Effect of a Biobehavioral Environmental Approach on Disability Among Low-Income Older Adults: A Randomized Clinical Trial

A protocol for a wait list control trial of an intervention to improve pain and depressive symptoms among middle-aged and older women living with disabilities

BACKGROUND

Women aging with disabilities experience higher rates of chronic pain and co-occurring depressive symptoms than women without disabilities and men with and without disabilities. Pain and depression can exacerbate the inability to fulfill social roles and complete activities of daily living among women with disabilities. Although there are existing interventions for both pain and depressive symptoms, few interventions have been developed with women aging with disabilities that address both chronic pain and depressive symptoms.

PURPOSE

The aim of this study is to ascertain the acceptability and feasibility of the Women in Pain Reduction & Improved Mood through Empowerment (PRIME) intervention in a sample of middle-aged and older women living with pain, depressive symptoms, and physical disabilities (i.e., mobility disability).

METHODS

In this wait-list, randomized controlled trial we will assess the intervention's 1) feasibility by determining recruitment and retention rates; 2) acceptability through qualitative interviews with all enrolled participants; and 3) preliminary efficacy by determining changes in pain and depressive symptoms between immediate intervention and waitlist control participants to estimate effect sizes to inform future research.

CONCLUSION

This intervention has two main components, which have the potential to decrease pain and depressive symptoms and lead to increased quality of life. It is imperative that clinical trials are designed and structured with the partnership and needs of women with disabilities at the center. This trial is registered at clinicaltrials.gov, NCT05619510, 11/09/2022.

Housing characteristics of low and moderate income older adults with and without disabilities

Housing is relevant to quality-of-life for older adults with and without disabilities, particularly those with limited financial resources. Among 4,898 low- and moderate-income community-living National Health and Aging Trends Study respondents, we describe and examine differences in housing characteristics of older adults with (n = 2774) and without disability (n = 2124). Next, among those with disability (self-care, household-activity, or mobility limitations), we examine associations of housing characteristics with adverse consequences due to unmet care needs, including soiling oneself or having to stay inside. In descriptive analyses, those with disability (vs without) more commonly rented, lived in subsidized housing, lived in apartments or mobile homes, and with home disorder, home disrepair, and street disorder. In adjusted logistic regressions among the subgroup with disability, several housing characteristics were statistically significantly associated with adverse consequences. Policy, programmatic, and clinical interventions that account for housing as an important social determinant of older adult quality-of-life should be advanced.

Effectiveness of the Interdisciplinary Home-bAsed Reablement Programme (I-HARP) on improving functional independence of people living with dementia: a multicentre, pragmatic, randomised, open-label, controlled trial

BACKGROUND

We investigated the effectiveness of an Interdisciplinary Home-bAsed Reablement Programme (I-HARP) on improving functional independence, health and well-being of people with dementia, family carer outcomes and costs.

METHOD

A multicentre pragmatic parallel-arm randomised controlled trial compared I-HARP to usual care in community-dwelling people with mild to moderate dementia and their family carers in Sydney, Australia (2018-2022). I-HARP is a 4-month, home-based, dementia rehabilitation model delivered by an interdisciplinary team. Assessments were conducted at baseline (time-1), 4-month (time-2) and 12-month (time-3) follow-up. The primary outcome measure was the client's functional independence using the Disability Assessment for Dementia (DAD) scale at time-2, based on intention-to-treat analyses.

RESULT

Of 130 recruited client-carer dyads, 116 dyads (58/group) completed the trial. The I-HARP group were not significantly better in most outcome measures than usual care at both time-2 and time-3; with the only statistically significant difference being a reduction in home environment hazards at time-2. Post hoc subgroup analysis of 66 clients with mild dementia found significantly better functional independence in the intervention group compared with those in usual care: difference 8.99 on DAD (95% CI 1.21, 16.79) at time-2 and difference 12.16 (95% CI 1.93, 22.38) at time-3. Economic evaluation suggests potentially lower resource use in I-HARP compared with usual care, but the cost-effectiveness is uncertain.

CONCLUSION

Primary outcomes were not met for a population of people with dementia, with severity ranging from mild to moderate and severe. The I-HARP model appeared to benefit functional independence of participants with mild dementia, with potential cost savings.

TRIAL REGISTRATION NUMBER

ACTRN12618000600246.

Age Self Care, a program to improve aging in place through group learning and incremental behavior change: Preliminary data

BACKGROUND

Few programs exist to support aging in place for older adults. Age Self Care is a novel program providing older adults with evidence-based information using group sessions embedded within the structure of a community-based organization (CBO) to facilitate behavior change and support aging in place. We report on a preliminary study of Age Self Care conducted in collaboration between the University of California, San Francisco (UCSF) Division of Geriatrics, At Home With Growing Older (AHWGO), and San Francisco Village (SF Village).

METHODS

We recruited middle-income, community-dwelling adults aged 65+ from university outpatient clinics. Participants attended eight 90-min, video-based group sessions and enrolled in SF Village, a non-profit mutual support organization for older adults. Data collection included direct observations and a participant focus group. We used rapid analysis methods informed by the COM-B model (Capability, Opportunity, Motivation, Behavior Change) to assess behavior change.

RESULTS

Fourteen participants completed the 8-week study (15 enrolled, 1 withdrew). Average attendance was 81% throughout the program. We found that 14 participants made concrete changes to optimize the ability to remain at home during the program. For example, participants engaged in evidence-based falls risk reduction activities such as decluttering and improving lighting. We identified three facilitators to behavior change. First, Age Self Care promoted self-management-the day-to-day management of health and chronic conditions by individuals-through education and community-based resources. Second, peer support empowered participants to take charge of their health, home environment, and social networks. Third, the online platform created a community and was a catalyst for social opportunity. We identified one non-modifiable barrier: pre-existing financial barriers hindered some behavior change.

CONCLUSIONS

In this preliminary study, Age Self Care facilitated behavior change, including minor home modifications, fall risk reduction, and engagement in social networks, all of which support aging in place.

Perceptions from people with physical disabilities about accessibility and social conditions: interventions for rehabilitation nursing

OBJECTIVES

to analyze the experiences of people with acquired physical disabilities regarding accessibility and social conditions; to identify nurse-led rehabilitation interventions for accessibility and social conditions; to determine nursing-sensitive indicators to improve accessibility and social conditions.

METHODS

a descriptive-exploratory qualitative study employed semi-structured interviews with people with acquired physical disabilities through purposive snowball sampling to address all objectives. Data analysis followed Bardin's content analysis principles. Furthermore, objectives 2 and 3 were achieved through a reflective theoretical approach.

RESULTS

the 27 participants reported accessibility challenges, impacting activities of living and social conditions. This influences rehabilitation nursing, leading to three intervention fields: Assess the ability to perform activities of living and influencing factors; Develop and implement training to perform activities of living; Promote mobility, accessibility, and social participation.

FINAL CONSIDERATIONS

based on participants experiences, we identified nurse-led rehabilitation interventions to promote accessibility and social conditions.

Functional Impairments, Phenotypic Frailty, and Sector-Specific Incremental Healthcare Costs in Older Adults

BACKGROUND

This study quantifies incremental healthcare expenditures of functional impairments and phenotypic frailty in specific healthcare sectors.

METHODS

Pooled 2023 analysis of 4 prospective cohort studies linked with Medicare claims including 4 318 women and 3 847 men attending an index examination (2002-2011). Annualized inpatient, skilled nursing facility (SNF), home healthcare (HHC), and outpatient costs (2023 dollars) ascertained for 36 months following index examination. Functional impairments (difficulty performing 4 activities of daily living) and frailty phenotype (operationalized using 5 components) derived from cohort data. Weighted multimorbidity index including demographics derived from claims.

