Technology for activity participation in older people with mild cognitive impairment or dementia: expert perspectives and a scoping review

PURPOSE

This two-phased study aimed to collate, summarize and characterize - through the lens of an occupation-based, person-centred framework - ongoing research and practice featuring activity participation-supportive digital health technology (DHT) for direct use by older persons with mild cognitive impairment or Alzheimer's disease and related dementias (PwMCI/ADRD).

MATERIALS AND METHODS

Phase 1: Using scoping review procedures, PubMed, MEDLINE and PsycInfo were searched to identify primary research studies. Phase 2: Semi-structured interviews were completed with MCI/ADRD expert stakeholders identified through publicly available biographies and snowball referral. Thematic analysis was used to identify, synthesize and cross-compare emergent themes from both data sources that were subsequently organized into core facets of the Human Activity Assistive Technology (HAAT) model.

RESULTS

The scoping review resulted in 28 studies, which were primarily feasibility work with small sample sizes. Interviewed experts (N = 17) had 4+ years of MCI/ADRD experience, came from a variety of settings, and held myriad roles. Real world and research-based use of DHTs held some commonalities, particularly around support for social participation and instrumental activities of daily engagement. No DHT for sleep or work/volunteerism were noted in either phase. People with milder MCI/ADRD conditions were most often targeted users. Soft technology strategies facilitating implementation centred on product design (e.g., prompting software, customisability, multimedia/multisensory experiences), instructional methods and technology partner involvement.

CONCLUSIONS

This study demonstrates that although DHT supportive of activity participation is being studied and integrated into the lives of PwMCI/ADRD, there are still key opportunities for growth to meet the needs of diverse MCI/ADRD end users.Implications for rehabilitationMainstream digital health technologies (DHTs) are being utilized by persons with mild cognitive impairment and Alzheimer's disease and related dementias (PwMCI/ADRD) in everyday life, in limited capacities, to support social participation, leisure, health management and instrumental activities of daily living (IADL).Innovative research-based technologies to be used directly by PwMCI/ADRD are under development, particularly to facilitate management of ADL, social participation and IADL in persons with mild-to-moderate forms of cognitive impairment.Soft technology strategies to support technology implementation with MCI/ADRD target users include close attention to design of the technology (e.g., customisability, sensory stimulators and prompting features), instructional strategies that promote learning and motivation and involvement of technology partners to facilitate engagement with the technology.Future studies will require more robust research designs with transparent reports of participant characteristics and facilitative instructional methods to expand DHT's potential to account for and better meet the needs of diverse MCI/ADRD communities in real-world contexts.

Racial Differences in the Dementia Caregiving Experience During the COVID-19 Pandemic: Findings From the National Health and Aging Trends Study (NHATS)

OBJECTIVES

Given racial disparities in both dementia and coronavirus disease 2019 (COVID-19), non-Hispanic Black (Black) dementia caregivers (CGs) may be at greater risk for care burden during the COVID-19 pandemic than non-Hispanic White (White) CGs. This study investigates the impact of dementia care provision on CGs' quality of life by race using the 2020 National Health and Aging Trends Study Family Members and Friends COVID-19 data (FF).

METHODS

This study features a secondary analysis of FF data (2020-2021), including 216 Black and 1,204 White CGs. We used ANOVA to determine differences in caregiving stressors (i.e., changes in providing help with activities of daily living [ADL], instrumental ADL [IADL], and emotional support). Ordinary least square regression was used to investigate the moderating effects of dementia care on the associations of race with perceived well-being, care burden, and self-reported health and to conduct subgroups analyses of Black and White dementia CGs.

RESULTS

Black dementia CGs provided significantly more help with ADL before and during the COVID-19 pandemic than Black nondementia, White dementia, and White nondementia CGs. Dementia care status did not moderate the associations between race and CG outcomes. For Black dementia CGs, changes in objective stressors (assistance with ADL and IADL) were associated with care burden and well-being. For White CGs, the provision of emotional support was associated with care burden and well-being.

DISCUSSION

This study highlights that increased caregiving demands during the pandemic amplified racial differences in CG stress. Findings suggest that outreach to reduce CG stress and burden is critical for Black dementia CGs.

Preliminary User Evaluation of a Physical Activity Smartphone App for Older Adults

Objectives

Mobile health (mHealth) delivered through smartphone apps is a viable means of improving health behaviors. Technologies can be strengthened and made more age-inclusive by involving older adults as co-designers, resulting in more accessible and effective products. This study's purpose is to describe preliminary acceptability and feasibility of a physical activity (PA) app tailored to underactive older people.

