l u d e d . A l s o , i n cases where the s u b j e c t s no longer do any of the a c t i v i t i e s t h a t they engaged i n p r i o r t o k idney f a i l u r e , s u b j e c t s were s imply a s s i gned a s co re of zero p e r c e n t , r e g a r d -l e s s of how many a c t i v i t i e s they f o r m e r l y engaged i n . Another weakness of t h i s in s t rument i s t h a t i t d i d not measure the extent of the s u b j e c t s invo lvement i n the v a r i o u s a c t i v i t i e s e i t h e r i n the pas t or r e c e n t l y . I t c o u l d a l s o be t h a t some of the s u b j e c t s had an u n r e a l i s t i c a l l y h i gh view of how much they engaged i n a c t i v i t i e s i n the p a s t . The POMS has a few p o s s i b l e sources of e r r o r connected w i th i t . One f a c t o r i s t h a t the mood s t a t e s of the s u b j e c t s were on ly measured once. Because mood s t a t e s f r e q u e n t l y change and are i n f l u e n c e d by many f a c t o r s , one c o u l d argue t h a t a more accu ra te a s s e s s -ment of t h e i r o v e r a l l mood s t a t e s would l i k e l y have been a c q u i r e d i f the POMS was adm in i s t e red s e v e r a l 85 . d i f f e r e n t times with each patient. Another concern i s that there i s no data on the v a l i d i t y of the POMS regarding the d i a l y s i s population. In addition, i t seems that the POMS has not been used previously with patients on hemodialysis. It would be erroneous to assume that because t h i s measure has proven to be appropriate with other populations, i t i s just as applicable to patients undergoing hemodialysis t r e a t -ment . Some potential l i m i t a t i o n s in methodology with respect to the SQ can also be noted. As with the POMS, the subject's severity of symptoms was assessed only one time. Since a patient's perception of his or her severity of symptoms, l i k e moods, can be influenc-ed by a variety of variables and i s l i k e l y to change from time to time, i t may be that t h i s single admini-str a t i o n of the SQ did not obtain a r e l i a b l e picture of the severity of symptoms experienced by the subjects. An additional concern i s that, although the SQ has face v a l i d i t y and has been used successfully in other studies (Maher et a l . 1983 and Teschan et a l . 1983), there i s no apparent research on i t s v a l i d i t y or r e l i a b i l i t y . 86 . Attention should be drawn as well to the manner in which occupation was coded in the personal history questionnaire. It seems that occupation was somewhat poorly coded. The subjects were given no d e f i n i t i o n s or examples in order to help them discern the d i f -ference between s k i l l e d , semi-skilled and unskilled workers. With regard to these categories, i t was simply l e f t up to the subject's d i s c r e t i o n to deter-mine t h e i r occupational l e v e l . One might also ques-tion, for instance, whether an unskilled or semi-s k i l l e d worker i s of a higher occupational l e v e l than a career o f f i c e r (which i s coded as the lowest occupa-t i o n a l l e v e l ) . Because of these concerns, i t i s possible that an accurate measurement of the subject's occupational l e v e l was not achieved. LIMITATIONS ASSOCIATED WITH THE SAMPLE The methodology f a l l s short of the ideal in a few ways regarding the sample. A factor that may have affected the results was the r e l a t i v e l y small size of the sample. Although the sample size was above the suggested minimum of 30 cases for a c o r r e l a t i o n a l study (Borg and G a l l 1983), the fact that there were s t i l l comparatively few subjects may have allowed some 87 . uncontrolled variables to influence the outcomes of t h i s study in some systematic way. A larger sample would have ensured to a greater extent that the uncontrolled variables present would themselves have been operating randomly. Also, because small c o r r e l a -t i o n a l c o e f f i c i e n t s could have reasonably been expect-ed, and since smaller samples require higher c o r r e l a -t i o n c o e f f i c i e n t s than larger samples to be s t a t i s t i c -a l l y s i g n i f i c a n t , i t would have been desirable to have had more subjects for t h i s study. A f i n a l consideration related to the sample i s that the subjects were f a i r l y homogeneous with regards to age. This may have resulted in smaller c o r r e l a t i o n c o e f f i c i e n t s than might normally appear. LIMITATIONS ASSOCIATED WITH THE DATA COLLECTION A number of factors pertaining to the data c o l l e c t i o n may l i m i t the g e n e r a l i z a b i l i t y of the findings. F i r s t of a l l , i t i s important to remember that d i a l y s i s units are not homogeneous settings. Consequently, s p e c i f i c c h a r a c t e r i s t i c s of the two units in which the data for the present study was collected may have influenced the r e s u l t s . 