An Internet-based Acceptance and Commitment Therapy intervention for older adults with anxiety complaints: study protocol for a cluster randomized controlled trial

Background

Anxiety is among the most prevalent and disabling mental health problems in older adults. Few older adults with mild to moderately severe anxiety symptoms receive adequate interventions, putting them at risk for developing anxiety disorders, depression, and various somatic problems. Effective, low-threshold interventions should be developed. Blended care, in which a web-based intervention is combined with a limited amount of face-to-face contacts with a mental healthcare counselor at the general practice, is a promising option. The online self-help intervention “Living to the Full”—an Acceptance and Commitment Therapy (ACT) intervention—has been proven to reduce depression and anxiety in several patient groups, but has not yet been investigated in older adults. The aim of this study is to evaluate the (cost-)effectiveness of a blended form of “Living to the Full” in reducing anxiety symptoms in adults aged 55 to 75 years. Furthermore, moderators and mediators of the treatment effect are investigated.

Methods/design

The (cost-)effectiveness of the ACT intervention will be investigated in a cluster single-blind randomized controlled trial (RCT). The blended intervention will be compared to treatment-as-usual. Thirty-six mental health counselors working at general practices in the Netherlands will be randomized to deliver blended care or treatment as usual. A total of 240 participants (aged 55–75 years) with mild to moderately severe anxiety complaints (defined as a total score of 5–15 on the GAD-7) will be recruited. There are four measurements consisting of online questionnaires (primary outcome: GAD-7) and a telephone interview: before the start of the intervention; directly following the intervention (14 weeks after baseline); and six and twelve months after baseline. Possible mediator variables will be assessed multiple times basis during the intervention.

Discussion

This RCT will evaluate the effectiveness of a blended ACT intervention for older adults with anxiety symptoms. If the intervention is shown to be effective, it will be implemented, thereby improving the accessibility and quality of preventive interventions for older adults with anxiety problems.

Trial registration

Netherlands Trial Register, NTR6270. Registered on 21 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2731-3) contains supplementary material, which is available to authorized users.

Physical activity attitudes, beliefs, and practices among adults 50 and older: baseline community assessment

This study aligned with the National Blueprint, a coalition of national organizations to identify the principal barriers to physical activity participation in older adults and to outline strategies for increasing physical activity levels. A community coalition took the initiative to conduct a baseline assessment of health attitudes, perceptions, and behaviors among community adults in order to understand the immediate needs of the adult community. Adults 50 and older (N = 309) completed surveys of health and physical activity (PA) behaviors. Individuals reported below average physical activity levels. Motives and barriers to PA differed by gender and race/ethnicity. Age and health perceptions significantly predicted PA levels. Findings support previous research with this age group, thus discussion of the utility of multi-level approaches (e.g., social ecological model) to health betterment in communities is forwarded. Providing multi-level resources (personal, social, environmental, policy) can increase opportunities for adoption and maintenance of health behaviors.

A comparison of eating practices of independently living older adults in private residences and in senior retirement housing: a pilot study

This study investigated eating-related habits and their importance in older people and compared those living in private residences with those in senior retirement community housing. A convenience sample of 58 seniors answered eating-related items from the Self-maintenance Habits and Preferences in Elderly questionnaire (SHAPE). Meal location, companions, concurrent activities, portion size, and food variety differed between private and retirement housing for some meals, but the overall importance assigned to eating practices was similar. The meals themselves appeared to be more important than any specific socio-environmental element. Eating practices associated with dinner were more important than those for the other meals.

Assessment of Impairments That Limit Exercise and Use of Impairment Information to Generate an Exercise

Prescribing the correct exercise program is a challenge for older adults with multiple physiological impairments. The authors evaluated an assessment instrument that incorporates results of multiple categories of impairment, including strength, balance, gait, vision, and cognitive function. The physical therapist made judgments on the relative impact of 9 different impairments on specific exercises and on the total impact of all impairments on particular exercises. In a cohort age 75–85 y, functional limitations, impaired balance, pain, and low physical endurance were estimated to have the largest impact on the ability to carry out exercise activities, primarily walking, stair climbing, balance exercises, and stationary bicycling. The assessments revealed that the ability to exercise was related to objective measures of function, indicating that the therapist incorporated such objective measures into the impairment-impact rating. The impairment-impact assessment facilitates creating individualized exercise prescriptions for individuals with impairments.