Methods

Moving Up is a multi-feature app designed to increase PA and reduce sedentary behaviors in underactive older adults. The suite houses a core activity tracker and three add-on features that target correlates of inactivity: sedentary behavior, stereotypes about aging, and PA knowledge and routines. Three groups of 4-5 older adult smartphone owners were provided with and oriented to the Moving Up app activity tracker and one add-on feature. Participants beta-tested the app for two weeks, after which each cohort reconvened to discuss experiences, make recommendations for app improvements, and complete a usability questionnaire on their assigned feature.

Results

Thirteen participants (median age, 71 years; iOS users, n=8; females, n=12) completed the beta-testing period and returned for follow-up. Reported usability was moderate across the features. Sentiments about app content and general impressions were mainly positive, although users made several recommendations for app improvements such as more individualized messaging and timely notifications.

Conclusions

A PA app for older adults demonstrated generally good usability and acceptability. Integrating the impressions and recommendations from older adults into the design of mHealth tools will enhance overall usability and likelihood to positively influence PA behaviors long-term.

Practice-Based Evidence of Lifestyle Redesign® for Hypertension and Diabetes in a Safety-Net Primary Care Setting

Date Presented 04/01/2022

This study used medical chart reviews to evaluate Lifestyle Redesign® OT services for hypertension and diabetes to improve health and well-being in a safety-net primary care setting. Patients showed significant improvements in clinical outcomes (systolic and diastolic blood pressure, HbA1c), as well as in patient activation and occupational performance. Findings support the promising role of OT as part of routine primary care for patients with chronic disease.

Primary Author and Speaker: Stacey L Schepens Niemiec

Additional Authors and Speakers: Daniel Padilla Vega

Contributing Authors: Gabrielle Granados, Jesus Diaz, Jeanine Blanchard, Elizabeth Pyatak

Unpaid Caregiving and Aging in Place in the United States: Advancing the Value of Occupational Therapy

Unpaid caregivers are often expected to help family members or friends overcome activity limitations and participation restrictions to successfully age in place. Caregivers assume multiple responsibilities, such as managing their own physical and psychosocial needs and navigating a complex health care system, and many feel ill equipped to fulfill the necessary health care responsibilities for their care recipients. Underprepared caregivers may cause poor outcomes for care recipients. Federal and state policy proposals call attention to the need to better support caregivers, especially as their numbers increase. Occupational therapy practitioners are well positioned to effectively engage caregivers as they navigate the health care system. The occupational therapy process looks broadly at the functional abilities, environmental contexts, and occupational demands that play a pivotal role in successful aging in place for clients and better outcomes for their caregivers. Now is the time to define occupational therapy's distinct value to this area.

Stimulating Research to Enhance Aging in Place

Older adults may benefit from interventions to successfully age in place. Research has an opportunity to test interventions and implementation strategies to fulfill the needs of older adults through collective evidence building. The purpose of this article is to describe the proceedings of the American Occupational Therapy Foundation (AOTF) 2019 Planning Grant Collective and describe the areas of research that were identified as critical. The AOTF convened scientists with expertise in the area of aging in place to catalyze research on aging in place for older adults. Four priority areas in the aging in place literature were highlighted: (a) identification of factors that support aging in place, (b) classification of processes by which family members and care partners are included in aging in place efforts, (c) categorization of technology supporting older adults to age in place, and (d) development of science that clarifies implementation of evidence-based practice.

Long-Term Follow-Up of a Lifestyle Intervention for Late-Midlife, Rural-Dwelling Latinos in Primary Care

Importance: Rural-dwelling Latinos are an underresourced population in need of accessible and effective wellness programs.

Objective: To evaluate patients’ long-term health-related outcomes after lifestyle intervention.

Design: An uncontrolled pilot trial assessing change in health from pretreatment to long-term follow-up (12 mo after intervention completion, no contact) and from posttreatment to long-term follow-up.

Setting: Rural, community-based primary care.

Participants: Latino and Hispanic safety-net primary care patients, ages 50 to 64 yr.

Intervention: A culturally tailored, 4-mo lifestyle intervention co-led by occupational therapy practitioners and Latino community health workers that features telehealth and in-home sessions covering topics such as healthy eating and navigating health care.

Outcomes and Measures: Self-reported and physiological outcomes: symptom–well-being (primary), stress, sleep disturbance, social satisfaction, physical activity, patient activation, blood pressure, and weight. Exit interviews addressed health experiences and intervention impact on participants’ lives.