88 . Related to t h i s , having the subjects complete the questionnaire while they were being dialyzed possibly provided an opportunity for uncontrolled variables to a f f e c t outcomes. Another conceivable shortcoming of the study i s that no attempts were made to control for tester a f f e c t s . Since the measures were administered i n d i v i -dually, i t i s possible that some c h a r a c t e r i s t i c s of the tester influenced the patient's reponses to the assessment instruments. Research (Strauch-Rahauser, G., Schafheulle, R., Lipke, R. and Strauch, M. 1977) suggests that d i a l y s i s patients tend to present them-selves in a s o c i a l l y desirable manner in order not to alienate those upon whom they are dependent. In l i g h t of t h i s , i t would perhaps have been ideal to have included, along with other measures, an instrument which assessed s o c i a l d e s i r a b i l i t y (eg. Marlowe-Crowne Social D e s i r a b i l i t y Scale, Edwards Social D e s i r a b i l i t y Scale). In such a fashion, s o c i a l d e s i r a b i l i t y could be used as a covariate and i t s effects s t a t i s t i c a l l y controlled. 89 . LIMITATIONS ASSOCIATED WITH THE CORRELATIONAL METHOD The study has some weaknesses which are either inherent in the correlational method or related to i t . One limitation of this approach is that i t cannot establish cause-and-effect. relationships. A correla-tion only indicates that two variables have a tendency to vary together in a systematic way. Investigations such as this one could possibly be c r i t i c i z e d for attempting to break down something which is complex into simpler components. Another problem concerning the use of the correlational method to identify vari-ables related to adjustment to hemodialysis is that this adjustment may be influenced by many factors presently known or unknown and numerous combinations of these. Because we know so l i t t l e about adjustment to hemodialysis and since i t is so complex, only the most careful interpretation of the correlational data generated by the present study can provide us with an understanding of i t . A few notes of caution with respect to the inter-pretation of correlational findings warrant being mentioned. It should be kept in mind that two vari-90 . ables may be correlated only because they are both related to a t h i r d variable. One must also remember that an obtained co r r e l a t i o n c o e f f i c i e n t i s lower than the true correlation c o e f f i c i e n t to the extent that the instruments are not perf e c t l y r e l i a b l e (Borg and Ga l l 1983). Furthermore, regardless of the r e l i a b i l -i t y of the measures, a population co r r e l a t i o n c o e f f i -cient may be either smaller or larger than the obtained correlation c o e f f i c i e n t . Another point to consider i s that when a population i s homogeneous in the variables of concern, we can expect to observe lower cor r e l a t i o n c o e f f i c i e n t s than when a population i s heterogeneous. Also, i t should be taken into account that the l e v e l of s t a t i s t i c a l significance of a correlation, which i s determined in large part by the sample size, cannot be used to predict the results of future studies, but can only help to make a deci-sion about re j e c t i n g the n u l l hypothesis. Although a s i g n i f i c a n t p provides reason to believe that two variables are correlated, r e p l i c a t i o n s of the i n v e s t i -gation should be conducted to gain further assurance that the obtained finding i s r e a l . 91 JUSTIFICATION OF THE STUDY This study responds to a ' need for more information on factors related to adjustment of hemodialysis treatment, and more s p e c i f i c a l l y , on how various demographic variables are related to t h i s adjustment. It proposes to contribute to the l i t e r a -ture new information on how the demographic variables of age, occupation, education and length of time on d a i l y s i s are correlated with the a c t i v i t y l e v e l s , severity of symptoms and mood states of patients undergoing hemodialysis treatment. A review of the l i t e r a t u r e has shown that, although these relationships have been examined to a limited degree, none of the foregoing studies have employed the a c t i v i t y inventory, POMS and SQ to measure the a c t i v i t