Psychosocial functioning on the Independent Living Skills Survey in older outpatients with schizophrenia

Schizophrenia Research 69 (2004) 307 – 316 www.elsevier.com/locate/schres

Psychosocial functioning on the Independent Living Skills Survey in older outpatients with schizophrenia Dimitri Perivoliotis a,*, Eric Granholm b,c, Thomas L. Patterson b,c a

San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA b Department of Psychiatry, University of California San Diego, San Diego, CA, USA c Veterans Affairs Healthcare System, San Diego, CA, USA Received 23 January 2003; received in revised form 23 September 2003; accepted 26 September 2003 Available online 27 November 2003

Abstract Improving real-life community functioning in patients with severe mental illness has been an important recent focus of treatment outcome research. Few studies, however, have examined psychosocial functioning in older psychotic patients. The Independent Living Skills Survey (ILSS) is a measure of the basic functional living skills of individuals with severe and persistent mental illness. The self-report version of the ILSS was administered to 57 middle-aged and older community dwelling outpatients with schizophrenia and 40 age-comparable nonpsychiatric participants. Regardless of whether patients resided in assisted living or independent settings, they showed significantly impaired functioning on a majority of the functional areas assessed by the ILSS. No consistent relationship was found between symptom severity and functioning. With certain modifications, the ILSS appears to be a sensitive indicator of functional impairment in this older sample of community-dwelling outpatients with schizophrenia. Information provided by the instrument might be useful to guide rehabilitation efforts and measure functioning changes in response to treatment in this population. D 2003 Elsevier B.V. All rights reserved. Keywords: Schizophrenia; Daily functioning; Activities of daily living; Self care skills; Quality of life; Symptoms

1. Introduction Psychosocial functioning is determined jointly by a patient’s physical, mental and social well being, and can be defined as the collection of abilities or skills necessary for successful community functioning (Patterson et al., 2001b). In the larger context, psychosocial * Corresponding author. V.A. San Diego Healthcare System, 116B, 3350 La Jolla Village Drive, San Diego, CA 92161, USA. Tel: +1-858-552-8585x2573; fax: +1-858-642-6416. E-mail address: [email protected] (D. Perivoliotis). 0920-9964/$ - see front matter D 2003 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2003.09.012

functioning appears to be a significant determinant of quality of life—a multidimensional concept that includes physical, social and neuropsychological functioning, emotional health, productivity and intimacy (Dernovsek et al., 2001; Patterson et al., 1996). Within the past two decades, targets of treatments for serious mental illness have expanded from symptom reduction to improvement of functioning in social and instrumental role domains (National Institute of Mental Health, 1991). Valid and reliable psychosocial functioning measures are needed both to identify functional domains to target in new treatments, and

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to evaluate treatment effectiveness. Recent attempts to reduce healthcare expenses have also necessitated an objective demonstration of treatment effectiveness in terms of functional outcomes (Atkinson et al., 1997). Studies of functioning in schizophrenia have concentrated largely on younger populations. Although there is still no gold standard by which to judge functioning, several categories of psychosocial functioning measures have been developed (Patterson et al., 1997). These include self-reports, collateral reports, clinicians’ ratings, direct observation and most recently, performance-based measures. On these measures, younger patients tend to be impaired across a variety of independent living skills, including financial management, decision-making and homemaking (Hintikka et al., 1999). They also appear to be more impaired than similarly aged patients with bipolar disorder, major depression and anxiety disorders across areas of social functioning, especially involvement in pro-social behavior and recreational activities (Addington et al., 2001; Birchwood et al., 1990; Dickerson et al., 2000). Although functional deficits clearly persist throughout the course of schizophrenia, less is known about the specific nature of this course. Like younger patients, older patients typically display greater functional disability than age-matched controls in their ability to perform daily activities (Klapow et al., 1997; Patterson et al., 1998), medication adherence (Fenton et al., 1997; Patterson et al., 2002) and social functioning. Aging has also been associated with further deterioration of functioning in schizophrenia patients, especially in late life (Friedman et al., 2001). For example, Dickerson et al. (1999) demonstrated that younger age was associated with better functioning at the end of a longitudinal investigation of schizophrenia. Functional deficits also strongly discriminate older patients in nursing homes from community-dwelling patients (Harvey et al., 1998). In order to better elucidate the relationship between aging and psychosocial functioning in schizophrenia, additional information is needed on the functional status of older patients. It is important to study psychosocial functioning in older patients with schizophrenia for several other reasons as well. First, the number and proportion of elderly Americans is expected to rapidly