RESULTS

Mean age at index examination was 79.2 years. After accounting for multimorbidity and each other, average annualized incremental costs of 3-4 functional impairments versus no impairment in women (men) were $2 838 ($5 516) in inpatient, $1 572 ($1 446) in SNF, and $1 349 ($1 060) in HHC sectors; average incremental costs of phenotypic frailty versus robust in women (men) was $4 100 (not significant for men) in inpatient, $1 579 ($1 254) in SNF, and $645 ($526) in HHC sectors. Incremental inpatient costs were primarily due to a higher hospitalization risk, while incremental SNF and HHC costs were related to both increased risks of utilization and higher costs among individuals with utilization. Neither geriatric domain was associated with outpatient costs.

CONCLUSIONS

In this study of community-dwelling beneficiaries, functional impairments were independently associated with higher subsequent expenditures in inpatient, SNF, and HHC sectors among both sexes. Phenotypic frailty was independently associated with higher subsequent inpatient costs in women, and higher SNF and HHC costs in both sexes.

Extreme Heat, Functional Disability, and Social Isolation: Risk Disparity Among Older Adults

This study examines how functional disability worsens among older adults exposed to extreme heat, particularly those socially isolated. Analyzing data from over 35,000 older adults aged 50 or older from the Health and Retirement Study from 1996-2018, this study found that more frequent exposure to extreme heat is associated with an increase in the number of instrumental activities of daily living (IADL) that older adults find difficulty in performing over time. This heat-related disability progression is greater among those living alone and not working. However, findings indicate that maintaining contact with children and receiving higher levels of support from friends can alleviate the risk of IADL disability progression amidst extreme heat days for older adults with limited social relationships at home and work. By examining various aspects of social isolation and their nuanced effects, this study underscores the need for social support and assistance for older adults during extreme heat.

Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis

Background

Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement.

Objectives

To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect.

Review design

Systematic review and network meta-analysis.

Eligibility criteria

Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention.

Main outcomes

Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year.

Data sources

We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists.

Review methods

Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis).

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive.

Limitations

High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts.

Conclusions

Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence.

Future work

Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.

Study registration

This study is registered as PROSPERO CRD42019162195.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Geriatric conditions and healthcare utilization among older adults living in subsidized housing

BACKGROUND

Nearly 2.9 million older Americans with lower incomes live in subsidized housing. While regional and single-site studies show that this group has higher rates of healthcare utilization compared to older adults in the general community, little is known about healthcare utilization nationally nor associated risk factors.

METHODS

We conducted a retrospective cohort study of Medicare beneficiaries aged ≥65 enrolled in the National Health and Aging Trends Study in 2011, linked to Medicare claims data, including individuals living in subsidized housing and the general community. Participants were followed annually through 2020. Outcomes were hospitalization, short-term skilled nursing facility (SNF) utilization, long-term care utilization, and death. Fine-Gray competing risks regression analysis was used to assess the association of subsidized housing residence with hospitalization and nursing facility utilization, and Cox proportional hazards regression analysis was used to assess the association with death.

RESULTS

Among 6294 participants (3600 women, 2694 men; mean age, 75.5 years [SD, 7.0]), 295 lived in subsidized housing at baseline and 5999 in the general community. Compared to older adults in the general community, those in subsidized housing had a higher adjusted subdistribution hazard ratio [sHR] of hospitalization (sHR 1.21; 95% CI, 1.03-1.43), short-term SNF utilization (sHR 1.49; 95% CI, 1.15-1.92), and long-term care utilization (sHR 2.72; 95% CI, 1.67-4.43), but similar hazard of death (HR, 0.86; 95% CI, 0.69-1.08). Individuals with functional impairment had a higher adjusted subdistribution hazard of hospitalization and short-term SNF utilization and individuals with dementia and functional impairment had a higher hazard of long-term care utilization.

CONCLUSIONS

Older adults living in subsidized housing have higher hazards of hospitalization and nursing facility utilization compared to those in the general community. Housing-based interventions to optimize aging in place and mitigate risk of nursing facility utilization should consider risk factors including functional impairment and dementia.

The effectiveness of preventive home visits on resilience and health-related outcomes among community dwelling older adults: A systematic review

BACKGROUND

This research aimed to assess the effectiveness of preventive home visits (PHVs) in enhancing resilience and health-related outcomes among older adults living in the community.

METHODS

A comprehensive literature search was conducted in nine databases (PubMed, MEDLINE, CINAHL, Embase, Emcare, Web of Science (WOS), Scopus, PsycINFO and Cochrane Library. The search was undertaken between March 15 and 31, 2022 with subsequent updates performed on October 15, 2023 and April 10, 2024. This review also included grey literature sourced via Google, Google Scholar and backward citation searches.

RESULTS

Out of 5,621 records, 20 articles were found to meet the inclusion criteria with a total of 8,035 participants involved and the mean age ranged from 74.0 to 84.4 years. Using McMaster Critical Review Form for Quantitative Studies, we ascertained that the studies included in our analysis had moderate to high levels of quality. In addition to health-related outcomes, PHV interventions were also conducted to evaluate psychological effects (16 studies) and social outcomes (seven studies). Five studies conducted financial assessment to evaluate the costs of health and social care utilisation during PHV interventions. Regarding the results of the review, seven studies showed favourable outcomes, five indicated no effect and eight had equivocal findings. Only one study assessed resilience and determined that PHV had no effect on the resilience of the subjects.

CONCLUSION

This review found that the effectiveness of PHV interventions was uncertain and inconclusive. PHV interventions often prioritise health-related objectives. The incorporation of a holistic approach involving psychosocial health into PHV interventions is relatively uncommon. Due to the paucity of research on resilience as PHV outcome, we are unable to draw a conclusion on the effectiveness of PHV on resilience. Resilience should be prioritised as a psychological assessment in the future development of comprehensive PHV interventions, as it enables older adults to adapt, manage, and respond positively to adversities that may arise with age. Performing financial analysis such as costs and benefits analysis to incorporate the return on investment of PHV interventions is an added value for future research on this topic.

CLINICAL TRIAL REGISTRATION

PROSPERO registration number: CRD42022296919.

Association Between Depression Symptoms and Disability Outcomes in Older Adults at Risk of Mobility Decline

Objective

To assess the association between depression symptoms and physical functioning and participation in daily life over 2 years in older adults at risk of mobility decline.

Design

A secondary analysis of 2-year observational data from the Boston Rehabilitative Impairment Study of the Elderly.

Setting

Nine primary care clinics within a single health care system.

Participants

Participants (N=432; mean age ± SD, 76.6±7.0y; range, 65-96y; 67.7% women) were community-dwelling adults (>65y) at risk of mobility decline.

Interventions

Not applicable.

Main Outcome Measures

Secondary data analyses of the Late Life Function and Disability Instrument (primary outcome), Short Physical Performance Battery (secondary outcome), and Patient Health Questionnaire-9 (PHQ-9) (predictor). Measures were administered at baseline, 12 months, and 24 months. Participants completed a self-report survey asking about 16 medical comorbidities, and demographic information was collected at baseline.

Results

Participants had an average ± SD PHQ-9 score of 1.3±3.1, ranging from 0 to 24 at baseline. Twenty-nine percent of participants reported a history of depression. Greater depression symptoms were associated with lower physical functioning (unstandardized beta [B]=-0.14, SE=0.05, P=.011) and restricted participation (frequency subscale: B=-0.21, SE=0.11, P=.001; limitation subscale: B=-0.45, SE=0.04, P<.001) cross-sectionally over 2 years. PHQ-9 was not significantly associated with the rate of change in Late Life Function and Disability Instrument score over 2 years.