y l e v e l s , mood states and severity of symptoms, respectively, in such a study. By follow-ing Borg and Gall's (1983) guidelines for planning a basic relationship study, an attempt has been made to make the research design of t h i s investigation as v a l i d and r e l i a b l e as possible. The independent v a r i -ables ( i . e . age, occupation, education and length of time on d i a l y s i s ) were selected because of the wide-spread b e l i e f s i n the medical community t h a t they tend to i n f l u e n c e adjustment to hemodialysis treatment. The r e s e a r c h e r , t h e r e f o r e , had good reason to b e l i e v e t h a t a study of the r e l a t i o n s h i p between these i n -dependent v a r i a b l e s and the dependent v a r i a b l e s ( i . e . a c t i v i t y l e v e l s , moods s t a t e s and s e v e r i t y of symptoms) was a worthwhile endeavor. JUSTIFICATION OF THE METHODOLOGY The sample can serve as another b a s i s f o r j u s t i f y i n g the present study. A key s t r e n g t h of t h i s i n v e s t i g a t i o n i s t h a t .the sample was s e l e c t e d i n a manner which allows one t o assume t h a t i t i s r e p r e s e n t -a t i v e of the p o p u l a t i o n from which i t was drawn. Because the study i n v o l v e s 37 s u b j e c t s , which i s a la r g e enough sample, we can have a reasonable l e v e l of confidence t h a t i f we were to s e l e c t a d i f f e r e n t sample of equal s i z e and employ the same procedures, our outcomes would be approximately the same. 93 . In addition, the subjects were r e l a t i v e l y homogeneous (thereby l i k e l y avoiding the p o s s i b i l i t y that relationships between variables might be obscur-red by the presence of subjects d i f f e r i n g widely from each other) and were measureable on the variables with which the study was concerned. Attention should also be drawn to the data c o l l e c t i o n of t h i s study. Both the independent and dependent variables were c l e a r l y defined and measured in quantified form, using instruments that have face v a l i d i t y for t h i s population. In order to analyze the data, the Pearson Product Moment Correlation technique was selected. This meth-od was chosen because i t has a smaller standard of error than the other bivariate techniques and i t s use is generally preferred when possible (Borg and G a l l , 1983). F i n a l l y , an attempt was made to present the meth-odology in as clear and complete a manner as possible so that others w i l l be able to re p l i c a t e t h i s invest-igation in order to determine the r e l i a b i l i t y of the obtained r e s u l t s . CONCLUSIONS & DISCUSSION The major findings of the present investigation were as follows. (1) A c t i v i t y levels were negatively correlated with age at a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l , but were not s i g n i f i c a n t l y correlated with occupation, education or length of time on d i a l y s i s . (2) Mood states were not s i g n i f i c a n t l y correlated with any of the demographic variables (with the excep-tion of the co r r e l a t i o n between the confusion/ bewilderment factor and age). (3) Total severity of symptoms were negatively correlated at a s t a t i s t i -c a l l y s i g n i f i c a n t l e v e l with education, but no s i g n i f i c a n t correlations were found between t h i s aspect of adjustment and the other demographic variables. Because th i s i s a relationship study, co r r e l a t i o n c o e f f i c i e n t s , whether s t a t i s t i c a l l y s i g n i f i c a n t or not, were equally meaningful. These results seem to support the b e l i e f that age and education tend to influence 1) a c t i v i t y levels and severity of symptoms, respectively, and 2) to a certain extent, adjustment to hemodialysis treatment. Conversely, the outcomes of t h i s study appear to suggest that occupational status and length of time on d i a l y s i s do not s i g n i f i c a n t l y influence the a c t i v i t y l e v e l s , mood states and severity of symptoms of patients maintained on hemodialysis. More generally, such findings do not substantiate the widely maintained assumption that adjustment to maintenance hemodialysis tends to be influenced by length of time on d i a l y s i s (Blodgett 1981-82) and occupational status (Strauch et a l . 