increase in the coming years. By 2011, members of the baby-boom generation will turn 65, which raises the possibility of an upcoming crisis in geriatric mental health care (Palmer et al., 1999). The aging of America, taken together with the recent increased emphasis on psychosocial functioning as a target of treatment, highlights the importance of developing reliable and valid measures of functioning in older patients with schizophrenia. Second, focusing on elderly patients is also important because age-related cognitive decline, which may be abnormally accelerated in schizophrenia (Granholm et al., 2000), may exacerbate functional decline in older patients (Friedman et al., 2001; Harvey et al., 1999). Finally, certain functional domains may be less relevant as important outcomes or targets of treatment for older patients compared to younger patients. The primary goal of this study, therefore, was to compare psychosocial functioning in a sample of older outpatients with schizophrenia to that of nonpsychiatric controls using the Independent Living Skills Survey (ILSS; Wallace, 1986; Vacarro et al., 1992; Wallace et al., 2000). The ILSS is a measure of the basic functional living skills of individuals with severe and persistent mental illness, like schizophrenia. It is convenient to administer in about 15 min, measures multiple areas of functioning that are relevant to the majority of individuals with schizophrenia, and has been shown to be a reliable, stable and sensitive measure of functional deficit in schizophrenia, but only in younger patients (Wallace, 1986; Vacarro et al., 1992; Wallace et al., 2000; C. J. Wallace, personal communication, 2002). The sensitivity of the ILSS subscales to functional deficits in this older sample was examined. While cognitive impairment has repeatedly shown to be the best predictor of psychosocial functioning in patients with schizophrenia, the predictive role of symptomatology is less clear (Green, 1996; Green et al., 2000; Harvey, 2001; Harvey et al., 1998, 1999; Klapow et al., 1997; Kurtz et al., 2001; McGurk et al., 2000; Patterson et al., 1998, 2001a,b; Trauer, 2001). A secondary goal of this study, therefore, was to examine the relationship between symptoms and functioning in an older sample. Finally, the independent contributions of demographic variables including

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Negative Syndrome Scale (PANSS; Kay et al., 1987). PANSS scores were computed according to a factor analytically derived five factor model of schizophrenia symptoms, which consists of positive, negative, cognitive, depression/anxiety and excitability factors (Lindenmayer et al., 1995). PANSS factor scores for the patients were as follows: positive, M(S.D.) = 1.92(0.9); negative, 1.97(0.9); cognitive, 1.83(0.6); depression/anxiety, 1.73(0.7); excitability, 1.50(0.7). Their total PANSS score was M(S.D.) = 53.4(15.3). Forty nonpsychiatric healthy control participants with no DSM-IV diagnoses of past or current mood, anxiety, or psychotic disorders (based on the SCIDNonpatient Version; Spitzer et al., 1990) were also recruited to be comparable in age to the patient group. These participants were recruited from among volunteers at the Veterans Affairs San Diego Healthcare System and the general community, using local advertisements. Table 1 displays demographic information for the patient and control samples. Controls did not differ significantly from the patient population in terms of age or ethnic composition. However, the patients were significantly more likely to be male, less educated, unemployed and living in a board-and-care facility (see Table 1).

age, gender and education, and interactions between these variables were examined to assess their relationship with psychosocial functioning.