Conclusions

Treating depression in primary care may be an important strategy for reducing the burden of functional limitations and participation restrictions at any 1 time. Further research is needed on treatment models to cotarget depression and physical functioning among at-risk older adults.

Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis

OBJECTIVE

To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies.

ELIGIBILITY CRITERIA

Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks' follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators.

MAIN OUTCOMES

Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months.

DATA SYNTHESIS

Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane's revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment.

RESULTS

The review included 129 studies (74 946 participants). Nineteen intervention components, including "multifactorial action from individualised care planning" (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine review with medication review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, -0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty.

CONCLUSIONS

The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts.

REGISTRATION

PROSPERO CRD42019162195.

A Process Evaluation of Intervention Delivery for a Cancer Survivorship Rehabilitation Clinical Trial Conducted during the COVID-19 Pandemic

The purpose of the present study was to conduct a process evaluation of intervention delivery for a randomized controlled trial (RCT) conducted during the COVID-19 pandemic (NCT03915548). The RCT tested the effects of a telephone-delivered behavioral intervention on changes in breast cancer survivors' satisfaction with social roles and activities, as compared to an attention control condition. This process evaluation examined (a) fidelity monitoring scores; (b) participants' perceived benefit ratings for gaining confidence, reducing distress, adjusting habits and routines, setting goals, and increasing exercise; and (c) field notes, email communications, and transcripts of coach supervision and debriefing sessions. The behavioral and attention control conditions were delivered with a high degree of fidelity (global quality rating score for the BA/PS condition was M = 4.6 (SD = 0.6) and M = 4.9 (SD = 0.3) for the attention control condition, where "5" is the highest rating). The behavioral intervention participants perceived greater benefits than the control participants pertaining to goal setting, t(248) = 5.73, p = <0.0001, adjusting habits and routines, t(248) = 2.94, p = 0.0036, and increasing exercise, t(248) = 4.66, p = <0.0001. Moreover, coaches' perceptions regarding the behavioral intervention's therapeutic aspects aligned with the study's a priori conceptual model including the use of a structured process to set small, observable goals and facilitate the independent use of problem-solving skills. However, coaches also noted that aspects of the attention control condition, including the perceived relevance of the educational content and opportunities for social support, may have made it more therapeutically potent than intended. The pandemic may have affected the activity goals behavioral intervention participants could set as well as augmented the relevancy of social support provided in both conditions.

Implementation of the CAPABLE Program With Older Adults During the COVID-19 Pandemic

This study explores the implementation and impact of an evidence-based client-driven program, CAPABLE (Community Aging in Place Advancing Better Living for Elders), during the COVID-19 pandemic. The study reviews outcomes related to client engagement and retainment, client-directed goals, therapeutic intervention, home modifications, and functional outcomes of older adult participants. The CAPABLE program addresses basic and instrumental activities of daily living, medication use, pain, mobility, fall prevention, and environmental modifications within the home. The services were provided by an interprofessional team which included an occupational therapist, a registered nurse, and home contractor professional. The study team utilized descriptive, paired t test, and correlational analyses to evaluate the CAPABLE programs' influence on the functional outcomes of older adults living within the city of St. Louis, during the COVID-19 pandemic. This study identified significant improvement in instrumental activities of daily living (IADLs) independence, readiness to change, self-reported health status, and depressive symptoms, and 11 significant correlations were found between age, implementation expenses, and functional outcomes.

Acceptability and Feasibility of a Pain and Depressive Symptoms Management Intervention in Middle-Aged and Older African American Women

Background and Objectives

The intersection of race, gender, and age puts older African American women at high risk of experiencing comorbid pain and depressive symptoms. The purpose of this study was to assess the feasibility and acceptability of a 12-week behavioral activation intervention to target self-selected goals related to pain and depressive symptoms in middle-aged and older African American women.

Research Design and Methods

This randomized waitlist control study included 34 self-identified African American women, 50 years of age or older, with moderate-to-severe chronic pain and depressive symptoms. The intervention consisted of 8 in-person or virtual 1-hour visits with a nurse. Follow-up acceptability assessments were conducted with 10 participants.

Results

The average age of the participants was 64.8 (standard deviation [SD] 10.5). They reported an average pain intensity score of 7.0 (SD 1.9) out of 10 and an average Patient Health Questionnaire-9 depressive symptoms score of 11.9 (SD 4.0) at baseline. Of the 34 participants who consented, 28 (82.4%) women started the intervention and 23 (82.1%) completed the intervention. Participants described the study as useful and beneficial. Participants recommended including a group component in future iterations. Effect sizes at 12 weeks were -0.95 for depressive symptoms indicating a substantial decrease in experienced depressive symptoms, but pain intensity was virtually unchanged (+0.09).

Discussion and Implications

The findings of this study demonstrate that the intervention is acceptable among middle-aged and older African American women and their personal goals were met. Including a group component and identifying effective ways to decrease attrition rates will be key in the next steps of development for this intervention. It is crucial to provide tailored, nonpharmacological approaches to pain, and depression symptom management in older adult populations who experience inequities in pain and mental health outcomes. This study emphasizes the importance of participant-driven goal-setting interventions.

Trajectories of Disability and Related Factors in Korean Adults Aged ≥75 years

This study aimed to identify distinct trajectories of activities of daily living (ADL) disability in older adults aged ≥75 years over 6 years. A growth mixture model and the multinomial logistic regression analysis were used to identify different disability trajectories and to investigate each trajectory. Four distinct disability trajectories were identified: low, moderate, high, and progressive. Activity restriction due to fear of falling, being underweight, impaired vision, and impaired cognition were highly associated with the progressive groups, compared with the low disability group. Activity restriction due to fear of falling, depression, impaired cognition, and poor subjective health status were associated with moderate and high disability. These findings contribute to increasing the understanding of ADL disability among older adults.

A protocol for a wait list control trial of an intervention to improve pain and depressive symptoms among middle-aged and older African American women

BACKGROUND

Pain and depression frequently co-occur among older adults with comorbidities and can exacerbate one another. The intersection of race, gender and age puts older African American women at high risk of experiencing comorbid pain and depression. The purpose of this study is to test the feasibility and acceptability of a 12-week behavioral activation intervention called DAPPER (Depression and Pain Perseverance through Empowerment and Recovery) that uses non-pharmacological, tailored strategies to target pain and mood symptoms. We will measure pain intensity and depressive symptoms as outcomes, although we are not powered to test differences.

METHODS

We describe the protocol for this study that uses a randomized waitlist control design to examine acceptability and feasibility of an intervention. The study population is comprised of self-identified African American women, 50 years of age or older with chronic pain and who self-report of depressive symptoms. Participants must also be pre-frail or frail and have an ADL or IADL limitation. The intervention consists of eight 1-2-h visits with a nurse interventionist via in-person or virtual telecommunication methods and two visits for non-invasive specimen collection. The primary outcomes include goal attainment, pain and depressive symptoms. Secondary outcomes include stress, frailty, and communication with providers. Follow-up qualitative interviews are conducted with participants to assess intervention acceptability.

DISCUSSION

Findings from this pilot study will provide further evidence supporting the use of non-pharmacological techniques to intervene in the cycle of pain and depression among an at-risk sub-population.

Community-Led, Cross-Sector Partnership of Housing and Health Care to Promote Aging in Place (Unite Health Project): Protocol for a Prospective Observational Study

BACKGROUND

For many older Americans, aging in place is their preferred living arrangement. Minoritized and socioeconomically disadvantaged older adults are up to 3 times more likely to experience disability than other groups, which increases their likelihood of being unable to age in place. Bold ideas to facilitate aging in place, particularly among vulnerable populations, are needed. One such idea is the Unite care model, a community-initiated, academic-supported, cross-sector initiative that combines 2 sectors: housing and health care. The Unite care model colocates a federally qualified health center clinic on an older adult affordable housing campus in Flint, Michigan.

