Department of Old Age Psychiatry, The Maudsley Hospital, London
Section of Community Psychiatry (PRiSM), Institute of Psychiatry, London
Section of Old Age Psychiatry, Institute of Psychiatry, London
Institute of Medical and Social Care Research, University of Wales, Bangor
Forest Grange Day Hospital, Bennion Centre, Glenfield Hospital, Leicester
Section of Community Psychiatry (PRiSM), Institute of Psychiatry, London
Department of Psychiatry and Behavioural Sciences, University College London Medical School, London
Declaration of interest This study was funded by a grant from the North Thames National Health Service Executive.
Correspondence: Dr Tom Reynolds, Department of Old Age Psychiatry, The Maudsley Hospital, Denmark Hill, London SE5 8AZ. e-mail: t.reynolds{at}iop.kcl.ac.uk
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aim To develop such an instrument which would take account of patients', staff and carers' views on needs.
Method Following an extensive development process, the assessment instrument was subjected to a test-retest and interrater reliability study, while aspects of validity were addressed both during development and with data provided by sites in the UK, Sweden and the USA.
Results The Camberwell Assessment of Need for the Elderly (CANE)
comprises 24 items (plus two items for carer needs), and records staff, carer
and patient views. It has good content, construct and consensual validity. It
also demonstrates appropriate criterion validity. Reliability is generally
very high: >0.85 for all staff ratings of interrater reliability.
Correlations of interrater and test-retest reliability of total numbers of
needs identified by staff were 0.99 and 0.93, respectively.
Conclusions The psychometric properties of the CANE seem to be highly acceptable. It was easily used by a wide range of professionals without formal training.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The Medical Research Council's topic review of health of the UK's elderly people (Medical Research Council, 1994) recommended that in future, "research in community care should be focused on areas of particular relevance to the changes in care within the community notably, needs based approaches". Comprehensive needs assessment helps to highlight specific areas where health and social services can concentrate their energies in providing individually tailored, high-quality care. Until now there has been a lack of adequate measures for defining needs in older people with mental health problems. This paper describes the development of a new instrument intended to fill that gap comprehensively.
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The initial adaptation of the CAN was carried out by one of the authors (M.A.) and colleagues, and resulted in a draft version called the Camberwell Assessment of Need for Older Adults (CANOA), which covered 27 different areas - 25 regarding the service user and two specific to the carer (the original CAN has 22 topics, all related to the service user). The overall format of the CAN was preserved and a number of the topics covered were identical, although the format of questions was of necessity adapted to be more suitable for the target population. The process of adaptation took place in the context of focus groups consisting of service users (the target population) and professionals working in mental health services for the elderly. The CANOA was piloted on an inner-city sample of 70 elderly African-Caribbean people with various mental health problems. Following this, further adjustments were made to the draft.
Further development of draft version - the Delphi process
A modified Delphi process was the consensus method used in refining the
instrument (Pill, 1971;
Rowe et al, 1991).
After piloting, a questionnaire was sent to service users, carers and
professionals, involved in all aspects of care of the elderly (psychiatrists,
psychologists, geriatricians, nurses, social workers, representatives of
voluntary groups and occupational therapists), asking them to rate the various
topics on a five-point scale of importance and asking for suggestions on any
other areas that they might consider important. Following the feedback from
these questionnaires and subsequent focus groups (again with service users,
carers and various professionals), a second draft version was prepared. This
draft was the subject of a consensus conference aimed at further refinement of
the CANE.
Consensus conference - continuing the Delphi process
Thirty-eight delegates attended the consensus conference representing most
of the relevant professional and voluntary groups involved in care of the
elderly (including representatives from the charities Age Concern and the
Alzheimer's Disease Society, mental health service managers, psychiatrists,
psychologists, general practitioners (GPs), social workers, nurses and
occupational therapists). The delegates were allocated to different workshop
groups (each group concentrating on specific topics in the draft version) and
scrutinised the layout and wording in detail to make sure that all the most
important areas were covered as far as possible. Each workshop group had a
core of specialists in the topics that they covered (psychiatrists covering
the aspects of psychiatric morbidity, GPs covering physical health issues,
etc.) and each group fed back to the whole conference after each session. The
results of these sessions were collated in order to prepare a penultimate
draft version of the CANE, which was later circulated to the conference
delegates for final opinions.