1971 and Levy 1976). In addition to the above findings, a few supplemental correlations were also deemed important. F i r s t of a l l , t o t a l severity of symptoms was d i s -covered to be both negatively correlated with a c t i v i t y levels and p o s i t i v e l y correlated with mood states at s t a t i s t i c a l l y s i g n i f i c a n t l e v e l . Secondly, mood states and a c t i v i t y levels were not s i g n i f i c a n t l y correlated. F i n a l l y , a s t a t i s t i c a l l y s i g n i f i c a n t positive c orrelation was found between education and occupational l e v e l . (This c o e f f i c i e n t was given a negative sign because these two variables were coded inversely of one another). The outcomes of t h i s further analysis seem to suggest that severity of symptoms and a c t i v i t y levels tend to influence each other. The b e l i e f that mood states and severity of symptoms have a tendency to influence one another also appears to be supported by these r e s u l t s . In contrast, however, the findings seem to point to another conclusion that a c t i v i t y levels and mood states do not have a s i g n i f i c a n t influence upon each other. These d i f f e r e n t outcomes may have two implications. F i r s t , i t could be that some components of adjustment to hemodialysis tend to influence (or to be influenced by) other elements of adjustment. Secondly, at the same time, i t may be that some aspects of adjustment to hemodialysis do not tend to influence (nor to be influenced) by other components of adjustment. The supplemental correlations generated by t h i s investigation are also noteworthy since there appears to be no previous research of these relationships. In addition to being of t h e o r e t i c a l interest, t h i s study may also play a part in leading to future studies of p r a c t i c a l importance. Through contributing to the l i t e r a t u r e on adjustment to hemodialysis treatment and factors related to t h i s adjustment, the present investigation might have a role in spawning and guiding such subsequent research as prediction studies which employ multivariate analysis. Such prediction studies could determine which demo-graphic variables, singly and in combination, are the best predictors, of the various aspects of adjustment to maintenance hemodialysis. 98 . SUGGESTIONS FOR ADDITIONAL RESEARCH In view of the p re sen t s tudy, s e v e r a l i m p l i c a t i o n s f o r f u r t h e r r e s e a r c h can be i d e n t i f i e d . An obv ious recommendation i s t h a t r e p l i c a t i o n s of t h i s i n v e s t i -g a t i o n be done i n o rder to g a i n a d d i t i o n a l assurance t h a t the observed r e s u l t s indeed r e f l e c t the t r u e c o r r e l a t i o n s . A number of changes c o u l d he lp improve the methodology of s i m i l a r f u t u r e s t u d i e s . The a c t i v i t y i n v e n t o r y shou ld i n c l u d e a more comprehensive l i s t of a c t i v i t i e s and shou ld have g r e a t e r s e n s i t i v i t y to cases where s u b j e c t s have d i s c o n t i n u e d a l l former a c t i v i t i e s . Fur thermore, i n f o r m a t i o n on the v a l i d i t y and r e l i a b i l i t y of t h i s measure shou ld be genera ted . A l s o , i f the POMS and SQ are a d m i n i s t e r e d s e v e r a l t imes , the o v e r a l l accuracy of the measurement may be improved. I t i s l i k e l y , t oo , t h a t the cod ing f o r occupa t i on c o u l d be improved. Another sugges t i on i s t o i n c l u d e a long w i th the p re sen t measure, o ther ins t ruments which assess a c t i v i t y l e v e l s , mood s t a t e s and s e v e r i t y of symptoms. I n t e r - c o r r e l a t i o n s c o u l d then be conducted to determine the r e l a t i o n s h i p among the i n s t rument s . A f u r t h e r recommended a d d i t i o n to the i n s t r u m e n t a t i o n i s an ins t rument which measures s o c i a l d e s i r a b i l i t y . F i n a l l y , a l a r g e r sample i s a l s o d e s i r a b l e . A prediction study using multiple l i n e a r regression would be the next l o g i c a l step in t h i s l i n e of research. Such an investigation could provide information regarding which independent variables (e.g. age, education, and marital status) and combinations thereof are the best predictors of a p a r t i c u l a r dependent variable (eg. severity of symptoms). 