Results: Participants (N = 27) demonstrated clinically significant pretreatment to long-term follow-up benefits in all symptom–well-being dimensions (Cohen’s d ≥ 0.8, p ≤ .004), with additional gains from posttreatment to long-term follow-up (d ≥ 0.4, p ≤ .05). Significant improvements from pre- to posttreatment in systolic blood pressure, stress, and social role and activity satisfaction were maintained at long-term follow-up. No changes were observed in weight, physical activity, or diastolic blood pressure. Participants described the intervention’s sustained positive effect on their wellness.

Conclusions and Relevance: A lifestyle intervention led by occupational therapy practitioners and community health workers in a primary care context has potential to achieve long-term health benefits in rural-dwelling, late-midlife Latinos.

What This Article Adds: This study reveals that rural, late-midlife Latinos showed long-lasting improvements in psychological and physical health after finishing a program that helped them make healthy lifestyle choices. This finding supports the unique contribution of occupational therapy in primary care settings.

FEASIBILITY OF A TELEHEALTH-DELIVERED LIFESTYLE INTERVENTION FOR LATE-MIDLIFE LATINOS LIVING IN RURAL CALIFORNIA

Late-midlife Latinos (50–64 years old) living in rural regions experience significant health disparities, oftentimes exacerbated by limited access to healthcare services. In a previous pilot study, we observed psychosocial, behavioral, and cardiometabolic health improvements sustained over 12-months in late-midlife Latinos who participated in ¡Vivir Mi Vida! (¡VMV!), a culturally tailored lifestyle intervention led by a Latino community health worker (promotor) and occupational therapist team. For the present study, we assessed the feasibility of telehealth-delivered ¡VMV! modules. Participants (N=10) received an abbreviated three-week version of ¡VMV! consisting of an in-person promotor-led orientation and two one-hour telehealth sessions. Telehealth opinions/experiences were assessed at baseline and follow-up using study-specific questionnaires and by interview. Patient-identified health quality was measured pre-post intervention using the Measure Yourself Medical Outcome Profile (MYMOP2) and a single-item stress index. Participants generally agreed that telehealth session quality was equivalent to in-person sessions, and demonstrated confidence in their ability to communicate freely with the promotor and actively participate in telehealth sessions. We observed significant improvements in nearly all MYMOP2 components and a trend in stress reduction. The intervening promotor reflected that telehealth ¡VMV! extended healthcare to patients impacted by risk factors such as geographic isolation, lack of available services, and hesitancy to access in-person services due to fear of discrimination or deportation. Participants provided highly positive feedback, highlighting the practicality and convenience of the telehealth program. Feasibility of delivering ¡VMV! via telehealth to late-midlife rural-dwelling Latinos and its potential for positive effect was supported.

Addressing Diabetes in Primary Care: Hybrid Effectiveness-Implementation Study of Lifestyle Redesign® Occupational Therapy

IMPORTANCE

Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy's feasibility and efficacy in primary care settings.

OBJECTIVE

To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign^® (LR)-occupational therapy (LR-OT) diabetes management intervention in a primary care clinic.

DESIGN

Patients were randomized to be offered LR-OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods.

SETTING

Safety-net primary care clinic.

PARTICIPANTS

Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18-75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%.

INTERVENTION

Eight 1-hr individual sessions of LR-OT focused on diabetes management.

OUTCOMES AND MEASURES

Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR-OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations.

RESULTS

Seventy-three patients were offered LR-OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation.

CONCLUSIONS AND RELEVANCE

LR-OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care.

WHAT THIS ARTICLE ADDS

This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy's effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

Understanding the Mechanisms of Change in a Lifestyle Intervention for Older Adults

Purpose of the Study

This study investigated the mechanisms of change underlying an activity-based lifestyle intervention, an occupational therapy program aimed at promoting healthy habits, and routines in older adults. We examined two activity-relevant factors as potential mediators linking the intervention to reduced symptoms of depression: activity frequency and global perceptions of activity significance. Social connections and perceived control were assessed to understand how activity-related factors relate to reduced symptoms of depression.

Design and Methods

The sample consisted of 460 multiethnic community-dwelling older adults aged 60-95 years. Participants were randomly assigned to a 6-month lifestyle redesign intervention (n = 232) or a no-treatment control (n = 228) condition. After the 6-month period, 360 individuals completed post-testing. Latent change score models were used to represent changes from baseline over the experimental interval. Structural equation models were applied to examine the indirect effects of the intervention on reduced depressive symptoms.