Pilot study
The penultimate draft was used to interview ten patients in an old age
psychiatry day hospital, their key staff and carers. The final draft (CANE
version 2) was prepared following these interviews; it involved only some
minor changes in wording and item order in order to clarify some areas and to
make it more user-friendly.
Table 1 compares the CAN and CANE. Overall, seven new items were created for the CANE (five relating to the service user and two relating to the carer). Two items from the CAN (education and telephone) were not used, while two (drugs and transport) were expanded (drugs to encompass problems with medication as well as possible drug misuse, while transport became mobility in the CANE so as to cover getting about inside and outside the home). The item sexual expression from the CAN was subsumed under intimate relationships in the CANE.
|
Data collection
Copies of the final draft and of some other rating scales (see below) and
pro formas used for gathering demographic details were sent to three centres
in the UK (North Wales, Liverpool and Southport), one in Sweden
(Jönköping) and
one in the USA (Lebanon, PA). The other scales, aimed at helping further in
the validation process, were the 12-item General Health Questionnaire (GHQ-12;
Golberg, 1978) (used as a
measure of carer stress); the Barthel Activities of Daily Living Index
(Wade & Collin, 1988)
(used as a measure of functional ability); the Medical Outcomes Study (MOS)
36-item Short-Form Health Survey (SF-36;
Ware & Sherbourne, 1992;
McHorney et al, 1993) (used as a quality-of-life instrument); and the behaviour rating scale from
the Clifton Assessment Procedures for the Elderly (CAPE-BRS;
Gilleard & Pattie, 1979)
(used as a measure of dependency). All of these scales were used as
comparative measures in order to help establish criterion and concurrent
validity.
Reliability data
Data were collected on 55 cases for the interrater and test-retest
reliability analysis. These data were collected by one of the authors (T.R.)
and four co-workers (two nurses and two psychiatrists) in a variety of
settings in a psychiatry of the elderly service covering urban and rural
settings in Hertfordshire and Essex (out-patients departments, day hospitals,
acute psychiatric wards, continuing care and dementia assessment wards).
Initially, 41 service users, 53 staff members and 22 carers were interviewed
in the presence of one of the four co-raters; one week later (on average), 40
service users, 53 staff and 18 carers were re-interviewed by T.R. Prior power
analysis had indicated that with power set at 0.9 and significance level set
at 0.05 we would need a sample size of about 46 to demonstrate that a
reliability () of 0.4 or above was different from zero.
Table 2 shows details of the study sample. Service users, staff and carers were interviewed separately, with the interviewer and observer both rating responses. The interviewer and observer switched roles with alternate cases in order to minimise interviewer bias. Fourteen (25%) of the service users could not be interviewed - 12 had moderate to severe dementia, one had chronic schizophrenia with clinical symptoms that precluded interview (severe negative syndrome) and one had depression.
|
Staff came from a variety of professional backgrounds - occupational therapy, social work, psychiatry and (mainly) psychiatric nursing. Two-thirds (n=37) of service users had an informal carer, of whom 60% (n=22) were interviewed. Carers in all cases were spouses, partners or family members.
Validity data
The validity data included those from the reliability sample plus records
collected in the other five centres (14 from Southport, 12 from Liverpool, 10
from North Wales, 6 from Sweden and 4 from the USA), making a total of 101
cases. Much of the validity was assessed concurrently with the development
process.
Analysis
Data for the validity and reliability studies were analysed using the
Statistical Package for the Social Sciences, version 6.0 for Windows
(SPSS, 1993). Cohen's
coefficient (Cohen, 1960) and
percentage complete agreement were calculated in order to assess the degree of
agreement between binary variables, and intraclass correlations, based on
analysis of components of variance, were used to compute interrater and
test-retest reliability of summary scores. Confidence intervals (95%) were
calculated for mean values and for the main reliability coefficients.