Motivational factors and physician advice for physical activity in older urban adults

This study aimed to ascertain by means of a new scale older adults' motives for engaging in physical activity, in a probability and representative sample of an older urban population. The sample size was 630 older adults, ranging from 65 to 94 years in age, randomly selected using multistage sampling. The participants completed a 17-item questionnaire, as well as answering questions on demographic variables, type of demand for physical activity, and physician's recommendation. A principal-component analysis was performed. The relationships among the four factors (physical health, social relationships, competence, and physician's advice) show a clearly motivational structure. Significant relationships have also been found between physician's recommendation and type of demand. The findings suggest that programs promoting physical activity in older adults should have different characteristics from those aimed at general adult populations.

Use of Medicare summary notice inserts to generate interest in the Medicare stop smoking program

PURPOSE

Evaluations of outreach strategies that effectively and efficiently reach the senior population often go unreported. The Medicare Stop Smoking Program (MSSP) was a seven-state demonstration project funded by the Centers for Medicare and Medicaid Services. The 1-year recruitment plan for MSSP included a multifaceted paid media campaign; however, enrollment was slower than anticipated. The purpose of this substudy was to test the effects of including envelope-sized advertisement inserts with Medicare Summary Notices (MSNs) as a supplemental recruitment strategy.

METHODS

Information obtained from enrollees on where they had learned about the program as well as overall enrollment rates were analyzed and compared with the time periods during which the inserts were included in MSN mailings.

RESULTS

Average call volume to the enrollment center increased by 65.7% in Alabama, the pilot state, and by more than 200% in the subsequent demonstration states. Despite the introduction of the MSN inserts late in the recruitment period, 32.2 % of the 7354 total enrollees stated that they learned about the project through the inserts.

CONCLUSIONS

This recruitment method is highly recommended as a cost-effective way to reach the senior population.

Lifestyle Interventions and Independence for Elders pilot study: recruitment and baseline characteristics

OBJECTIVES

To describe several recruitment parameters derived from the Lifestyle Interventions and Independence for Elders pilot (LIFE-P) study for use in a full-scale trial of mobility disability prevention.

DESIGN

A description of the recruiting methods and baseline characteristics of a four-site randomized, controlled trial testing the effectiveness of a physical activity intervention at preventing mobility disability.

SETTING

The Cooper Institute, Dallas, Texas; Stanford University, Stanford, California; University of Pittsburgh, Pittsburgh, Pennsylvania; and Wake Forest University, Winston-Salem, North Carolina.

PARTICIPANTS

Community-living persons aged 70 to 89 who were able to walk 400 m within 15 minutes and were at high risk for disability (scoring<10 on the Short Physical Performance Battery (SPPB)) but without comorbidity severe enough to preclude full study participation.

MEASUREMENTS

Measures of efficiency included number of randomized participants per recruitment technique and costs per randomized participant across randomization techniques.

RESULTS

The 9-month recruiting period resulted in 3,141 telephone screens, of which 424 (13.5%) participants were randomized (68.9% women, 25.7% minorities, 41.5% with SPPB scores<8). Forty percent of telephone-screened participants were excluded primarily because of regular participation in physical activity, health exclusions, or self-reported mobility disability. Of the 1,252 persons attempting the physical performance assessments, 41% scored above the SPPB cutoff. Of the 566 remaining eligible, 9.9% could not complete the 400-m walk, and another 18.9% had various medical exclusions. Direct mailing was the most productive recruitment strategy (61.6% of all randomized participants). Recruitment cost approximately $439 per randomized participant.

CONCLUSION

The LIFE study achieved all recruitment goals and demonstrated the feasibility of recruiting high-risk community-dwelling older persons for trials of disability prevention in diverse geographic areas.

Self-maintenance Habits and Preferences in Elderly (SHAPE): reliability of reports of self-care preferences in older persons

BACKGROUND AND AIMS

Self-care preferences can be used in designing programs of care. Yet little has been documented concerning the self-care habits and preferences of older adults.