1 00 . EPILOGUE COUNSELLING AND ADJUSTMENT TO HEMODIALYSIS Numerous stresses are associated with kidney f a i l u r e and hemodialysis treatment. As a r e s u l t of these stresses, a variety of psychological problems are common among hemodialysis patients. Counselling can help patients manage t h e i r stresses and resolve t h e i r psychological d i f f i c u l t i e s and in turn can play a therapeutic role in f a c i l i t a t i n g t h e i r adjustment to hemodialysis. Patients on hemodialysis could benefit from counselling for several kinds of problems. These problems include: depression, anxiety, s u i c i d a l behaviour, r e h a b i l i t a t i o n d i f f i c u l t i e s , marital and family d i s t r e s s , sexual concerns, poor self-concept, and non-compliance to the medical regimen. Each patient has both a d i f f e r e n t experience with and a unique set of reactions to kidney f a i l u r e and hemodialysis treatment. I t i s therefore important to select a modality of counselling and therapy which suits the individual patient's personality as well as other relevant factors. 101 Some spec i f i c s t rateg ies and interventions which may prove he lp fu l in counsel l ing these pat ients are: 1) i dent i f y ing and discuss ing pat ients ' stresses and react ions to these stresses; 2) providing information on the signs and causes of various psychological problems associated with kidney f a i l u r e and hemodialysis; 3) helping pat ients develop interpersonal s k i l l s ; 4) encouraging pat ients to get involved in regular soc i a l a c t i v i t i e s , phys ica l exercise, and other ga in fu l or useful a c t i v i t i e s ; 5) a s s i s t ing pat ients with se l f -concept enhancement; 6) doing cathart ic work in cases of major emotional responses to stresses; 7) providing anxiety management thereapy; 8) f a c i l i t a t i n g the formation and continued funct ion of small support groups for hemodialysis patients and the i r partners. 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(1979). Limitations of psychological tests in a d i a l y s i s population. Psychosomatic Medicine, 41, 7, 557-567. Zung, W.W.K., (1965). S e l f - r a t i n g depression scale. Archives-of General Psychiatry, 12, 63-70. 118. APPENDIX A PERSONAL HISTORY QUESTIONNAIRE 1 1 9 . PERSONAL HISTORY PATIENT'S NAME PATIENT'S CODE (1-2) DATE FORM COMPLETED HOSPITAL NUMBER INSTRUCTIONS: PLEASE RESPOND TO THE FOLLOWING QUESTIONS BY FILLING IN THE BLANKS OR BY CHECKING ANSWER(S), UNLESS OTHERWISE SPECIFIED. 1. Place of Birth: (check one) (3) 1 Non U.S. 2 U.S. 2. Age to nearest year: ( 4-5 ) Years 3. Occupation: Spec i fy (check one) (6) 1 Administrative personnel, and professionals 2 Owners of small business, and technicians 3 Skilled workers 4 Semi-skilled workers 5 Unskilled workers 6 Career enlisted person 7 Career officer 4. Do you live with: (1 = Yes; 2 = No) owners of concerns cl e r i c a l , sales workers (7) Parents (8) Relatives (including children) ( 9 ) Wife (10) Friends (11) Alone 5. Number of people living with you: (12-13) ' 6. Where are you living? (check one) (14) 1 House 2 Apartment 3 Room 4 Trailer 5 Other 1 20 . 7. Sex: (23) 1 Male 2 Female 8. Race/ethnic group: (24) 1 Caucasian 2 Black 3 Asian 4 Hispanic 5 Other 9. a. Current marital status: (check one) (25) 1 Single 2 Married 3 Separated 4 Divorced 5 Widowed b. If married, separated, divorced or widowed, give date: c. If married, spouse's occupation: Spec i fy (check one) (28) 1 Administrative personnel, owners of concerns and professionals 2 Owners of small business, c l e r i c a l , sales workers, and technicians 3 S k i l l e d workers 4 Semi-skilled workers 5 Unskilled workers 6 Career enlisted person 7 Career o f f i c e r . 10. Number of children: ( 29-30 ) 121. 1 1 Religion (check one (31 ) 1 2~ 3~ 4~ 5~ Catholic Protestant Jewish Other None 12. Do you attend r e l i g i o u s meetings or services? (check one) (32) 1 2 3~ 4" Weekly or more often Monthly Less than monthly Never 1 3 Father: (check one) ( 33) 1 2" 3" Aliv e , in good health Al i v e , in poor health; Dead 1 4 Mother: (check one! (34) 1 2 3" Alive, in good health Al i v e , in poor health Dead 1 5 Parents are: (check one) ( 35 ) Living together Separated Divorced One or both not 16. a. Were both of you parents born in the United States? (check one) ( 36 ) 1 Yes No b. If one or both parents were born in t h i s country, where were they (he/she) born? •Mother Father 1 22 . 17. Your highest educational l e v e l : (check one) V (46) 1 Less than 7 years school 2 7-9 years schooling 3 P a r t i a l high school or trade school 4 High school or trade school graduate 5 P a r t i a l college or university 6 College or university graduate (2 year degree or 4 year degree). 7 16+ years schooling. 18. a. Are you currently working? (check one) (47) 1 Yes, f u l l time 2 Yes, part time 3 No, r e t i r e d 4 No, unemployed 19. How man hours per week do you usually work? (check one): (49) 1 41+ hours 2 26-40 hours 3 1 1 -25 hours 4 Less than 10 hours 5 Not working 20. What i s your current t o t a l annual family income including VA and other benefits? (check one) (50) 1 $25,000.. or more 2 $15,000. - $24,999. 