2. Method 2.1. Participants Fifty-seven middle-aged and elderly outpatients with a DSM-IV diagnosis of schizophrenia (American Psychiatric Association, 1994) were recruited from the University of California, San Diego Geriatric Psychiatry Clinical Research Center (GPCRC). The GPCRC recruits participants from the Veterans Affairs San Diego Healthcare System, University of California, San Diego Psychiatry Outpatient Services, San Diego County Mental Health Services and private physicians. All patients were community-dwelling outpatients (i.e., not institutionalized). A clinical diagnostic evaluation was completed using the Structured Clinical Interview for DSM-IV or SCID-patient version (Spitzer et al., 1990) and data collected from medical and neurological exams for consensus diagnostic staffing when necessary. Symptom severity ratings were also acquired using the Positive and Table 1 Demographics and clinical comparison of the two groups of participants

Age (years) Education (years)

Gender Male Female Ethnicity Caucasian African – American Latino Asian – American Living situation Board-and-care home Alone or with someone Employment Employed Unemployed

Nonpsychiatric group (n = 40)

Schizophrenia group (n = 57)

t

df

p

Mean (S.D.)

Mean (S.D.)

60.0 (7.2) 14.3 (2.0)

57.2 (7.2) 12.2 (3.3)

1.9 3.6

95 95

ns < 0.001

N (%)

N (%)

v2

df

p

14 (35.0) 26 (65.0)

36 (63.2) 21 (36.8)

7.46

1

< 0.01

28 7 4 1

44 6 2 5

4.11

3

ns

(70.0) (17.5) (10.0) (2.5)

(77.2) (10.5) (3.5) (8.8)

0 (0.0) 40 (100.0)

29 (50.9) 28 (49.1)

29.0

1

< 0.001

16 (40.0) 24 (60.0)

5 (8.8) 52 (91.2)

13.5

1

< 0.001

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2.2. Independent Living Skills Survey Participants were administered the self-report version of the ILSS in an interview format, where the examiner read questions aloud if needed. The questionnaire assesses functioning in 10 areas: personal hygiene (12 items) measures the ability to maintain cleanliness; appearance and care of clothing (9 items) assesses the ability to keep clothes clean and store them appropriately; care of personal possessions (6 items) measures the ability to perform common everyday household chores; food preparation/storage (7 items) measures the ability to obtain and cook simple, nutritional foods and to maintain a clean cooking space; health maintenance (7 items) assesses the ability to take care of one’s health; money management (5 items) assesses performance of common financial chores, such as paying bills and cashing checks; transportation (5 items) reflects the use of public transportation or automobile travel; leisure and community (12 items) measures the extent to which respondent engages in recreational activities; job seeking (4 items) assesses the execution of job-seeking behaviors; and job maintenance (3 items) assesses the quality of the current or previous job experience. Each area is scored by summing and then averaging its responses over the number of items answered ‘‘yes’’ or ‘‘no’’ in that area (0 = no, 1 = yes); items answered ‘‘not apply’’ are ignored. An area is not scored if there are less than four ‘‘yes’’ or ‘‘no’’ responses except for the three-item job seeking section, which was not scored unless all three responses were either ‘‘yes’’ or ‘‘no.’’ In order to obtain an overall summary score of functioning, all scored functional areas on the ILSS were averaged into a Global Functioning Score. Functional areas that had been dropped from the analysis due to having too few ‘‘yes’’ or ‘‘no’’ responses were not included in the calculation of the Global Functioning Score. The criteria for a ‘‘not apply’’ response given by Wallace et al. (2000) state that the response should only be coded if the behavior assessed by an item is not allowed in the respondent’s current setting. We originally coded participants who were unemployed due to either disability or retirement as ‘‘not apply’’ on the items in the job seeking area. However, the resultant samples size for that item drastically re-