OBJECTIVE

There are two aims to this study. Aim 1 is to evaluate the implementation of the Unite care model in terms of acceptability, adoption, and penetration. Aim 2 is to determine which older adults use the care model and whether the care model promotes aging in place through risk factor reduction and improvement in the physical and social environment.

METHODS

We will assess the care model using a concurrent, exploratory mixed methods design. For aim 1, acceptability will be assessed through semistructured interviews with key stakeholder groups; adoption and penetration will be assessed using housing and health care records. For aim 2, residents residing in the Unite clinic building will participate in structured outcome assessments at 6 and 12 months. Risk factor reduction will be measured by change in systolic blood pressure from baseline to 12 months and change in the physical and social environment (item counts) will also be assessed from baseline to 12 months.

RESULTS

Data collection for aim 1 began in July 2021 and is anticipated to end in April 2023. Data collection for aim 2 began in June 2021 and concluded in November 2022. Data analysis for aim 1 is anticipated to begin in the summer of 2023 and analysis for aim 2 will begin in the spring of 2023.

CONCLUSIONS

If successful, the Unite care model could serve as a new care model to promote aging in place among older adults living in poverty and older Black Americans. The results of this proposal will inform whether larger scale testing of this new model of care is warranted.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47855.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Chinese expert consensus on prevention and control interventions for older adults with physical functional impairment (2022)

Older adults are at high risk for functional impairment, which is closely related to sarcopenia, falls, and frailty. This seriously affects their quality of life and health, and places a heavy burden on society and families. Although domestic and foreign sports recommendations and prevention and control guidelines/expert consensus have been issued for healthy older adults and functional impairment-related diseases, there is no guidance on prevention and control interventions for older adults with physical functional impairment. In China, there is insufficient understanding of the importance of prevention and control interventions for functional impairment in older adults, and there are many drawbacks, such as unstandardized diagnosis and treatment, and relatively simple intervention methods. Therefore, the consensus expert group formulated a consensus based on domestic and foreign guidelines related to functional impairment in older adults to provide guidance for Chinese medical professionals working in the field of geriatrics.

Assessment of Frailty Index at 66 Years of Age and Association With Age-Related Diseases, Disability, and Death Over 10 Years in Korea

Importance

A frailty index has been proposed as a measure of aging among older individuals. However, few studies have examined whether a frailty index measured at the same chronologic age at younger ages could forecast the development of new age-related conditions.

Objective

To examine the association of the frailty index at 66 years of age with incident age-related diseases, disability, and death over 10 years.

Design, Setting, and Participants

This retrospective nationwide cohort study used the Korean National Health Insurance database to identify 968 885 Korean individuals who attended the National Screening Program for Transitional Ages at 66 years of age between January 1, 2007, and December 31, 2017. Data were analyzed from October 1, 2020, to January 2022.

Exposures

Frailty was defined using a 39-item frailty index ranging from 0 to 1.00 as robust (<0.15), prefrail (0.15-0.24), mildly frail (0.25-0.34), and moderately to severely frail (≥0.35).

Main Outcomes and Measures

The primary outcome was all-cause death. Secondary outcomes were 8 age-related chronic diseases (congestive heart failure, coronary artery disease, stroke, type 2 diabetes, cancer, dementia, fall, and fracture) and disability qualifying for long-term care services. Cox proportional hazards regression and cause-specific and subdistribution hazards regression were used to examine hazard ratios (HRs) and 95% CIs for the outcomes until the earliest of date of death, the occurrence of relevant age-related conditions, 10 years from the screening examination, or December 31, 2019.

Results

Among the 968 885 participants included in the analysis (517 052 women [53.4%]), the majority were classified as robust (65.2%) or prefrail (28.2%); only a small fraction were classified as mildly frail (5.7%) or moderately to severely frail (1.0%). The mean frailty index was 0.13 (SD, 0.07), and 64 415 (6.6%) were frail. Compared with the robust group, those in the moderately to severely frail group were more likely to be women (47.8% vs 61.7%), receiving medical aid insurance for low income (2.1% vs 18.9%), and less active (median, 657 [IQR, 219-1133] vs 319 [IQR, 0-693] metabolic equivalent task [min/wk]). After adjusting for sociodemographic and lifestyle characteristics, moderate to severe frailty was associated with increased rates of death (HR, 4.43 [95% CI, 4.24-4.64]) and new diagnosis of all chronic diseases, including congestive heart failure (adjusted cause-specific HR, 2.90 [95% CI, 2.67-3.15]), coronary artery disease (adjusted cause-specific HR, 1.98 [95% CI, 1.85-2.12]), stroke (adjusted cause-specific HR, 2.22 [95% CI, 2.10-2.34]), diabetes (adjusted cause-specific HR, 2.34 [95% CI, 2.21-2.47]), cancer (adjusted cause-specific HR, 1.10 [95% CI, 1.03-1.18]), dementia (adjusted cause-specific HR, 3.59 [95% CI, 3.42-3.77]), fall (adjusted cause-specific HR, 2.76 [95% CI, 2.29-3.32]), fracture (adjusted cause-specific HR, 1.54 [95% CI, 1.48-1.62]), and disability (adjusted cause-specific HR, 10.85 [95% CI, 10.00-11.70]). Frailty was associated with increased 10-year incidence of all the outcomes, except for cancer (moderate to severe frailty adjusted subdistribution HR, 0.99 [95% CI, 0.92-1.06]). Frailty at 66 years of age was associated with greater acquisition of age-related conditions (mean [SD] conditions per year for the robust group, 0.14 [0.32]; for the moderately to severely frail group, 0.45 [0.87]) in the next 10 years.

Conclusions and Relevance

The findings of this cohort study suggest that a frailty index measured at 66 years of age was associated with accelerated acquisition of age-related conditions, disability, and death over the next 10 years. Measuring frailty at this age may offer opportunities to prevent age-related health decline.

Home Modifications for Older Adults: A Systematic Review

While ≧10,000 Americans turn 65 years old every day, only 10% of American homes are "aging ready." Unsafe homes can exacerbate disability, lead to falls, and increase the likelihood of hospitalization. With increased investments in home and community-based services, public health stakeholders are considering home modifications to promote successful aging. While several home modification models exist, there is significant heterogeneity between models and no consensus on critical features. PubMed, EMBASE, and Web of Science were reviewed and twelve randomized controlled trials of home modifications for older adults were identified and evaluated for model structure, reported outcomes, and risk of bias. Overall, occupational therapist-driven home modifications supplemented with clinical, physical activity, and/or behavioral components saw the greatest success. This systematic review discusses the components of these models, highlights particularly effective and frequently used features, and the practice and research needed to create effective next-generation home modification models which promote healthy longevity.

Older Adults Receiving Rehabilitation Services Are More Likely to Get Bathing and Toileting Equipment Installed

IMPORTANCE

Adaptive equipment, such as shower grab bars and modified toilet seating, is effective but underused in the United States. To change this, a better understanding of how equipment ends up being installed is needed. We hypothesized that rehabilitation services were a major mechanism.

OBJECTIVE

To examine the association between receipt of rehabilitation services and installation of adaptive equipment.

DESIGN

Observational cohort of the National Health and Aging Trends Study in 2015 and 2016.

SETTING

Community.

PARTICIPANTS

A total of 416 community-dwelling adults age 65 yr or older who needed bathing equipment and 454 who needed toileting equipment.

OUTCOMES AND MEASURES

Study outcomes were the installation of bathing or toileting equipment. The primary independent variable was the receipt of rehabilitation services between 2015 and 2016.