METHODS

This study assessed the reliability of reports of self-care preferences and their importance among older adults using the Self-maintenance Habits and Preferences in Elderly (SHAPE) instrument. Twenty community-dwelling seniors completed the SHAPE questionnaire twice within a one- to two-week interval. Percent agreement, both exact and close/partial, was computed to assess the reliability of preference content, and intra-class correlations (ICCs) were used for preference importance. Test and subject factors affecting reliability were also investigated.

RESULTS

Exact agreement rate for item content was 73%, and that for close/partial agreement was 93%. Mean ICC for item importance was 0.72. Reliability was greater for dichotomous items than for either ordinal or categorical questions. Reliability of item content varied with number of response options and importance reliability varied with age and IADL status.

CONCLUSIONS

Information from SHAPE about self-care preferences can be used to plan services for seniors and to individualize care for older persons, especially those transitioning to new living environments or those receiving home care.

Comparison of exercise models in an elderly population

BACKGROUND AND AIMS

Two different models of exercise behavior in an older population have been previously published (Schuster et al., 1995 and Resnick et al., 2000). We aimed to validate the models with data from a different sample, and to examine whether any of these models explained a greater proportion of the variance in exercise behavior in this population.

METHODS

Participants were 324 community- dwelling persons aged 74-85 years who completed a mailed questionnaire. The questionnaire included questions about demographics, current exercise habits, health, activities of daily living, depressed affect, living arrangement, attitudes about exercise, self-efficacy, barriers to exercise, and enjoyment of exercise.

RESULTS

While our data explained some of the variance of the two previously published models of exercise behavior, the percentage of variance explained was less impressive than that reported by those authors. A path analysis of demographic and psychological constructs, which have been used in both models, demonstrated that physical health, mental health, gender, and past enjoyment of exercise affect self-efficacy, attitudes/outcome expectancy, and reported barriers to exercise. These psychological constructs in turn affect exercise habits.

CONCLUSIONS

The relatively low percentage of variance explained by the models may imply that other factors contribute to exercise behavior in older adults, that the constructs are very sensitive to measurement differences, or that these factors are not as important as previously thought. Our results are consistent with the models of both Schuster et al. and Resnick et al., but suggest that a combined model may better represent the data. Future investigations of exercise behavior in older persons should examine this possibility.

Sleep-related habits and preferences in older adults: a pilot study of their range and self-rated importance

This article explores the sleep-related habits of older persons, as well as the level of importance they assign to these practices. A convenience sample of 58 community-dwelling seniors responded to sleep-related items from the Self-Maintenance Habits and Preferences in Elderly questionnaire. Sleep practices varied greatly across individuals, but did not show much systematic difference between men and women. However, as with many health care issues, women rated them as more important than did men. Knowledge of sleep habits and preferences is important so that it can be taken into account by those responsible for planning care for older adults or for aiding their adaptation to a new setting.

Strategies for retaining study participants in behavioral intervention trials: retention experiences of the NIH Behavior Change Consortium

Failing to retain an adequate number of study participants in behavioral intervention trials poses a threat to interpretation of study results and its external validity. This qualitative investigation describes the retention strategies promoted by the recruitment and retention committee of the Behavior Change Consortium, a group of 15 university-based sites funded by the National Institutes of Health to implement studies targeted toward disease prevention through behavior change. During biannual meetings, focus groups were conducted with all sites to determine barriers encountered in retaining study participants and strategies employed to address these barriers. All of the retention strategies reported were combined into 8 thematic retention categories. Those categories perceived to be most effective for retaining study participants were summarized and consistencies noted among site populations across the life course (e.g., older adults, adults, children, and adolescents). Further, possible discrepancies between site populations of varying health statuses are discussed, and an ecological framework is proposed for use in future investigations on retention.

Incidence of loss of ability to walk 400 meters in a functionally limited older population

OBJECTIVES

To assess the incidence of and factors related to nondisabled but functionally limited older adults aged 75 to 85 years losing the ability to walk 400 m.

DESIGN

Observational study with average follow-up of 21 months.

SETTING

Community.