Each item in the research version of the CANE has four sections (a structure similar to the research version of the CAN). Section 1 asks whether a need exists, sections 2 and 3 rate the level of help received from family/friends and statutory services, respectively, and section 4 rates whether the right amount and type of help are given. If no need exists, sections 2-4 are not completed. The measurements of agreement in this study are based on section 1.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The number of needs rated by staff for each item of the CANE in the total sample is shown in Table 3, which shows that staff felt that approximately a fifth of patients had serious unmet needs relating to household skills, food, daytime activities and psychological distress; almost a third had serious unmet needs concerning memory (reflecting the numbers with dementia); almost a quarter had serious unmet needs with money; and over a fifth of carers were also rated as suffering from significant psychological distress. Staff were able to rate needs for most items, but approximately a fifth did not know whether there were any needs with money and intimate relationships, and over two-fifths did not know whether their clients were receiving the appropriate state benefits. Half of the sample was receiving some help with daytime activities, physical health and psychological distress, and two-fifths with food. Over two-fifths of carers were receiving help with psychological distress. The serious unmet needs least often identified in the patient sample were in the areas of benefits (1%, but skewed by the number of unknowns), deliberate self-harm (2%), information (3%), abuse/neglect (4%) and behaviour (5%). None of the sample was regarded as having a serious unmet need with alcohol, but 3% were receiving some help for alcohol misuse. Only one of the sample of carers (n=65) was rated as having a serious unmet need for information.
|
All reliability interviews were timed; mean times for patient, staff and carer interviews were 23.5 minutes (range 9-60), 12.5 minutes (range 3-28) and 23.5 minutes (range 5-45), respectively.
Validity
Face validity
The extensive development process entailed rigorous scrutiny by a large
number of experts, clinicians, carers and service users in the UK and other
countries. The overall consensus was that the CANE covers the main areas of
need for the target population. The choice of words and word length are
suitable for most readers. The Flesch reading ease score (71.8) and average
word length (4.4 characters) indicate that most readers could comprehend the
vocabulary. We therefore conclude that the CANE has good face validity.
Content validity
The 26 items of the CANE were drawn from a survey of currently available
assessment tools and the expert discussions held during the validation
process. Using the questionnaire mentioned above, a survey of patients
(n=35), carers (n=30), professionals and representatives of
voluntary organisations (n=55) was carried out. The average scoring
showed that all items were rated as at least moderately important (a rating of
three on a five-point scale), precluding item bias. No additional areas of
need were suggested by more than two respondents. Content (or sampling)
validity is therefore shown to be good.
Consensual validity
The overall consensus from the surveys, focus groups and conference was
that there was a definite requirement for a needs-assessment instrument for
elderly people with mental illness and that the CANE would certainly help to
fulfil that requirement comprehensively. Although some of the original CAN
items such as telephone, basic education and
sexual expression were felt to be potentially important areas to
assess in the elderly age group, the consensus was that their inclusion was
not essential in the CANE (on the grounds that we were trying to cover the
most important areas of need rather than all possible areas), but space could
be included in the final documents for research and clinical use so that
raters could add these or other topics in order to customise
their own data-gathering.
Construct validity
Both convergent and divergent construct validity were assessed by creating
a correlation matrix for the first section of all 26 items as rated by
patients, staff and carers and examining whether there were positive or
negative correlations between items where one would intuitively expect to find
such correlations (convergent) or whether there was a lack of
any correlation where it is obvious that no relationship should exist
(divergent). Evidence of convergent construct validity is
particularly shown in correlation measures between memory and those functions
that one would expect to be impaired with cognitive impairment
(Table 4) - in the staff domain
the correlation between memory and self-care is 0.43 (P < 0.001),
that for memory and accidental self-harm is 0.39 (P < 0.001), that
for memory and money is 0.41 (P < 0.001), and that for self-care
and household skills is 0.7 (P < 0.001). Similarly, there are good
correlations for these items in the carer domain. However, there are poor
correlations between these items in the patient domain, presumably because of
poor recognition of functional disability among the cognitively impaired group
in the sample. Divergent validity is shown by the lack of any significant
correlations between items such as carer's and patient's need for information
and all other items. Overall, the correlation coefficients indicate reasonable
construct validity.
|
Criterion validity
As there was no contemporary scale specific to needs of elderly people with
mental illness, there is some difficulty in establishing concurrent validity.