RESULTS

Among older adults who needed equipment in 2015, 34.3% had bathing equipment and 19.2% had toileting equipment installed by 2016. In multivariate logistic regression analyses, rehabilitation services were associated with installation of bathing (odds ratio [OR] = 5.07, 95% confidence interval [CI] [2.60, 9.89]) and toileting equipment (OR = 2.67, 95% CI [1.48, 4.84]).

CONCLUSIONS AND RELEVANCE

A minority of those in need have adaptive equipment installed within a year. In the current health care system, rehabilitation providers play a major role in equipment installation. What This Article Adds: Rehabilitation providers are involved in the installation of adaptive bathroom equipment among older persons who need it. Still, most in need of equipment do not have it after a year, suggesting that further work is needed to increase access to rehabilitation providers and develop other avenues for obtaining equipment.

Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults

Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.

Promoting sleep in low-income older adults with disabilities: Comparing CAPABLE with a social engagement control

Sleep plays a vital role in older adults' health. The Community Aging in Place-Advancing Better Living for Elders (CAPABLE) trial, conducted in Maryland between 2012 and 2016, is a 5-month biobehavioral environmental intervention study to reduce functional disabilities in 300 low-income older adults. Individual and environmental factors impacting sleep were addressed in CAPABLE. This secondary data analysis was to test the preliminary effect of CAPABLE on actigraph-measured sleep, compared with a social engagement control in 73 CAPABLE participants with pretest-posttest actigraph data. Participants in this analysis were aged 75.8±7.5 years; 86.3% of them were females and 84.9% were Black/African Americans. Both CAPABLE intervention and social engagement control improved sleep efficiency and reduced sleep onset latency. The effect of CAPABLE on sleep was comparable to social engagement. These findings underline the importance of promoting physical function and maintaining social activity for sleep in low-income older adults with disabilities.

Addressing Medical and Social Needs to Reduce Unnecessary Health Care Utilization and Costs: A Qualitative Study

This study explored the goals, and care delivery approaches, of 14 interventions to address patients' medical and social needs. In qualitative interviews with clinicians and researchers, several themes emerged. Participants frequently described their overall goal as meeting patients' diverse needs to prevent avoidable acute care utilization. Medical needs were addressed by ensuring patients received primary care and actively coordinating care across clinical settings. Participants perceived social needs as tightly linked with medical needs, as well as a need for interpersonal skills among intervention staff. Descriptions of overall approaches to meeting patients' needs frequently aligned with principles of trauma-informed care and patient-centered care.

Examining Consequences Related to Unmet Care Needs Across the Long-Term Care Continuum

OBJECTIVES

To examine how different care arrangements across the long-term care continuum are associated with experiencing unmet care need consequences (UCNCs), such as skipping meals, going without clean clothes, or taking the wrong medication.

METHODS

We include older adults receiving assistance with at least one self-care, mobility, or household activity (for health/functioning reasons) in the 2015 National Health and Aging Trends Study (N = 2,388). We examine the likelihood of experiencing a UCNC across the long-term care continuum: those receiving unpaid community care only, paid community care, and residential care. Cross-sectional logistic and longitudinal multinomial logistic regression models examine if type of care arrangement in 2015 is associated with UCNCs in 2015 and change in UCNCs by 2017.

RESULTS

In adjusted cross-sectional models, paid community care recipients had roughly 2 times greater odds of experiencing a UCNC in 2015 compared to those living in residential care or receiving only unpaid care. In adjusted longitudinal models, the risk of experiencing persistent UCNCs (compared to having needs met in both years) was 4.81 times higher for those receiving paid community care compared to those in residential care and 2.17 times that of those receiving unpaid care only.

DISCUSSION

Older adults receiving paid care face significant and consequential gaps in care, particularly in comparison to those in other care arrangements. More attention is needed to determine how paid care arrangements can be improved and/or expanded to meet the needs of the growing number of older adults receiving paid care in the community.

Effects on clients' daily functioning and common features of reablement interventions: a systematic literature review

This systematic review aimed to provide an overview of reablement interventions according to the recently published ReAble definition and their effect on Activities of Daily Living (ADL). In addition, the most common and promising features of these reablement interventions were identified. Four electronic bibliographic databases were searched. Articles were included when published between 2002 and 2020, which described a Randomised or Clinical Controlled Trial of a reablement intervention matching the criteria of the ReAble definition, and had ADL functioning as an outcome. Snowball sampling and expert completion were used to detect additional publications. Two researchers screened and extracted the identified articles and assessed methodological quality; discrepancies were resolved by discussion and arbitration by a third researcher. Twenty relevant studies from eight countries were included. Ten of these studies were effective in improving ADL functioning. Identifying promising features was challenging as an equal amount of effective and non-effective interventions were included, content descriptions were often lacking, and study quality was moderate to low. However, there are indications that the use of more diverse interdisciplinary teams, a standardised assessment and goal-setting method and four or more intervention components (i.e. ADL-training, physical and/or functional exercise, education, management of functional disorders) can improve daily functioning. No conclusions could be drawn concerning the effectiveness on ADL functioning. The common elements identified can provide guidance when developing reablement programmes. Intervention protocols and process evaluations should be published more often using reporting guidelines. Collecting additional data from reablement experts could help to unpack the black box of reablement.

Do Interventions Reducing Social Vulnerability Improve Health in Community Dwelling Older Adults? A Systematic Review

Background

Social vulnerability occurs when individuals have been relatively disadvantaged by the social determinants of health. Complex interventions that reduce social vulnerability have the potential to improve health in older adults but robust evidence is lacking.

Objective

To identify, appraise and synthesize evidence on the effectiveness of complex interventions targeting reduction in social vulnerability for improving health related outcomes (mortality, function, cognition, subjective health and healthcare use) in older adults living in the community.

Methods

A mixed methods systematic review was conducted. Five databases and targeted grey literature were searched for primary studies of all study types according to predetermined criteria. Data were extracted from each distinct intervention and quality was assessed using the Mixed Methods Appraisal Tool. Effectiveness data were synthesized using vote counting by direction of effect, combining p values and Albatross plots.

Results

Across 38 included studies, there were 34 distinct interventions categorized as strengthening social supports and communities, helping older adults and their caregivers navigate health and social services, enhancing neighbourhood and built environments, promoting education and providing economic stability. There was evidence to support positive influences on function, cognition, subjective health, and reduced hospital utilization. The evidence was mixed for non-hospital healthcare utilization and insufficient to determine effect on mortality.

Conclusion

Despite high heterogeneity and varying quality of studies, attention to reducing an older adult's social vulnerability assists in improving older adults' health.

The Behavioral Factors That Influence Person-Centered Social Care: A Literature Review and Conceptual Framework

The last decade has seen numerous policy reforms to emplace person-centered social care. Consequently, the public has been given more information, choice, and autonomy to decide how best they want to be cared for later in life. Despite this, adults generally fail to plan or prepare effectively for their future care needs. Understanding the behavioral antecedents of person-centered decision-making is thus critical for addressing key gaps in the provision of quality social care. To this end, we conducted a literature review of the psychological and health sciences with the aim of identifying the aspects that influence person-centered decision-making in social care. Using an established theoretical framework, we distilled nine behavioral factors-knowledge, competency, health, goal clarity, time discounting, familiarity, cognitive biases, cognitive overload, and emotion-associated with "Capability," "Opportunity," "Motivation," and "Behavior" that explained person-centered decision-making in social care. These factors exist to different degrees and change as a person ages, gradually impacting their ability to obtain the care they want. We discuss the role of carers and the promise of shared decision-making and conclude by advocating a shift from personal autonomy to one that is shared with carers in the delivery of quality social care.