duced, because 78.4% of our total sample was not working, and the domain dropped out for most participants, especially patients. We resolved the ambiguity by assigning all participants, regardless of reason for unemployment (e.g., retirement, disability), the code ‘‘no’’ for any job seeking items not performed (reading classified ads, contacting potential employees, contacting others to obtain job leads and participating in job interviews), and this coding scheme was adhered to consistently across all patients and controls. We reasoned that job opportunities exist in the community setting, regardless of whether participants are retired or disabled, so the setting does allow for job seeking behaviors. The only participants with items in the job seeking domain coded as ‘‘not apply’’ were those who were currently employed (21.6%), because job-seeking behaviors were not applicable to this group. Internal consistency of the ILSS was calculated by computing coefficient alphas for each functional area. After accounting for dropped functional areas due to the ‘‘not apply’’ scoring convention, the smallest sample size for any a was 23, the largest was 85 and the average was 68. a for the entire instrument was not computed because the number of participants with data for all 10 areas was too small (n = 6). The coefficient a’s for each functional area were comparable to those reported by Wallace et al. (2000), and ranged from marginal to good: hygiene = 0.79, appearance and clothing = 0.52, care of personal possessions = 0.56, food preparation/storage = 0.49, health maintenance = 0.56, money management = 0.71, transportation = 0.48, leisure = 0.66, job seeking = 0.90, job maintenance = 0.76. 2.3. Data analyses Data were examined for normality of distribution, and severe violations were found in the distributions of both ILSS and PANSS scores. Several transformation attempts were made to improve normality, yet these were largely unsuccessful. Therefore, group differences for each domain were evaluated using the nonparametric Mann – Whitney U-test. To determine the strength of the relationship between functioning and measures of psychiatric symptoms, we used the nonparametric Spearman correlation coefficient. We then further

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examined the relationship between the ILSS and our measures of psychopathology by splitting the patient population into quartiles according to their PANSS factor scores. Due to the restricted range of symptoms in this relatively high functioning outpatient sample, we restricted analyses to patients with symptoms in the top (high symptoms) and bottom (low symptoms) quartiles. The Mann – Whitney Utest was used to compare the two PANSS negative symptom factor groups and the two PANSS positive symptom factor groups (defined by quartiles) on the ILSS areas of functioning. In order to determine the relative importance of the various demographic variables in predicting the participants’ ILSS scores, multiple regression analyses were conducted with ILSS functional area as dependent variable and group, age, gender, education and the interactions between group and these variables as independent variables. In order to reduce type I errors associated with multiple comparisons, only a levels that were < 0.01 (two-tailed) were considered significant in all tests involving group comparisons (i.e., excluding demographic regressions).

3. Results Patients with schizophrenia scored significantly worse than controls on the ILSS Global Functioning Score (U = 143.5, p < 0.001, d = 2.22). The two groups were also compared on the 10 areas of functioning assessed by the ILSS (Fig. 1). Patients scored significantly worse than controls on 8 of the 10 functional areas: appearance and clothing (U = 605.5, p < 0.001, d = 0.92), personal hygiene (U = 375.5, p <0.001, d = 1.23), food preparation and storage (U = 314.5, p < 0.001, d = 0.90), health maintenance (U = 716.0, p < 0.01, d = 0.69), money management (U = 382.0, p < 0.01, d = 0.67), transportation (U =292.5, p < 0.001, d = 1.43), leisure and community (U = 350.0, p < 0.001, d = 1.31) and job seeking (U =494.5, p < 0.001, d = 1.08). To remove the influence of the minority of participants who were employed from the job seeking section, only unemployed, disabled and retired patients (n = 52) and controls (n = 24) were compared on this area, and patients still scored significantly worse than controls (U = 468.5, p < 0.01, d = 0.94). Patients and