However, as mentioned above, we used four other scales to act as comparisons:
the CAPE-BRS to rate dependency and behavioural function; SF-36 as a
quality-of-life measurement, the Barthel Index as a measure of physical
functional status; and the GHQ-12 for measuring carer stress. Analysis yielded
the correlation coefficients shown in Table
5. There is strong correlation between specific CANE items and
corresponding items of the CAPE-BRS. Similarly, the CANE total score (the sum
of met and unmet needs) correlates strongly with the total CAPE-BRS score
(r=0.66) and has a strong negative correlation with the Barthel score
(r=-0.53). There is also a strong correlation between the carer-item
carer's psychological distress and the GHQ-12 score
(r=0.6). When comparing with the SF-36, negative correlations would
be expected. Interestingly, there are weak negative correlations generally
between staff-rated CANE scores and the (patient-rated) SF-36 scores, except
between the CANE item distress and the SF-36 general health
perception sub-scale (r=-0.46). On the other hand, there are
significant negative correlations between patient-rated CANE items and
sub-scales and corresponding SF-36 scores
(Table 5). These results
suggest reasonable criterion validity.
|
Reliability
Interrater and test-retest reliability were assessed by calculating
percentage complete agreement and coefficients for the first section
of the CANE (level of need present) for each item in patient, staff and carer
ratings. According to Fleiss
(1981), a
value of less
than 0.40 indicates poor agreement, values of 0.40-0.59 show fair agreement,
values of 0.60-0.74 show good agreement and values of 0.75-1.00 show excellent
agreement. The values of
for interrater reliability in patient, staff
and carer domains are therefore generally excellent with all but one reaching
0.75 or above (Table 6). In the
interrater staff interviews the mean value of
is 0.97 (range
0.87-1.00). Overall, ratings of
for test-retest reliability
(Table 7) are lower than for
interrater reliability, but in general they appear adequate, with a mean of
0.77 (range 0.35-1.00) in the staff domain. Agreement on retesting for 58% of
items in this domain was excellent (
< 0.75), while for 31% of items
it was good (0.60-0.74). In the patient domain, on retesting, agreement for
27% of items was excellent, 35% good, 8% fair and 15% poor; agreement for the
remaining 15% was impossible to calculate because of very low base rates in
the binary characteristics. In the carer domain,
showed excellent
agreement on retesting in 58% of items, good agreement in 12% and fair
agreement in 12%; it could not be calculated for the remaining five items.
Intraclass correlations between summary scores, based on analysis of
components of variance, showed a correlation coefficient of 0.99 (95% CI
0.99-1.00) for interrater reliability for patient, staff and carer ratings.
Calculations for test-retest reliability yielded correlations of 0.87 (95% CI
0.78-0.92), 0.93 (95% CI 0.90-0.96) and 0.97 (95% CI 0.93-0.98) for patient,
staff and carer ratings, respectively.
|
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The MRC Needs for Care Assessment (Brewin et al, 1987) was designed to measure the needs of people with long-term mental illness, where need was deemed to be present if a patient's level of functioning fell below, or threatened to fall below, some minimum specified level and if a potentially effective remedy existed. Although a number of studies suggest that the scale has good reliability if used by trained investigators (Brewin & Wing, 1993), some problems were highlighted when it was used in hostels for the homeless (Hogg & Marshall, 1992) and when used for long-term in-patients (Pryce et al, 1993). Hogg & Marshall (1992) concluded that their data were difficult to interpret because of a failure to take account of patients' and carers' views "in sufficient detail"; they therefore went on to develop a suitably modified version (Marshall et al, 1995).
The CAN (Phelan et al, 1995) was developed to measure the needs of people in the general adult population with severe mental illness, and has been shown to have good reliability and validity. Studies comparing the assessments made by staff and patients showed that the two groups tended to rate similar numbers of needs (but different ones), agreeing moderately on met needs but less often on unmet needs (Slade et al, 1996, 1998).
Elderly patients may also have perceptions of their needs that differ from those of clinicians (McEwan, 1992), but standardised needs assessment in elderly people with mental illness has been largely neglected until now (Hamid et al, 1995, 1998). There has been some literature looking at population needs (Victor, 1991; Cooper, 1993), but specific attempts to address assessment of need have concentrated on people with dementia (Aronson et al, 1992; Wattis et al, 1992; Gordon et al, 1997; McWalter et al, 1998), just as the CAN is aimed at those with severe mental illness.