3 $1 2,000. - $1 4 , 999. 4 $ 9,000. -$1 1,999 . 5 $ 6,000. - $ 8 , 999 . 6 $ 3 , 000 . - $ 5 , 999 . 7 $0 - $2 , 999 . 123. ACTIVITY INVENTORY In the f i r s t column, indicate a c t i v i t i e s l i s t e d that you once did in the past. In the second column, indicate a c t i v i t i e s you have been engaged in recently, that i s , over the l a s t 3 months (or l a s t winter). 1 = Yes; 2 = No. Past Recently Pleasure Walking Lawn Care Gardening Housecleaning Swimming Dancing Bi c y c l i n g Bowling Golf Tennis 124. APPENDIX B PROFILE OF MOOD STATES D.M. McNair, M. Lorr and L.F. Droppleman Educational and Industrial Testing Service, C a l i f . , 1971 125. NCS Trant-Optic M08-7OA16-33 Below i* a list of words that describe feelings people have. Please read each one carefully. Then fill in ONE circle under the answer to the right which best describes HOW YOU HAVE BEEN FEELING DURING THE PAST WEEK INCLUDING TODAV. The numbers refer to these phrases. 0 = Not at all 1 = A little 2 - Moderately 3 = Quite a bit 4 - Extremely Col c- O P ? g i § 11 i < I o £ 21. Hopeless ® © 0 ® 4 ' 22. Relaxed . . . . . . . .®©®'®4' - i i s 2 ! 5 { < I < F £ fi £ i - t o t E O J O 3 K z « 3 o 2 45. Desperate V? i .? 4 5 46. Sluggish 3' 4- ? * •i fits t s s ; i * t « fi 2 5 s 8 § e * « > o 5 1. Friendly S I U 4-2. Tense ®0&S>® 23. Unworthy ®0®®®> 24. Spiteful ® 0 ® ® 4 : 47. Rebellious .4 04 V4 : 48. Helpless 4 4 4 5 '«' 25. Sympathetic ® 0 ® 0 4 26. Uneasy ® 0 ® 4 0 49. Weary 4 J 4 '.»• 4 50. Bewildered 4 1 1 4 t 3. Angry .'® J 4 4' 4 4. Worn ouf . . . . . . . 4 J 4 •?• 27. Restless ® ® 4 0 ® 28. Unable to concentrate ® © ® ® 0 51. Alert 4 4 * 4 A 52. Deceived 4 4 4 4- .«. 5. Unhappy ;5 1 4 4 4 6. Clear-headed . . . . ;4 .! 44 29. Fatigued ® 0 ® 0 ® 30. Helpful . . . 4 0 4 4 4 53. Furious 4 4- 4 4 4 54. Efficient 5 4 4 4 4 7. Lively 5 .?• •*• » 4 8. Confused 4 44 ? * 31. Annoyed ® 0 ® 4 4 32. Discouraged 40 :044 55. Trusting 4 4 > 4 4 56. Full of pep .4 ' * » i 9. Sorry for things done . • .' * 4 10. Shaky 4. J, > 4 4 33. Resentful 4 0 0 4 4 34. Nervous ® 0 ® 4 V ® 57. Bad-tempered 0 1 2 5 * 58. Worthless 4 04 4 * 11. Listless 4 -! I 1 • i 12. Peeved . 4 4-4-4 35. Lonely ® 0 ® 4 ® 36. Miserable . ® 0 ® 0 ® 59. Forgetful 4 1' 4 4 « 60. Carefree '5 4 4 4 4 13. Considerate 4 J-4 J 14. Sad 4 l 4 I 5 37. Muddled ®®-®'®0 38. Cheerful 4 ' 0 ® 0 ' 4 : 61. Terrified 4 .'. * i 4 62. Guilty .? ! .? 44 15. Active 4 I 4 4'4 16. On edge 4 T 1 1 * 39. Bitter . ® © 0 0 4 40. Exhausted ® 0 ® 0 ® 63. Vigorous ° • 5 4 4 64. Uncertain about things . .'•!• 4 '•? 1 * 17. Grouchy V.4 i v* 4 £• 18. Blue 4 04 1 4 41. Anxious ® 0 ® 4 ' 4 42. Ready to fight . . . . ® 0 ® 4 4 65. Bushed '!• * »' * MAKE SURE YOU HAVE ANSWERED EVERY ITEM POM 021 19. Energetic (5 4 1 4 4 20. Panicky '?' -5' I 4 4 43. Good natured . . . . . ® 0 ® 4 - 4 44. Gloomy ®04;®'4 : f ^ i i " m . '*•>' i • POMS COPYRIGHT « 1971 EdlTS/EOucational and Industrial Testing Service. San Diego. CA 82107. Reproduction o< this lorm by any means strctiy pronioiteo APPENDIX C SYMPTOM QUESTIONNAIRE 1 27 . SYMPTOM QUESTIONNAIRE NAME DATE OF TEST SUBJECT # 1 - 3 SEX (M-F) 4 AGE 5 - 6 ED. 7 - 8 This i s a questionnaire which concerns symptoms from which d i a l y s i s patients or patients with chronic renal f a i l u r e commonly suffer. I t represents an attempt to estimate the presence or absence and, i f present, the severity of each symptom for p a r t i c u l a r patients and groups of patients. Though presented in question form, i t should not be regarded as an examination or indication of how you are doing. A pair of statements w i l l be presented, and you should enter the l e t t e r of the statement which you f e e l i s more appplicable for your p a r t i c u l a r case. It may well be that neither statement d i r e c t l y or precisely describes what you f e e l . However, one of the two statements should be closer to what you r e a l l y f e e l , and you should choose that statement. Your answers are expected to be highly subjective and you should pick one of the two statements, even though you f e e l that i t does not completely describe your p a r t i c u l a r case. 1 . a. My appetite i s not as good as i t should be. [ ] b. I have an excellent appetite. [ ] 2. a. I occasionally experience mild bruising. [ ] b. I almost always have abnormal bruises. [ ] 3. a. I am almost never short of breath. [_ ] b. I sometimes notice shortness of breath which somewhats l i m i t s my a c t i v i t y . [ ] 4. a. I have very l i t t l e pep or energy and barely manage to accomplish my d a i l y duties. [ ] b. I do not have enough pep or energy to do much of anything. [ ] 5. a. I never have muscular cramps. b. I have muscular cramps which are troublesome. 