Prospective assessment of dementia on transitions in homeboundness using multistate Markov models

BACKGROUND

One in 20 older adults in the United States is homebound and rarely/never leaves home. Although being homebound decreases the quality of the lived experience of individuals with serious illnesses, little is known about the frequency or likelihood of transitions in or out of homebound status. The objective of this study was to characterize the probability of transitions to and from homebound status among older adults and examine the relationship between dementia status and homebound transitions.

METHODS

Using 2011-2018 data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study of aging in the United States, we identified 6375 community-dwelling Medicare beneficiaries. Homebound status (independent, semi-homebound (leaving home but with difficulty or help), homebound (rarely or never leaving home), nursing home resident, dead) was assessed annually via self-report. Transition probabilities across states were assessed using a multistate Markov model.

RESULTS

Less than half of homebound individuals remain homebound (probability = 41.5% [95% CI: 39.2%, 43.5%]) after 1 year. One out of four dies (24% [22.3%, 26.0%]) and there is a low probability (3.2% [2.5%, 4.1%]) of transition to a nursing home. Dementia status was associated with increased risk of progression from independence to homebound status (HR: 1.83 [1.01, 3.34]). Dementia was consistently associated with increased probabilities of transitions to death including a two-fold increased hazards of progression from homebound to death (HR: 2.18 [1.69, 2.81]). Homebound individuals with dementia have a 34.2% [25.8%, 48.1%] probability of death in 5 years, compared with 17.4% [13.7%, 24.3%] among those without dementia.

DISCUSSION

Dementia is associated with greater risk of transitioning across homebound states. There is a greater need to support home-based care for patients with dementia, especially as the ongoing COVID pandemic has raised concerns about the need to invest in alternative models to nursing home care.

Drivers and restrainers to adoption and spread of evidence-based health service delivery interventions: The case of CAPABLE

CONTEXT

Very few programs improve physical function among older adults and those that do should achieve farther reach.

METHODS

We used Force Field Analysis to examine drivers and restrainers for the CAPABLE program to impact the function of older adults throughout the United States.

FINDINGS

We found 19 distinct drivers for CAPABLE. These include robust research findings demonstrating clinical and economic utility, expansion from an evidence-based program, grounding in theory, high value to older adults themselves, and common sense approach. A major policy environment shifting towards value-based payment and payer flexibility to experiment with social determinants significantly changed the perception of the program's value by key stakeholders. We found 8 distinct restrainers.

CONCLUSIONS

Factors which drive and restrain CAPABLE provide lessons for other programs to move from research to sustainability. Policymakers, payers, and communities should look to proven programs as solutions to improve function for older adults and society.

Longer Residence in the United States is Associated With More Physical Function Limitations in African Immigrant Older Adults

Acculturation and racial discrimination have been independently associated with physical function limitations in immigrant and United States (U.S.)-born populations. This study examined the relationships among acculturation, racial discrimination, and physical function limitations in N = 165 African immigrant older adults using multiple linear regression. The mean age was 62 years (SD = 8 years), and 61% were female. Older adults who resided in the United States for 10 years or more had more physical function limitations compared with those who resided here for less than 10 years (b = -2.62, 95% confidence interval [CI] = [-5.01, -0.23]). Compared to lower discrimination, those with high discrimination had more physical function limitations (b = -2.51, 95% CI = [-4.91, -0.17]), but this was no longer significant after controlling for length of residence and acculturation strategy. Residing in the United States for more than 10 years is associated with poorer physical function. Longitudinal studies with large, diverse samples of African immigrants are needed to confirm these associations.

Improvements of Disability Outcomes in CAPABLE Older Adults Differ by Financial Strain Status

The Community Aging in Place-Advancing Better Living for Elders (CAPABLE) program reduces disability in low-income older adults. In this study, we used CAPABLE baseline and 5-month data to examine whether its effects in reducing activities of daily living (ADLs) and instrumental ADLs (IADLs) difficulties differed by participants' financial strain status. At baseline, participants with financial strain were more likely to report higher scores on depression (p < .001), have low energy (p < .001), and usually feel tired (p = .004) compared with participants without financial strain, but did not differ in ADL/IADL scores. Participants with financial strain benefited from the program in reducing ADL (relative risk [RR]: 0.61, 95% confidence interval [CI]: 0.43, 0.86) and IADL disabilities (RR: 0.69, 95% CI: 0.54, 0.87), compared with those with financial strain receiving attention control. Individuals with financial strain benefited more from a home-based intervention on measures of disability than those without financial strain. Interventions that improve disability may be beneficial for financially strained older adults.

The concept of disability and its causal mechanisms in older people over time from a theoretical perspective: a literature review

Ageing with a disability increases the risk of hospitalization and nursing home admission. Ageing in place interventions aiming to reduce disability are often not sufficiently effective and inadequately theory-based. There are many models available on disability, but it is unclear how they define disability, what their differences are, and how they evolved throughout the years. This paper aims to provide an overview of the evolution of these models and to elaborate on the causal mechanisms of disability. A literature review was conducted as part of the TRANS-SENIOR international training and research network. PubMed and Google Scholar were searched, and snowball sampling was applied to eligible publications. Data were extracted from the included publications, and a thematic analysis was performed on the retrieved data. Overall, 29 publications were included in the final sample. All included models arose from three original models and could be divided into two types: linear models and models on the interaction between the person and the environment. Thematic analysis led to three distinct evolutionary trends: (1) from a unidirectional linear path to a multidirectional nonlinear path, (2) from the consequences of disease towards the consequences of person-environment interaction, and (3) from disability towards health and functioning. Our findings suggest that by optimizing the use of personal as well as environmental resources, and focusing on health and functioning, rather than disability, an older person's independence and wellbeing can be improved, especially while performing meaningful daily activities in accordance with the person's needs and preferences.

OUP accepted manuscript

BACKGROUND AND OBJECTIVES

Despite evidence linking financial challenges to poor health among older adults, effective interventions are lacking. This study examined the experience of living with financial challenges, useful strategies to handle them, and social norms that may constrain options and decision-making.

RESEARCH DESIGN AND METHODS

This two-staged qualitative study recruited low-income older adults from the United States Baltimore City area. First, semistructured individual interviews examined older adults' experiences and strategies used to handle financial challenges. Then, vignette-based focus groups examined relevant social norms. Transcripts were coded, and hierarchical themes were described using thematic analysis.

RESULTS

Two themes were generated. First, the social norms relevant to financial challenges share a common underlying assumption of personal responsibility. Second, social norms about personal responsibility are inconsistent with the experiences of older adults facing financial challenges, who typically lack control over their situation and face structural barriers to preventing and handling financial challenges. Differences between statements related to norms and personal responsibility were found across six subthemes, including how finances should be handled to prevent financial challenges, the causes of financial challenges, asking for help from community resources, navigating community resources, getting help from family, and cutting back to handle financial challenges.

DISCUSSION AND IMPLICATIONS

The disconnect between social norms and the reality of financial challenges among older adults may explain why so many older adults cut back to the point of foregoing necessities. There is an urgent need to strengthen the social safety net and remove normative barriers to services.

Setting realistic expectations for an innovative program of home-based care for vulnerable older persons

This editorial comments on the article by Szanton et al.

Living with pain in 'age-(un)friendly' housing environments: A qualitative study with African American older adults

Understanding the dynamic relationship between housing environment and older adults' pain may identify important factors that influence disparities in later life. We used a qualitative description approach to examine the context of environmental lifespaces in older African Americans (ages 61-81) with chronic osteoarthritis pain living in income-adjusted housing. Environmental inequity, healthcare needs, and mobility limitations influenced their perceptions of lifespace equity and interfered with their vitality and feeling of security. Their housing environments lacked age-friendly amenities, and specific enhancements to assist aging individuals with everyday function and reduction of pain were identified. This study contributes new evidence on the impact of macro, meso, and micro environments on pain management while also calling for greater attention to parity in infusing age-friendly resources into minority housing.