Gordon et al (1997) designed the Tayside Profile for Dementia Planning, an instrument aimed at gathering data for population needs assessment and service planning for people with dementia. They found that it had satisfactory validity and reliability but noted that informal carers and professionals perceived needs differently. As it was not clear which group had the more valid opinion, a mix of informal carers and professionals as informants is postulated to offer the best approach when using the profile.
The Care Needs Assessment Pack for Dementia (McWalter et al, 1998) was designed to allow multi-disciplinary teams to rate the met and unmet needs of people with dementia and their carers in the community and related settings (e.g. day hospitals). It does not differentiate between information sources (such as interviews with the person with dementia, the carer or others involved, and information from case notes) but allows discrepancies or differences of opinion to be recorded at the rater's discretion for each of the seven sub-scales of need (health and mobility, self-care and toileting, social interaction, thinking and memory, behaviour and mental state, house-care, community living). The section specific to the carer allows assessment of need over six domains - health, daily difficulties, support, breaks from caring, feelings and information. Preliminary research suggests that the instrument has a degree of validity and resonable reliability.
By contrast, the CANE is designed for the whole elderly population with mental illness (not just those with dementia or severe mental illness). As it allows patients, their carers and staff to rate their own opinions on need, it automatically records differences in perceptions of need at the key interface. This sort of data not only will help at the micro level in the formulation of highly specific individual care planning but can also be used on the macro level to plan health service provision based on the identified needs.
Psychometric properties
According to the criteria outlined at the beginning of the study, the CANE
performs well. The initial development and piloting involved working with a
sample of innercity Black Caribbean elderly people, whereas subsequent
development and the main reliability study involved a sample population from
rural and urban areas in Essex. This broad sample was further enhanced in the
main validity work by collaboration with other centres in England, Wales,
Sweden and the USA. It was therefore a varied group in terms of both sample
and opinion. We also used a variety of consensus methods in the initial
development and, as there is no agreement about which consensus methods are
most appropriate (Jones & Hunter,
1996), it is hoped that the multiple methods lead to greater
validity of the instrument. Raters came from backgrounds in nursing, social
work, psychology and psychiatry, demonstrating the CANE's usability by a wide
range of professionals. All raters were able to use the instrument after
consulting the brief instruction document, occasionally supplemented by short
discussions via telephone and the internet. Staff who were interviewed
commented consistently on the usefulness of the CANE in honing their own
assessment skills. The inclusion of a section specifically looking at the
needs of carers was a universally popular idea during development. Providing
carers with the opportunity to give their opinions on the patients' needs was
also universally appreciated, particularly by carers of people with dementia,
for whom the process often proved cathartic. The good correlation between the
CANE item carer's psychological distress and the GHQ-12 should
further enhance the instrument's usefulness.
The staff ratings in the CANE were easily completed in under 30 minutes (mean 12.5 minutes), meeting the time criterion. However, as it is a slightly longer instrument than the CAN and also has an additional section for carers, the process of completing staff, patient and carer ratings in full would clearly take considerably longer. The version of the CANE proposed for clinical practice is a much shorter instrument. A follow-up paper to this one (details available from the first author upon request) will detail the relationship between staff, patient and carer views of needs.
Test-retest coefficients for the item psychological
distress were modest in all domains, despite relatively good percentage
agreements. This may be due to a skew in the distributions of the ratings, low
numbers of actual needs or changing needs over time between the two ratings.
In particular, the test-retest value of
was low for the item
deliberate self-harm, an area where one would clinically expect
to see change in a short time frame. Further work needs to be done to assess
whether this means that the CANE has a degree of sensitivity that makes
measurements of change in needs possible over a short interval of time.
