Letters to the Editor. Kenneth F. Ferraro's interesting article (1992) on the images of older people held by American adults, and their relevance to various definitions of ageism, inaccurately states that in my 1982 Kent Lecture I "asserted that the public opinion tide had turned such that Americans by and large regarded older people as relatively well-off and politically mobilized" (Ferraro, 1992, p. 297). Rather, I observed that these stereotypes had recently emerged "in the media, political speeches, public policy studies, and the writings of scholars" (Binstock, 1983, p. 136). The distinction should be maintained between public opinion, on the one hand, and images expressed (and held, perhaps) by journalists, politicians, policy analysts, and academicians, on the other hand. If Ferraro were to conduct his analysis for the years 1982-1992 he might still find, as he did for 1974-1981, that the American citizenry regards older people as less well-off than they are and, by implication, would be supportive of expansions in public benefits for the stereotyped "needy elderly." But contemporary public rhetoric suggests that the Old-Age Welfare State, which benefits the prosperous, hedonistic, selfish, and politically powerful elderly — the "greedy geezers" (Fairlie, 1988) — should be dismantled. The framing of public issues — or, as it is termed in the political science literature, agenda-building (Elder & Cobb, 1984) — shapes policy decisions. And policies, in turn, can express and promulgate ageism (whichever definition of the term one employs), even as they can foster racism and sexism. Those of us who are concerned with maintaining and enhancing the status of the most disadvantaged older persons through public policies cannot rest easy because the populace (in 1974-1981, and perhaps today) may hold compassionate stereotypes of older persons. Robert H. Binstock, Ph.D. Henry R. Luce Professor of Aging, Health, and Society Case Western Reserve University Cleveland, OH References

Binstock, R. H. (1983). The aged as scapegoat. The Gerontologist, 23,136-143. Elder, C. D., & Cobb, R. W. (1984). Agenda-building and the politics of aging. Policy Studies Journal, 13, 115-129. Fairlie, H. (1988). Talkin' 'bout my generation. New Republic, 198 (13), 19-22. Ferraro, K. F. (1992). Cohort change in images of older adults, 1974-1981. The Gerontologist, 32, 296-304.

Kenneth F. Ferraro, Ph.D. Associate Professor of Sociology Purdue University West Lafayette, IN Reference Cook, F. L. (1992). Ageism: rhetoric and reality. The Gerontologist, 32, 292293.

Ferraro replies

I appreciate the comments on my recent article in Fay Cook's accompanying editorial (1992) and in Robert Binstock's letter. They help clarify some issues regarding images and rhetoric about "older people" in American society. In response to Dr. Cook, two points are in order. First, I did not intend for the paper to be simplified as a statement that "we are ageist" (p. 292). I examined change in images of older persons during 1974-1981 and found that (a) most Americans felt that the overall status of older people declined between the surveys and (b) more recent cohorts were among those most likely to believe this. This second

Vol. 32, No. 4,1992

MDS Data Should be Used for Research

The recent editorial by Teresi and Holmes (1992) raises issues about the validity and reliability of data from the Minimum Data Set (MDS) for nursing home residents (Morris et al., 1990). Although they make some appropriate warnings, some of their issues reflect confusion about how valid and reliable data can be gathered in nursing homes. Unfortunately, both the editorial's title "Should MDS Data

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finding, in light of cohort flow and social change, led me to suggest that gerontologists would be mistaken to assume that America is becoming less stereotypical in its images of older adults. Second, although I agree with Dr. Cook that survey questions about "older people" may underestimate the public's appreciation for the diversity of the older population, the data showed that the public did not even understand the direction of change in status experienced by most older adults. Moreover, age norms and images merit study because they influence the very substance of the social order— people act upon the basis of shared expectations of social categories and groups. As a neighbor recently remarked, "I don't like to swim at the YWCA when the elderly are in the pool." Apropos of Dr. Binstock's concern, I may have oversimplified his characterization of change in public rhetoric as affecting public opinion. Discussing the genesis of compassionate ageism, the Kent lecture noted that rhetoric affected opinion prior to 1978: "The message took hold. American society accepted the notion that all older persons are essentially the same" (p. 140). I now see that he did not conclude that the rhetoric after 1978 had been so influential. Indeed, it was clear from the 1974-1981 results I presented that Americans were not persuaded by the public rhetoric into characterizing elders as well off. Whether the rhetoric has moved opinion in the last decade is still an open question. As long as people avoid "the elderly," and images of "greedy geezers" and "anti-aging diets" are included in public rhetoric, I conclude we need continued study of images of aging and how they affect social interactions. I agree with Dr. Cook that we need further research on the specific determinants of stereotypes and discrimination affecting older people. I hope that my article will stimulate some of that research as well as critical thought about assumptions of social change in images of aging. Whereas more recent cohorts showed less understanding of the positive changes experienced by the older adult population, I share Dr. Binstock's uneasiness about the prevalence of compassionate stereotypes of older Americans.