Association Between Neighborhood Disadvantage and Functional Well-being in Community-Living Older Persons

IMPORTANCE

Neighborhood disadvantage is a novel social determinant of health that could adversely affect the functional well-being of older persons. Deficiencies in resource-poor environments can potentially be addressed through social and public health interventions.

OBJECTIVE

To evaluate whether estimates of active and disabled life expectancy differ on the basis of neighborhood disadvantage after accounting for individual-level socioeconomic characteristics and other prognostic factors.

DESIGN, SETTING, AND PARTICIPANTS

This prospective longitudinal cohort study included 754 nondisabled community-living persons, aged 70 years or older, who were members of the Precipitating Events Project in south central Connecticut from March 1998 to June 2020.

MAIN OUTCOMES AND MEASURES

Disability in 4 essential activities of daily living (bathing, dressing, walking, and transferring) was assessed each month. Scores on the Area Deprivation Index, a census-based socioeconomic measure with 17 education, employment, housing quality, and poverty indicators, were obtained through linkages with the 2000 Neighborhood Atlas. Area Deprivation Index scores were dichotomized at the 80th state percentile to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80).

RESULTS

Among the 754 participants, the mean (SD) age was 78.4 (5.3) years, and 487 (64.6%) were female. Within 5-year age increments from 70 to 90, active life expectancy was consistently lower in participants from neighborhoods that were disadvantaged vs not disadvantaged, and these differences persisted and remained statistically significant after adjustment for individual-level race and ethnicity, education, income, and other prognostic factors. At age 70 years, adjusted estimates (95% CI) for active life expectancy (in years) were 12.3 (11.5-13.1) in the disadvantaged group and 14.2 (13.5-14.7) in the nondisadvantaged group. At each age, participants from disadvantaged neighborhoods spent a greater percentage of their projected remaining life disabled, relative to those from nondisadvantaged neighborhoods, with adjusted values (SE) ranging from 17.7 (0.8) vs 15.3 (0.5) at age 70 years to 55.0 (1.7) vs 48.1 (1.3) at age 90 years.

CONCLUSIONS AND RELEVANCE

In this prospective longitudinal cohort study, living in a disadvantaged neighborhood was associated with lower active life expectancy and a greater percentage of projected remaining life with disability. By addressing deficiencies in resource-poor environments, new or expanded social and public health initiatives have the potential to improve the functional well-being of community-living older persons and, in turn, reduce health disparities in the US.

Home and Neighborhood Context of Falls Among Black and White Older Americans

Objectives: To examine social and physical environmental fall-risk factors in a nationally representative sample of community-living older adults overall and by racial group. Methods: We used data from the 2015 and 2016 rounds of the National Health and Aging Trends Study (n = 5581) linked to census tract measures from the American Community Survey. Recurrent falls are defined as 2+ self-reported falls over 12 months. Results: Older adults with recurrent falls were more likely to have lower education, lower income, financial hardship, live in homes with disorder and disrepair and in neighborhoods without sidewalks, with high social deprivation, and in nonmetropolitan counties. Home disrepair, lack of sidewalks, and residence in a nonmetropolitan county were important fall-risk factors among White older adults only. Financial hardship was an important risk factor among Black older adults. Discussion: Environmental factors are associated with recurrent falls among older Americans and should be incorporated into fall-risk profiles and prevention efforts.

Aging Gracefully in Place: An Evaluation of the Capability of the CAPABLE© Approach

As American adults live longer, society must prioritize effective strategies promoting safe aging-in-place and decreasing institutional health care costs. Social determinants of health, especially housing, critically influence older adult health, particularly for disadvantaged, low-income older adults. Johns Hopkins University developed Community Aging in Place-Advancing Better Living for Elders (CAPABLE^©), a client-centered, home-based program to improve older adults' function and capacity to age in place. This evaluation studied CAPABLE's long-term effectiveness in four distinct locations in California, North Carolina, Pennsylvania, and Vermont. Seven months after CAPABLE, intervention group participants experienced greater improvements than the control group in activities of daily living limitations (2-point vs. 0.7-point improvement, p = .012), falls efficacy (8.9-point improvement vs. 0.1-point worsening, p = .012), depression (1.3-point improvement vs. 0.4-point worsening, p = .021), and pain (1.5-point improvement vs. 0.3-point worsening, p = .002). These results add to existing research on short-term effectiveness in urban locales, showing CAPABLE yields long-term health improvement for older adults in micropolitan and small urban locations, with different implementation organizations, housing stocks, and clients.

Home medicines reviews: a national survey of Australian accredited pharmacists' health service time investment

Background

In Australia, polypharmacy and medication-related problems are prevalent in the community. Therefore, medicines safety initiatives such as the Home Medicines Review (HMR) service are critical to health care provision. While the evidence continues to expand around HMR service, little is known of accredited pharmacists' experiences of HMR time investment.

Objective

This study aimed to explore accredited pharmacists' experiences of HMR practice regarding time investment in the study's defined HMR Stages: 1 (initial paper-based assessment and review), 2 (in-home patient-accredited pharmacist consultation), and 3 (HMR report collation, generation, completion, and provision to the patient's General Practitioner, including any liaison time).

Methods

An electronic survey was developed and piloted by a panel of reviewers. Convenience sampling was used to distribute the final anonymous survey nationally via professional pharmacy organisations. Data were analyzed for frequency distributions and a chi-square test of independence was performed to evaluate any association between demographic variables relating to HMR time investment.

Results

There was a total of 255 survey respondents, representing approximately 10% of national accredited pharmacist membership. The majority were experienced accredited pharmacists who had completed >100 HMRs (73%), were female (71%), and aged >40 years (60%). Regarding time investment for a typical instance of HMR, most spent: <30 minutes performing Stage 1 (46.7%), and 30-60 minutes performing Stage 2 (70.2%). In Stage 3, 40.0% invested 1-2 hours, and 27.1% invested 2-3 hours in HMR report collation and completion. Quantitative analysis revealed statistically significant (p=0.03) gender findings where females performed longer patient consultations than males (Stage 2). More HMR career experience resulted in statistically significant (p=0.01) less time performing Stage 1 (initial paper-based assessment and review); with a trend to less time performing Stage 3 (HMR report writing).

Conclusions

Accredited pharmacists invest significant time in performing comprehensive HMRs, especially during in-home patient consultations and during HMR report collation and completion. Their significant HMR time investment as medicines experts provides insight for program and workforce considerations and warrants further research to better understand their work processes for optimizing medicines use and improving health.

Home Hazard Removal to Reduce Falls Among Community-Dwelling Older Adults: A Randomized Clinical Trial

IMPORTANCE

Falls are the leading preventable cause of morbidity, mortality, and premature institutionalization for community-dwelling older adults.

OBJECTIVE

To test the effectiveness of a behavioral intervention on fall risk among older adults receiving services from an Area Agency on Aging.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial examined a home hazard removal intervention in the community using a race- and sex-stratified randomization design. Older adults receiving services from the Area Agency on Aging in urban St Louis, Missouri, were assigned to a home hazard removal intervention delivered over 2 weeks with a 6-month booster or usual care control. Eligible participants were adults aged 65 years or older who did not have dementia, were at high risk for falling, and resided in the community. Enrollment occurred from January 2015 to September 2016; 12-month follow-up occurred from February 2016 to October 2017. Data were analyzed from February 2019 to July 2021.