Other items
There were various arguments for and against the inclusion of certain items
from the CAN that were not, in the end, included in the CANE. Of these items,
telephone is worth further consideration, as deterioration in
ability to use the telephone is one of four domains of instrumental activities
of daily living significantly associated with cognitive impairment, and is
therefore a potentially useful screening item
(Eccles et al, 1998). The other three domains (managing medication, using transportation and
managing a budget) are covered in the CANE. A possible option would be to
include telephone as an additional prompt in the item
household skills when the CANE is being used to assess the needs
of those with suspected cognitive impairment. This may lead to a greater
correlation between memory and household skills as
a construct validity measurement (Table
4).
Limitations
Interrater reliability as measured by intraclass correlations between
summary scores is almost perfect. This means that raters were rating almost
exactly the same numbers of needs - usually, although not always, the same
ones. In fact, the scores for individual interrater items are also
generally very high. This finding is likely to reflect a natural bias in the
method of data collection for this part of the study. Raters were not blind,
and the layout structure of the instrument means that the interviewer does not
ask any subsequent questions if he or she decides to rate at zero (no
need exists) each item in Section 1. This provides a cue to the
co-rater, which potentially biases the ratings. A study using only the first
section would help to prevent this occurrence, although there would still be
some lack of independence as only one rater asks the questions.
Although the carer data for test-retest reliability are limited by the small sample size (n=18), the intraclass correlation, as measured by components of variance analysis, takes account of the whole carer sample (n=65) in the estimation of between-patient variance. Although not making up for the limited size of this part of the sample, this does add some credibility to the test-retest results for the carers. It should also be noted that although the confidence intervals reflect the influence of small sample size on precision, they do not reflect the upward bias in interrater reliability estimates caused by lack of independence. However, further testing in this area would be warranted before making any definitive statements.
Reliability, validity and use of the CANE
The results of this study indicate that the CANE is popular and easy to
use, and overall has good validity. Intraclass correlations also demonstrate
very good reliability. Although these correlations apparently demonstrate
almost perfect interrater reliability, the interpretation of this part of the
study has to be guarded in light of the limitations discussed. However,
test-retest reliability as measured by intraclass correlations of summary
scores is generally excellent, and this part of the reliability study did not
have the same potential limitations.
Interest in the CANE has resulted in its translation into five other European languages (Swedish, Spanish, German, French and Portuguese), and it is currently being used in several centres in the UK and Europe for research studies or clinical work. With experience, completion of the CANE took much less time. The time taken to complete the assessment would be further improved in clinical settings where the patient is well known or where the CANE is used as part of the standard assessment procedure. As mentioned above, it is envisaged that the clinical version will be a much shorter instrument, incorporating only the first section for each item. The final versions for general use will be published in a single pack that includes an instruction manual containing case vignettes and scoring examples.
Further work needs to be done to supplement this study and assess the qualities of the instrument in more detail, but it can be said at this stage that the CANE is able to assess the needs of elderly people with mental illness effectively and comprehensively over a wide range of diagnoses and settings. Our hope is that it will contribute positively to delivering better-quality mental health services to the elderly.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Brewin, C. R., Wing, J. K., Mangen, S. P., et al (1987) Principles and practice of measuring needs in the long-term mentally ill: the MRC Needs for Care Assessment. Psychological Medicine, 17, 971-981.[Medline]
Brewin, C. R., Wing, J. K., Mangen, S. P., et al (1993) The MRC Needs for Care Assessment: progress and controversies. Psychological Medicine, 23, 837-841.[Medline]
Cohen, J. A. (1960) A coefficient of agreement for nominal scales. Education and Psychological Measurement, 20, 37-46.
Cooper, B. (1993) Principles of service provision in old age psychiatry. In Psychiatry in the Elderly (eds R. Jacoby & C. Oppenheimer), pp. 274-300. London: Oxford University Press.
Eccles, M., Clarke, J., Livingstone, M., et al
(1998) North of England evidence based guidelines development
project: guideline for primary care management of dementia. British
Medical Journal, 317,
802-808.
Fleiss, J. L. (1981) The measurement of inter-rater agreement. In Statistical Methods for Rates and Proportions (ed. J. L. Fleiss). New York: John Wiley & Sons.
Gilleard, C. & Pattie, A. (1979) Clifton Assessment Procedures for the Elderly. Windsor: NFER-Nelson.
Goldberg, D. (1978) Manual of the General Health Questionnaire. Slough: National Foundation of Educational Research.