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controls were not significantly different on care of personal possessions (U = 819.0, p>0.05, d = 0.23) or job maintenance (U = 761.0, p>0.05, d = 0.05). Participants who lived at board-and-care facilities responded ‘‘not apply’’ to items in several domains (e.g., care of personal possessions, food preparation), since these facilities typically provide cleaning, cooking and other community functioning services for their residents. As a result, these areas dropped out for these participants, creating the possibility that functional deficits in some domains were masked by a scoring artifact. To investigate this possibility, analyses were repeated only for patients not living at a board-and-care facility (n = 28). This subset of patients still displayed impaired functioning relative to controls, scoring significantly worse on seven of the same functional areas as in the previous analysis: appearance and clothing (U = 365.0, p < 0.01, d =0.74), personal hygiene (U = 236.5, p < 0.001, d =1.13), food preparation and storage (U = 294.5, p < 0.01, d = 0.78), health maintenance (U = 334.0, p < 0.01, d = 0.78), transportation (U = 173.5, p <0.001, d = 1.35), leisure and community (U = 147.0, p < 0.001, d = 1.54) and job seeking (U = 242.0, p <0.01, d = 0.90). This analysis, however, also revealed three findings not seen in the previous analysis of the sample as a whole. First, the subset of nonboard-and-care residing patients scored worse than controls on care of personal possessions (U = 341.0, p < 0.05, d = 0.57), which is consistent with the presence of a scoring artifact in the sample as a whole. Second, whereas in the sample as a whole, patients displayed functional impairment in money management, the nonboard-and-care patients did not differ from controls in this area (U = 330.5, p>0.05, d = 0.42). Finally, there was a trend for these nonboard-and-care patients to score worse than controls on job maintenance (U = 328.0, p = 0.06, d = 0.20). 3.1. Psychopathology effects Spearman’s correlation coefficients were computed within the schizophrenia group to investigate the relationship between symptoms and functioning in each functional area (Table 2). Food preparation and storage abilities were significantly negatively correlated with positive symptoms, but no other evidence

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Fig. 1. Mean scores (with standard error bars) on the 10 ILSS functional areas for the nonpsychiatric participants and patients with schizophrenia. Numbers below bars indicate the number of participants whose data entered the analysis.

of a consistent relationship was found, and the majority of correlations were very weak. These correlations may have been compromised, however, by the relatively low variability of symp-

toms in our patient sample. Therefore, patients with the worst negative symptoms were compared to those with the least negative symtomps, based on their quartile scores on the negative symptom factor

Table 2 Correlations between functioning measured by the ILSS and symptom scores for schizophrenia group PANSS positive Appearance and clothing Care of personal possessions Food preparation/storage Health maintenance Personal hygiene Job maintenance Job seeking Leisure and community Money management Transportation Global Functioning Score * p < 0.01.

0.128 0.153 0.497* 0.020 0.019 0.010 0.095 0.018 0.003 0.140 0.114

PANSS negative 0.143 0.097 0.172 0.120 0.120 0.202 0.144 0.044 0.391 0.021 0.002

PANSS cognitive 0.187 0.093 0.159 0.017 0.184 0.079 0.234 0.139 0.101 0.165 0.206

PANSS depression/ anxiety

PANSS excitability

0.130 0.002 0.200 0.021 0.052 0.031 0.164 0.066 0.043 0.002 0.104

0.074 0.138 0.275 0.049 0.005 0.070 0.182 0.154 0.042 0.322 0.148

PANSS grand total 0.172 0.040 0.352 0.041 0.186 0.168 0.161 0.002 0.206 0.005 0.086