PARTICIPANTS

At baseline, 101 persons with objective signs of functional limitations and intact cognitive function agreed to participate in the study. Of these, 81 were able to walk 400 m at baseline, and 62 participated in the follow-up examination.

MEASUREMENTS

Mobility disability was defined as an inability to complete a 400-m walk test. At baseline, eligible participants (n=81) had the ability to walk 400 m, scored between 4 and 9 on the Short Physical Performance Battery (SPPB; range 0-12), and scored 18 or more on the Mini-Mental State Examination. Demographics, difficulty in daily activities, disease status, behavioral risk factors, and muscle strength were assessed at baseline and follow-up.

RESULTS

Of 62 persons at follow-up, 21 (33.9%) developed incident mobility disability. The strongest predictors of loss of mobility were the time to complete the 400-m walk at baseline (odds ratio (OR)=1.6 per 1-minute difference, 95% confidence interval (CI)=1.04-2.45), and decline in SPPB score over the follow-up (OR=1.4 per 1-point difference, 95% CI=1.01-1.92).

CONCLUSION

Older persons with functional limitations have a high rate of loss of ability to walk 400 m. The 400-m walk test is a highly relevant, discrete outcome that is an ideal target for testing preventive interventions in vulnerable older populations.

Socio-environmental exercise preferences among older adults

BACKGROUND

To examine preferences concerning social and environmental aspects of exercise in the elderly population.

METHODS

Participants were 324 community-dwelling persons aged 74-85 years who completed a health questionnaire that included items on exercise preferences as well as questions on demographic variables, health, and exercise habits. Selected participants then completed a physical performance battery to measure lower body functioning.

RESULTS

A physician's advice to exercise, monitoring by a health professional, an evaluation of the exercise program by a professional, and the quality of the instructor were all rated as important or very important by at least 70% of the participants. Several other factors such as easy access to exercise facilities, type of exercise performed, free or low cost of a program, and other participants being of the same age were rated as slightly important or important. Preferences were related to participants' health and demographic characteristics. For example, participants who were not married were more interested in the social aspects of exercise programs, and those with higher levels of education and more resources were less concerned with program costs.

CONCLUSIONS

The findings suggest that exercise programs should be tailored to meet the needs and wishes of subgroups of this population. In order to motivate at-risk elderly persons to exercise, programs must take these varying preferences into account and explore their meaning for program design.

The Association of Physical-Performance Level with Attitude Toward Exercise in Older Adults

The Hebrew Home Study of Impairment and Exercise is a cross-sectional community-based study of nondisabled adults age 75–85 years that assessed attitude toward exercise by asking level of agreement with four statements evaluating participants’ perceptions of the health benefits and personal rewards of exercise. A physical-performance battery evaluated lower extremity function on a scale of 0 to 12. Attitude toward exercise was compared across 4 groups: non-vigorous exercisers with scores of 4–6 (n= 21), 7–9 (n= 90), or 10–12 (n= 113) and vigorous exercisers (n= 71). Vigorous exercisers had a significantly better attitude toward exercise than the reference group did, with odds ratios of 1.8-5.5 in all attitude statements. The lowest and moderate-performance groups had less positive attitudes toward exercise than the reference group did, with odds ratios of 0.27–0.62 for all statements. There was a highly significant gradient with better attitude toward exercise and higher functional-status level. Future work in improving older adults’ compliance with exercise should take into account the less positive attitude of those with functional limitations toward the benefits of exercise.

Motivators and Barriers to Exercise in an Older Community-Dwelling Population

This study aimed to ascertain perceived barriers and motivators to exercise in people age 74–85 and to clarify the meaning of these barriers and motivators by examining participant characteristics that relate to them. 324 community-dwelling participants age 74–85 completed a health questionnaire that included items on barriers and motivators to exercise, as well as questions on demographic variables, health, and exercise. Selected participants then completed a physical-performance battery to measure functional performance. Barriers and motivators were related internally, as well as to many other factors including pain and depressed affect on the Geriatric Depression Scale. The findings suggest a need for individualized and comprehensive approaches to the presentation of exercise programs. Health interventions are needed that will address both physical pain and depressed affect and explain the importance of exercise even in the presence of health problems. An understanding of the context of reported barriers and motivators is necessary for correct interpretation and program development.