Gordon, D. S., Spicker, P., Ballinger, B. R., et al (1997) A population needs assessment profile for dementia. International Journal of Geriatric Psychiatry, 12, 642-647.[CrossRef][Medline]
Hamid, W. A., Howard, R. & Silverman, M. (1995) Needs assessment in old age psychiatry - a need for standardization. International Journal of Geriatric Psychiatry, 10, 533-540.
Hamid, W. A., Holloway, F. & Silverman, M. (1998) The needs of elderly chronic mentally ill - unanswered questions. Ageing and Mental Health, 2, 167-170.[CrossRef]
Hogg, L. I. & Marshall, M. (1992) Can we measure needs in the homeless mentally ill: using the MRC Needs for Care Assessment in hostels for the homeless. Psychological Medicine, 22, 1027-1034.[Medline]
Jones, J. & Hunter, D. (1996) Consensus methods for medical and health services research. In Qualitative Research in Health Care (eds N. Mays & C. Pope). London: BMJ Press.
Marshall, M., Hogg, L. I., Gath, D. H., et al (1995) The Cardinal Needs Schedule-a modified version of the MRC Needs for Care Assessment Schedule. Psychological Medicine, 25, 605-617.[Medline]
Maslow, A. H. (1954) Motivation and Personality. New York: Harper & Row.
McEwan, E. (1992) The consumer's perception of need. In Long-Term Care for Elderly People. London: HMSO.
McHorney, C. A., Ware, J. E. & Raczek, A. E. (1993) The MOS 36-item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care, 31, 247-263.[Medline]
McWalter, G., Toner, H., McWalter, A., et al (1998) A community needs assessment: the Care Needs Assessment Pack for Dementia (CARENPD) - its development, reliability and validity. International Journal of Geriatric Psychiatry, 13, 16-22.[CrossRef][Medline]
Medical Research Council (1994) Topic Review on Care of the Elderly. London: MRC.
Murphy, E. (1992) A more ambitious vision for residential long-term care. International Journal of Geriatric Psychiatry, 7, 851-852.
Phelan, M., Slade, M., Thornicroft, G., et al (1995) The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness. British Journal of Psychiatry. 167, 589-595.[Abstract]
Pill, J. (1971) The Delphi method: substance, context, a critique and an annotated bibliography. Socio-Economic Planning Science, 5, 57-71.[CrossRef]
Pryce, I. G., Griffiths, R. D., Gentry, R. M., et al (1993) How important is the assessment of social skills in current long-stay in-patients? An evaluation of clinical response to needs for assessment, treatment, and care in a long-stay psychiatric in-patient population. British Journal of Psychiatry, 162, 498-502.[Abstract]
Rowe, G., Wright, B. & Bolger, F. (1991) Delphi: a re-evaluation of research and theory. Technological Forecasting and Social Change, 39, 235-251.[CrossRef]
Slade, M., Phelan, M., Thornicroft, G., et al (1996) The Camberwell Assessment of Need (CAN): comparison of assessments by staff and patients of the needs of the severely mentally ill. Social Psychiatry and Psychiatric Epidemiology, 31, 109-113.[Medline]
Slade, M., Phelan, M., Thornicroft, G., et al (1998) A comparison of needs assessed by staff and by an epidemiologically representative sample of patients with psychosis. Psychological Medicine, 28, 543-550.[CrossRef][Medline]
SPSS (1993) SPSS for Windows. Base System User's Guide. Release 6.0. Chicago, IL: SPSS Inc.
Victor, C. R. (1991) Health and Health Care in Later Life. Buckingham: Open University Press.
Wade, D. T. & Collin, C. (1988) The Barthel ADL Index: a standardised measure of physical disability? International Disabilities Studies, 10, 64-67.
Ware, J. E. & Sherbourne, C. D. (1992) The MOS 36-item Short-Form Health Survey (SF-36): I Conceptual framework and item selection. Medical Care, 30, 473-483.[Medline]
Wattis, J. P., Hobson, J. & Barker, G. (1992) Needs for continuing care of demented people: a model for estimating needs. Psychiatric Bulletin, 16, 465-467.
Received for publication January 21, 1999. Revision received June 8, 1999. Accepted for publication July 20, 1999.