6. a. I never or only r a r e l y have headaches. b. I have headaches which are sometimes severe. 7. a. I often have d i f f i c u l t y sleeping. b. I occasionally experience some d i f f i c u l t y sleeping 8. a. I often i t c h and i t may be severe. b. I i t c h occasionally and t h i s causes some annoyance 9. a. I never or only rarely become depressed, b. I often become depressed about things. 10. a. The l e v e l of my d a i l y a c t i v i t y i s somewhat reduced but i t i s adequate except for the time I spend on d i a l y s i s , b. Even during the times when I am not being d i a l y -zed, my dai l y a c t i v i t i e s are d e f i n i t e l y limited. 11. a. I am almost always able to remain quiet or s t i l l for r e l a t i v e l y long periods of time, b. I am frequently unable to l i e or s i t s t i l l and t h i s i s occasionally a source of annoyance. 12. a. I frequently find great d i f f i c u l t y in concentra-ti n g . b. I am sometimes unable to concentrate even when I am rested. 13. a. I notice d e f i n i t e burning or numbness in my feet which may be somewhat uncomfortable, b. I never experience any numbness or burning in my feet. 14. a. My sex l i f e i s not as good as i t should be. b. I have a very good sex l i f e . 15. a. I p r a c t i c a l l y never have any d i f f i c u l t y concen-t r a t i n g . b. I am sometimes unable to concentrate even when I am rested. 16. a. I fe e l that I have ample pep and energy. b. I have very l i t t l e pep or energy and barely manage to accomplish my d a i l y duties. 1 17. a. I may experience some mild numbness or burning in my feet which r e a l l y doesn't bother me. b. I notice d e f i n i t e burning or numbness in my feet which may be somewhat uncomfortable. 18. a. I have muscular cramps which are troublesome, b. I have mild muscular cramps which are not of great concern to me. 19. a. I have often noticed that I bruise abnormally. b. I v i r t u a l l y never experience any abnormal bruising. 20. a. I have headaches which are sometimes severe, b. I have severe headaches which are a source of de f i n i t e d i s a b i l i t y to me. 21. a. I v i r t u a l l y never sleep well. b. I often have d i f f i c u l t l y sleeping. 22. a. I fe e l that my sex l i f e i s generally quite poor, b. I would describe my sex l i f e as adequate. 23. a. I occasionally notice some shortness of breath which i s mild, b. I sometimes notice shortness of breath which somewhat l i m i t s my a c t i v i t y . 24. a. I never i t c h . b. I i t c h occasionally and t h i s causes some annoy-ance . 25. a. I f e e l that my appetite i s generally quite poor, b. I would describe my appetite as adequate. 26. a. I sometimes notice that I am unable to s i t or l i e s t i l l . b. I am frequently unable to l i e or s i t s t i l l and t h i s i s occasionally a source of annoyance. 27. a. My da i l y a c t i v i t i e s are severely limited so that I am v i r t u a l l y incapacitated - even when I am not on d i a l y s i s . b. Even during the times when I am not being dialyzed my d a i l y a c t i v i t e s are d e f i n i t e l y limited. 1 3 28. a. I sometimes become a l i t t l e depressed but i t doesn't bother me too much, b. I am usually very depressed. 29. a. I sometimes notice shortness of breath which somewhat l i m i t s my a c t i v i t y , b. I am short of breath and my a c t i v i t y i s quite limited due to t h i s symptom. 30. a. I would describe my appetite as adequate, b. My appetite i s not as good as i t should be. 31. a. I do not have enough pep or energy to do much of anything. b. I have adequate pep and energy but only enough to accomplish my d a i l y duties. 32. a. I usually experience no d i f f i c u l t y sleeping, b. I often have d i f f i c u l t y sleeping. 33. a. I almost always have abnormal bruising. b. I have often noticed that I bruise abnormally. 34. a. I can almost always concentrate well but must be rested to do so. b. I p r a c t i c a l l y never have any d i f f i c u l t y concen-t r a t i n g . 35. a. I have severe numbness or burning in my feet which distresses me. b. I may experience some mild numbness or burning in my feet which r e a l l y doesn't bother me. 36. a. I only i t c h r arely and never complain of t h i s symptom. b. I i t c h occasionally and t h i s causes some annoyance. 37. a. I would describe my sex l i f e as adequate, b. My sex l i f e i s not as good as i t should be. 38. a. I have muscular cramps which are troublesome, b. I have severe muscular cramps which are a d e f i n i t e source of d i s a b i l i t y to me. 39. a. I never seem to be able to s i t or l i e q u ietly and i t interferes with my d a i l y l i v i n g , b. I sometimes notice that I am unable to s i t or l i e s t i l l . 