INTERVENTIONS

The intervention was a home hazard removal program delivered by an occupational therapist in the home that included a comprehensive clinical assessment and a tailored hazard removal plan. Usual care control consisted of annual assessments and community referral.

MAIN OUTCOMES AND MEASURES

The primary outcome was the hazard of a fall over 12 months. Prespecified secondary outcomes included the rate of falls over 12 months, daily activity performance, falls self-efficacy, and self-reported quality of life.

RESULTS

A total of 310 participants (mean [SD] age, 75 [7.4] years; 229 [74%] women; 161 Black participants [52%]) were randomized, with 155 participants assigned to the intervention and 155 participants assigned to usual care. Retention was 127 participants (82%) in the intervention group and 126 participants (81%) in the control group. There was no difference for our primary outcome of fall hazard (hazard ratio, 0.90; 95% CI, 0.66-1.27). There was a 38% reduction in the rate of falling in the intervention group compared with the control group (relative risk, 0.62; 95% CI, 0.40-0.95; P = .03). At 12 months, the rate of falls per person-year was 1.5 (95% CI, 1.32-1.75) in the intervention group and 2.3 (95% CI, 2.08-2.60) in the control group. There was no difference in daily activity performance (adjusted difference, -0.20; 95% CI, -0.95 to 0.55; P = .60), falls self-efficacy (adjusted difference, -0.12; 95% CI, -1.25 to 1.01; P = .84), or quality of life (adjusted difference, 0.84; 95% CI, -0.95 to 2.64; P = .35).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that a brief home hazard removal program did not reduce the hazard of falls among community-dwelling older adults at high risk for falling. The intervention was effective in achieving a reduced rate of falls, a prespecified secondary outcome. This effectiveness study has the potential for delivery through the national aging services network.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02392013.

CAPABLE program improves disability in multiple randomized trials

BACKGROUND

Programs to reduce disability are crucial to the quality of life for older adults with disabilities. Reducing disability is also important to avert unnecessary and costly hospitalizations, relocation, or nursing home placements. Few programs reduce disability and few have been replicated and scaled beyond initial research settings. CAPABLE is one such program initially tested in a randomized control trial and has now been tested and replicated in multiple settings. CAPABLE, a 10-session, home-based interprofessional program, provides an occupational therapist, nurse, and handyworker to address older adults' self-identified functional goals by enhancing individual capacity and home environmental supports. We examine evidence for the CAPABLE program from clinical trials embedded in different health systems on outcomes that matter most to older adults with disability.

METHODS

Six trials with peer-reviewed publications or reports were identified and included in this review. Participants' outcomes included basic and instrumental activities of daily living (ADLs, IADLs), fall efficacy, depression, pain, and cost savings.

RESULTS

A total of 1144 low-income, community-dwelling older adults with disabilities and 4236 matched comparators were included in the six trials. Participants were on average ≥74-79 years old, cognitively intact, and with self-reported difficulty with ≥1 ADLs. All six studies demonstrated improvements in ADLs and IADLs, with small to strong effect sizes (0.41-1.47). Outcomes for other factors were mixed. Studies implementing the full-tested dose of CAPABLE showed more improvement in ADLS and cost savings than studies implementing a decreased dose.

CONCLUSIONS

The CAPABLE program resulted in substantial improvements in ADLs and IADLs in all six trials with other outcomes varying across studies. A dose lower than the original protocol tested resulted in less benefit. The four studies examining cost showed that CAPABLE saved more than it costs to implement.

Community-dwelling older adults who are low-income and disabled weathering financial challenges

Despite interventions aiming to improve outcomes among older adults experiencing financial challenges, the challenges and strategies employed to handle them are poorly understood. This study examined the experiences of financial challenges among low-income adults aged ≥65 years. Eleven semi-structured interviews were analyzed using thematic analyses. An overarching theme was "I guess it balances", capturing attempts to maintain hope and proactively address challenges despite stress, uncertainty and limitations. Balancing was demonstrated within four domains, including cognitive bandwidth ("think a lot" versus "I don't dwell on that"), emotional experience ("depressing" versus "be thankful"), learned resilience ("that was a shock" versus "there's always a way"), and meeting daily needs ("we learned to do without" versus "take a dollar and stretch it"). Participants described being weathered by challenges and using predominately high-effort coping strategies to weather the challenges. These findings call for strengthening the safety net for older adults facing financial challenges.

Frailty and HIV: Moving from Characterization to Intervention

PURPOSE OF REVIEW

While the characteristics associated with frailty in people with HIV (PWH) have been well described, little is known regarding interventions to slow or reverse frailty. Here we review interventions to prevent or treat frailty in the general population and in people with HIV (PWH).

RECENT FINDINGS

Frailty interventions have primarily relied on nonpharmacologic interventions (e.g., exercise and nutrition). Although few have addressed frailty, many of these therapies have shown benefit on components of frailty including gait speed, strength, and low activity among PWH. When nonpharmacologic interventions are insufficient, pharmacologic interventions may be necessary. Many interventions have been tested in preclinical models, but few have been tested or shown benefit among older adults with or without HIV. Ultimately, pharmacologic and nonpharmacologic interventions have the potential to improve vulnerability that underlies frailty in PWH, though clinical data is currently sparse.

Unmet Need for Equipment to Help With Bathing and Toileting Among Older US Adults

IMPORTANCE

Home modification through seemingly mundane equipment, such as grab bars and shower seats, mitigates injury, dependence, and reduced quality of life in older adults coping with increasing disability. However, whether these interventions are underused in the US is unclear.

OBJECTIVE

To estimate how many older adults who need equipment to help with bathing and toileting do not have it, describe factors associated with not having equipment, and describe how many who did not initially have equipment acquired equipment over time.

DESIGN

This observational cohort study of participants 65 years or older used secondary data from the 2015 to 2019 waves of the US National Health and Aging Trends Study. Participants included community-dwelling older adults who would unequivocally benefit from equipment, defined as those with poor physical performance or substantial difficulty bathing, toileting, transferring, or walking. Respondents were representative of the US population 65 years and older. Data were collected from May 2015 to October 2019 and analyzed from August 1, 2019, to February 24, 2021.

EXPOSURES

Population characteristics (eg, age, sex, income, health conditions, and physical performance), environmental factors (eg, home ownership and living arrangement), and health behaviors (eg, prior knee and/or hip surgery).

MAIN OUTCOMES AND MEASURES

Prevalence of any unmet need for equipment, defined as either needing bathing equipment (bath grab bars and shower seat) but having none or needing toileting equipment (toilet grab bars and raised toilet seat) but having none and the cumulative incidence of equipment acquisition during 4 years of follow-up.

RESULTS

A total of 2614 participants representing 12 million US individuals would benefit from equipment. The mean (SD) age was 80.5 (8.2) years, and 1619 individuals (62%) were women. Of these, an estimated 5 million individuals (42%; 95% CI, 39%-44%) had an unmet need. After adjustment for age, sex, and race/ethnicity, unmet need was associated with younger age (49% if aged 65-74 years, 37% if aged 75-84 years, and 29% if aged ≥85 years; P < .001), having fewer health conditions (55% if none vs 39% if ≥3; P = .002), non-White race/ethnicity (40% if White vs 51% if Black, 54% if Hispanic, and 55% if other; P < .001), no recent hospitalization (46% vs 37% if hospitalized; P = .001), and no prior knee and/or hip fracture or surgery (46% vs 35% if prior fracture or surgery; P < .001). After 4 years of follow-up, 35% of those with bathing equipment needs and 52% of those with toileting equipment needs never received equipment.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that in the US, 42% of older adults with impairments that would make bathing or toileting difficult lack equipment to assist. This situation is a missed opportunity to help 5 million individuals live independently and safely.