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of the PANSS. There were no significant differences in functioning between these patients for any functional area. Similarly, patients with the worst positive symptoms did not significantly differ in functioning than those with the least positive symptoms, as defined by their quartile scores on the positive symptom factor of the PANSS, for any functional area. 3.2. Demographic effects Multiple regression analyses revealed that demographics were related to several ILSS functional areas. Demographics appeared to be most related to job seeking. Older age (b = 1.21, t = 3.51, p < 0.01), male gender (b = 0.66, t = 2.03, p = 0.05) and lower education (b = 0.67, t = 1.92, p = 0.06) were all significantly associated with worse performance on this functional area (education was marginally significant). There was also a significant age by group interaction (b = 2.46, t = 3.17, p < 0.01) for job seeking; there was no significant correlation between age and job seeking in schizophrenia patients (r = 0.08, p>0.05), but there was a negative relationship between age and job seeking in controls (r = 0.52, p < 0.01). There was a significant gender by group interaction for personal hygiene (b = 0.99, t = 3.04, p < 0.01); female patients with schizophrenia scored significantly better on this functional area compared to males (U = 155.0, p < 0.001, d = 1.12), while female and male controls did not differ (U = 171.0, p>0.05, d = 0.07). There was a marginally significant gender by group interaction for transportation (b = 0.667, t = 1.89, p = 0.06); male schizophrenia patients scored significantly better on this functional area than female patients (U = 194.0, p < 0.05, d = 0.65), while male and female controls did not differ (U = 155.0, p>0.05, d = 0.00). Finally, education significantly predicted job maintenance ratings (b = 2.07, t = 5.18, p < 0.001), and there was a significant education  group interaction (b = 3.36, t = 4.9, p < 0.001); there was a negative relationship between self-reported job maintenance and education in schizophrenia patients (r = 0.17, p>0.05) and a positive relationship in controls (r = 0.12, p>0.05), but neither correlation was statistically significant.

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4. Discussion The self-report version of the ILSS appears to be a sensitive measure of basic functional living skills in middle-aged and older patients with schizophrenia. Patients demonstrated worse overall functioning than age-comparable nonpsychiatric participants, as indicated by the ILSS Global Functioning Score. This finding is consistent with the literature on younger patients (Klapow et al., 1997; Patterson et al., 1998). More specifically, patients were impaired on the majority of the functional areas assessed by the ILSS, including their ability to maintain a neat appearance and clean clothing, prepare and store food correctly, engage in effective health maintenance behaviors, maintain personal hygiene, engage in job-seeking behaviors, participate in recreational activities, manage their finances and use transportation. In the sample as a whole, patients did not appear impaired in their care of personal possessions, which includes chores like making the bed and keeping the living space clean. We hypothesized that due to the nature of the ‘‘not apply’’ scoring scheme of the ILSS, functional deficits in areas like care of personal possessions could be masked by a scoring artifact in patients living at board-and-care facilities. The finding of impaired functioning in this area in a subset of nonboard-and-care patients is consistent with the effects of such an artifact. In the sample as a whole, the lack of a significant difference in functioning between groups on the job maintenance area may be related to the fact that the items ask about current or previous job. Most of the patients with schizophrenia (78.4%) were not employed, and therefore answered the questions with reference to their last period of employment. The majority of patients in this older sample had not been employed since before the onset of their illness, which was on average thirty years ago. It is not clear whether the patients were able to accurately recall the nature of that work environment so long ago. Interestingly, however, the subset of nonboardand-care-residing patients tended to score worse than controls on job maintenance. Patients who do not reside at such facilities are likely higher functioning and may therefore have better memory of their previous employment; also, their previous employment may have been more recent. This explanation

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of higher-functioning nonboard-and-care patients might also account for the finding that nonboardand-care residents were not impaired on money management skills, relative to controls. Money management skills are essential to paying rent and bills to maintain independent housing. Related to job maintenance is job seeking. A vast majority of patients stated that they were not looking for work due to illness disability. Under the original ‘‘not apply’’ scoring convention, these patients had missing data on the job seeking area, and analyses were limited to the few patients who were employed or seeking employment. As a result, patients appeared comparable to controls on job seeking, which was clearly not the case. We decided to use a new scoring convention that better captured this problem. Under this convention, patients reported significantly less job-seeking behaviors than controls, even when comparing unemployed patients to unemployed controls. This is consistent with the finding that unemployment rates for individuals with mental disorders are three to five times higher than those with no disorder (Sturm et al., 1999). Recent evidence suggests, however, that a sizable minority of older outpatients with schizophrenia is able to maintain surprisingly high levels of independence (Palmer et al., 2002). Improvement of job-seeking behaviors may, therefore, be a worthwhile target of vocational rehabilitation interventions, even for older patients with schizophrenia nearing retirement age. We found that although scizophrenia patients did less job-seeking than controls, older age was associated with less job-seeking only in controls. Therefore, in this sample of older individuals, job-seeking declines with normal aging and remains stable yet still markedly deficient in schizophrenia. This suggests that job-seeking may become impaired much earlier in schizophrenia patients, thereby highlighting the importance of early intervention in this functional area. Results from previous research regarding the relationship between psychosocial functioning and symptoms in patients with schizophrenia have been mixed (Green, 1996, 2000; Harvey, 2001; Klapow et al., 1997; Kurtz et al., 2001; McGurk et al., 2000; Patterson et al., 1998, 2001a,b; Trauer, 2001). Some studies of younger patients and older institutionalized patients suggest that negative symptoms