Public Opinion Versus Public Rhetoric

Furthermore, particularly in the field of cognitive testing, typical standardization is not a sufficient condition for assuring validity and reliability. For example, in William Belson's experimental work (1981) on design of survey items, only 30% of respondents answering 29 standardized items correctly interpreted the questions that they were asked. Studies of the convergent validity of MDS-based scales compared to standardized instruments are currently in

progress, and in many areas the correlation of new MDSbased measures with measures currently in use is impressive (Hawes et al., 1992). As with other research efforts, many of these studies use MDS data derived from research efforts involving considerable training and supervision of data collectors to assure rigorous adherence to the specified data collection protocols. Under these circumstances, we know that the MDS yields valid and reliable data. Indeed, the MDS is already being used in a major, multisite research effort. Many of the MDS items and protocols have recently been mandated as part of the "core" data base for the National Institute of Aging's Cooperative Agreement for the Study of Alzheimer's Special Care Units. This decision was supported by NIA staff, an expert panel, and principal investigators for the 10 individual grants. Teresi and Holmes are correct to expect variability among facilities in implementation of the MDS. Some states, such as New York, have chosen what may be less than ideal implementation strategies. Others have devoted considerable resources to maximize the quality of MDS data. In fact, determining the degree to which MDS data in facilities corresponds to MDS data developed by independent assessors is a major task in a 10-state evaluation of the MDS now underway. Moreover, we note that far less complete populationbased data systems have proven extraordinarily useful. For example, the hospital discharge abstracts and Medicare claims files used in studies of acute and ambulatory care have had an enormous influence on health policy. The MDS has the potential for even greater impact on longterm care policy, precisely because it emerged from a process in which clinical utility was deemed paramount. Like any researcher doing secondary analysis, future researchers using MDS-derived data must be concerned about the quality of the data collection process from which their data are derived and exercise due care in their analyses and interpretations. However, such a warning in no way impugns the effectiveness of clinical data bases, including those based on the MDS, to test important clinical and policy hypotheses. Catherine Hawes, PhDa Charles D. Phillips, PhD, MPH Vincent Mor, PhD Brant E. Fries, PhD John N. Morris, PhD References Belson, W. A. (1981). The design and understanding of survey questions. Aldershot, England: Cower Publishing Company, Ltd. Fleiss, J. L, (1986). The design and analysis of clinical experiments. New York: John Wiley and Sons. Hawes, C , Morris, J. N., Phillips, C. D., Fries, B. E., & Mor, V. (1991). Development of resident assessment system and data base for nursing home residents: Report on the field test of the resident assessment instrument. Unpublished manuscript, Research Triangle Institute, Research Triangle Park, NC. Hawes, C , Morris, )., Phillips, C , Mor, V., & Fries, B. E. (1992, June). Validity and reliability of the Minimum Data Set for assessment and care screening. Presentation at the Annual Meeting of the Association for Health Services Research, Chicago, IL. Morris, J. N., Hawes, C , Fries, B. E., Phillips, C. D., Mor V., Katz, S., Murphy, K., Drugovich, M. L, & Friedlob, A. (1990). Designing the national resident assessment instrument for nursing homes. The Cerontologist, 30, 293-307. Teresi, J. A., & Holmes, D. (1992). Should MDS date be used for research? The Gerontologist, 32, 148-149. ^Catherine Hawes and Charles D. Phillips are at Research Triangle Institute, Research Triangle Park, NC; Vincent Mor is at Brown University, Providence, Rl; Brant E. Fries is at University of Michigan, Ann Arbor; and John N. Morris is at Hebrew Rehabilitation Center for the Aged, Boston, MA.

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be Used for Research?" and the subsequent commentary fail to distinguish between two very different questions. First, can the MDS items and data collection strategies, when used in a research protocol, provide reliable and valid data? Second, can MDS data in nursing homes' charts be used for research? On both points, they are unduly negative. Teresi and Holmes are concerned about the utility of MDS data in research efforts, given the instrument's origins as a clinical tool: "Constructs measured adequately from a clinical standpoint may not be sensitive enough for research purposes" (p. 148). Their contention that good clinical practice demands less precise information than good research seems more rooted in the hubris of health services researchers than in a careful comparison of the data needs of gerontological researchers and of clinicians involved in the complex reality of clinical decision making in geriatrics. Research tools are often used in clinical settings, and clinical tools are often used for rigorous research. Historically, measurement emerging from clinical practice has been the gold standard for the validity of a research tool. Both good clinical practice and good research require accurate data. The MDS protocols require facility staff to complete the form using multiple information sources. Teresi and Holmes consider this a near-fatal weakness. Yet, the explicit use of multiple sources of information about residents' status significantly strengthens the validity and reliability of MDS data. All research on institutionalized populations requires proxies to complete data on residents. Given realities of care in nursing facilities, a single source of information is insufficient. Different proxies may assess residents differently, in part, because of variation in the relationship between the respondent and the proxy (e.g., night shift aide vs. day shift RN). Thus, MDS protocols require that staff identify the most knowledgeable sources of data for each item; that the assessor obtain information from direct staff caregivers from all shifts; that they use multiple sources of information; and that they use additional probes of records and staff, as well as clinical judgement, to resolve any apparent discrepancies in information from those data sources. For example, licensed nurses and the medical record may be queried about diagnoses, but nursing aides on different shifts will be queried about mobility and continence. Furthermore, most item definitions offer explicit guidance in how to interpret diverse responses via a "sometimes" option and by specifying the timeframe (e.g., last 7 days). The reliability results from the final testing of the MDS (Hawes et al., 1991) demonstrate that excellent researchquality data can be gathered with the MDS. Using established criteria for research reliabilities (Fleiss, 1986), 88% of the MDS items achieved adequate reliability (.4 or higher). Items on cognitive/decision-making skills (.88), ADL selfperformance (.92), and ADL support provided (.84) were among many items that achieved excellent reliabilities; moreover, 61% of the items achieved a reliability of .6 or higher (Hawes et al., 1991). These reliabilities were achieved with data gathered by facility staff and research staff who followed the MDS protocols, including gathering data from multiple informants and sources.

MDS data should be used for research.

Letters to the Editor. Kenneth F. Ferraro's interesting article (1992) on the images of older people held by American adults, and their relevance to v...
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