1 40. a. The l e v e l of my da i l y a c t i v i t y i s somewhat reduced but i s adequate except for the time I spend on d i a l y s i s . b. My d a i l y a c t i v i t i e s are severely limited so that I am v i r t u a l l y incapacitated - even when I am not on d i a l y s i s . 41. a. I sometimes become a l i t t l e depressed but i t doesn't bother me too much, b. I often become depressed about things. 42. a. I have severe headaches which are a source of de f i n i t e d i s a b i l i t y for me. b. I sometimes have headaches but they are not abnormal or troublesome. 43. a. I am almost always able to remain quiet or s i t • s t i l l for r e l a t i v e l y long periods of time, b. I sometimes notice that I am unable to s i t or l i e s t i l l . 44. a. Except for the time spent on d i a l y s i s , I f e e l my dai l y a c t i v i t y i s quite normal, b. The l e v e l of my da i l y a c t i v i t y i s somewhat reduced but i t i s adequate except for the time I spend on d i a l y s i s . 45. a. I am usually very depressed. b. I often become depressed about things. 46. a. I never experience any numbness or burning in my feet. b. I may experience some mild numbness or burning in my feet which r e a l l y doesn't bother me. 47. a. I occasionally experience some d i f f i c u l t y sleeping, b. I v i r t u a l l y never sleep well. 48. a. I sometimes have headaches but they are not abnormal or troublesome, b. I never or rarely have headaches. 49. a. I only i t c h r a rely and nevery complain of t h i s symptom. b. I often i t c h and i t may be severe. 1 50. a. I v i r t u a l l y never experience any abnormal bruising, b. I occasionally experience mild bruising. 51. a. My appetite i s not as good as i t should be. b. I f e e l that my appetite i s generally quite poor. 52. a. My sex l i f e i s not as good as i t should be. b. I f e e l that my sex l i f e i s generally quite poor. 53. a. I have severe muscular cramps which are a d e f i n i t e source of d i s a b i l i t y to me. b. I have mild muscular cramps which are not of great concern to me. 54. a. I am short of breath and my a c t i v i t y i s quite limited due to t h i s symptom, b. I occasionally notice some shortness of breath which i s mild. 55. a. I have adequate pep and energy but only enough to accomplish my d a i l y duties, b. I have very l i t t l e pep or energy and barely manage to accomplish my d a i l y duties. 56. a. I can almost always concentrate well but must be rested to do so. b. I frequently f i n d great d i f f i c u l t y in concentrat-ing. 57. a. I notice d e f i n i t e burning or numbness in my feet which may be somewhat uncomfortable, b. I have severe numbness or burning in my feet which distresses me. 58. a. I have adequate pep and energy but only enough to accomplish by d a i l y duties, b. I f e e l that I have ample pep or energy. 59. a. I never seem to be able to s i t or l i e quietly and i t interferes with my d a i l y l i v i n g , b. I am frequently unable to l i e or s i t s t i l l and t h i s i s occasionally a source of annoyance. 60. a. I occasionally notice some shortness of breath which i s mild, b. I am almost never short of breath. 1 61. a. I occasionally experience mild bruising. b. I have often noticed that I bruise abnormally. 62. a. I have an excellent appetite. b. I would describe my appetite as adequate. 63. a. I only i t c h r arely and never complain of t h i s symptom, b. I never i t c h . 64. a. I usually experience no d i f f i c u l t y sleeping, b. I occasionally experience some d i f f i c u l t y sleeping. 65. a. Even during the times when I am not being dialyzed, my dai l y a c t i v i t i e s are d e f i n i t e l y limited, b. Except for the time spent on d i a l y s i s , I f e e l my d a i l y a c t i v i t y i s quite normal. 66. a. I have a very good sex l i f e . b. I would describe my sex l i f e as adequate. 67. a. I sometimes have headaches but they are not abnormal or troublesome, b. I have headaches which are sometimes severe. 68. a. I can almost always concentrate well but must be rested to do so. b. I am sometimes unable to concentrate even while I am rested. 69. a. I never have muscular cramps. b. I have mild muscular cramps which are not of great concern to me. 70. a. I sometimes become a l i t t l e depressed but i t doesn't bother me too much, b. I never or only rarely become depressed. 

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