are more strongly associated with functional impairment than are positive symptoms (Harvey et al., 1998, 1999). Patients with worse positive symptoms were more likely to be impaired on food handling activities, but otherwise we did not find evidence of a consistent relationship between symptomotology and the functional areas assessed on the ILSS in this sample of older outpatients with schizophrenia. Realizing that this may have been due to the limited range of symptoms in the sample, we compared functioning only on patients with the most and least severe positive and negative symptoms, but again, no relationship was found. Nonetheless, if we had sampled patients with a broader range of symptom severity, we might have had greater power to detect relationships between functioning and symptomotology. For both patients and controls, the lowest levels of functioning were found in the transportation, leisure and community, and job seeking areas of the ILSS, suggesting that these areas are particularly susceptible to impairment in older individuals. Effect size estimates indicated that schizophrenia patients differed most from controls (highest ds) on two of these same areas—transportation and leisure and community skills. Taken together, these findings suggest that age-related functional decline may add to or interact with the effects of schizophrenia to produce the most impairment in these functional areas. These may be important areas particularly relevant to target in new interventions for older schizophrenia patients. Notably, our sample consisted of a limited age range. A true test of age-related decline in psychosocial functioning would examine a broader range of ages. We examined the relationship between education, gender and psychosocial functioning and found varying results. Male gender predicted worse job seeking functioning in the sample as a whole. Male patients showed worse personal hygiene functioning that female patients and female patients showed worse transportation functioning than male patients. These gender differences were not found in the control sample. Lower education predicted worse job seeking functioning in the sample as a whole. Education had differential effects on job maintenance in the patient and control groups—unexpectedly, higher education was associated with worse

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job maintenance scores in patients but better job maintenance scores in controls. Taken together, these results suggest that gender and education may be associated with certain aspects of psychosocial functioning, but there is no evidence of a consistent relationship of these demographic variables on functioning. While previous studies have focused on establishing the psychometric properties of the ILSS (Vacarro et al., 1992; Wallace et al., 2000), our findings uniquely cotribute to the literature by demonstrating that the ILSS is sensitive to deficiencies across numerous areas of functioning in older outpatients with schizophrenia. Our results indicate several areas of functioning that could serve as targets of interventions, and support the recent need for development of vocational and psychosocial rehabilitation interventions for this population (Bozzer et al., 1999). The ILSS may serve as a useful tool to measure functional gains in such intervention programs, which are becoming increasingly needed to address the needs of the rapidly growing elderly population. The ILSS can be improved by modifying it for use in older psychiatric populations. As evidenced by our findings on the care of personal possessions and job seeking areas, its scoring convention may obscure functional deficits in these populations by assigning ‘‘not apply’’ to patients with severe deficits, such as those who live in board-and-care facilities or those who do not seek employment due to mental illness. It would also be useful to examine the relationship between psychosocial functioning on the ILSS and measures of cognitive functioning, since increasing evidence indicates that the latter may be a stronger predictor of functioning in patients with schizophrenia than symptom severity (Green, 1996; Green et al., 2000).

Acknowledgements Support for this work was provided in part by National Institute of Mental Health grants R01 MH6138 and R01 MH6255, and in part by the 1P30MH066248-01 Center for Research in Older People with Psychoses of the Department of Veterans Affairs.

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