Results

The results demonstrated significant indirect effects from intervention receipt to decreased depressive symptoms via increased activity frequency and activity significance. Higher activity frequency was linked to fewer depressive symptoms via heightened social connections, whereas increased activity significance was associated with fewer depressive symptoms via enhanced perceived control.

Implications

The results support basic principles of occupational therapy by highlighting important mediating roles of activity frequency and activity significance in reducing depressive symptoms. Understanding of these change mechanisms can help optimize activity-centered interventions to reduce depressive symptoms.

A Pilot Study of the ¡Vivir Mi Vida! Lifestyle Intervention for Rural-Dwelling, Late-Midlife Latinos: Study Design and Protocol

Older, rural-dwelling Latinos face multiple health disparities. We describe the protocol of a pilot study of a community health worker-occupational therapist-led lifestyle program, ¡Vivir Mi Vida! ( ¡VMV!), designed for delivery in primary care and adapted for late-midlife, Latino rural-living patients. Using mixed methods, we collected feasibility, acceptability, and preliminary efficacy data on ¡VMV!. Forty 50- to 64-year-old Latinos participated in a 16-week lifestyle intervention led by a community health worker-occupational therapist team. We conducted pre- and post-intervention assessments to evaluate the efficacy of ¡VMV! in improving psychosocial and clinical health outcomes. Focus groups and interviews were held post-intervention with participants and key stakeholders to assess feasibility and acceptability. This is the first trial designed to evaluate a lifestyle intervention that includes collaboration between occupational therapists and community health workers within primary care. The detailed description of methodology promotes research transparency and reproducibility of a community health worker-occupational therapist-led lifestyle intervention.

Assessing Fatigability in the Lab and in Daily Life in Older Adults With Osteoarthritis Using Perceived, Performance, and Ecological Measures

BACKGROUND

Fatigue in older adults is associated with functional decline and reduced participation in daily life; however, it is not well characterized. Examining fatigue within activity performance, or "fatigability," is a recommended approach to begin to understand fatigue and its underlying mechanisms. This study examined the construct validity of lab-based measures of fatigability and compared these measures with fatigability in daily life (termed ecological fatigability).

METHODS

Participants with osteoarthritis and fatigue (n = 163) underwent laboratory assessments, completed questionnaires, and wore accelerometers for 7 days while tracking symptoms and behaviors. Lab-based fatigability measures were quantified using the 6-minute walk test. Perceived fatigability was assessed by asking participants before and after the test to report: (i) fatigue severity and (ii) perceived exertion. Performance fatigability was calculated using change in walking speed divided by total distance walked. Ecological fatigability was calculated from the 7-day assessment in which fatigue severity was reported five times a day and physical activity was continuously measured. Additional ecological measures (eg, self-pacing) were examined.

RESULTS

Lab-based perceived and performance fatigability measures were highly inter-correlated, moderately correlated with gait speed and metabolic measures, and weakly correlated with physical activity. Although ecological fatigability was weakly correlated with lab-based measures, participants with high fatigability on lab-based measures demonstrated more self-pacing behaviors than participants with low fatigability.

CONCLUSION

Lab-based fatigability measures are related to physical capacity measured both in the lab and daily life. Lab-based fatigability measures provide important information regarding daily life fatigability useful for future intervention development.

Developing Occupation-Based Preventive Programs for Late-Middle-Aged Latino Patients in Safety-Net Health Systems

Latino adults between ages 50 and 60 yr are at high risk for developing chronic conditions that can lead to early disability. We conducted a qualitative pilot study with 11 Latinos in this demographic group to develop a foundational schema for the design of health promotion programs that could be implemented by occupational therapy practitioners in primary care settings for this population. One-on-one interviews addressing routines and activities, health management, and health care utilization were conducted, audiotaped, and transcribed. Results of a content analysis of the qualitative data revealed the following six domains of most concern: Weight Management; Disease Management; Mental Health and Well-Being; Personal Finances; Family, Friends, and Community; and Stress Management. A typology of perceived health-actualizing strategies was derived for each domain. This schema can be used by occupational therapy practitioners to inform the development of health-promotion lifestyle interventions designed specifically for late-middle-aged Latinos.

Development and validation of the activity significance personal evaluation (ASPEn) scale

BACKGROUND/AIM

Engagement in desired occupations can promote health and wellbeing in older adults. Assessments of engagement often measure frequency, amount or importance of specific activities. This study aimed to develop a scale to measure older adults' evaluation of the extent to which their everyday activities are contributing to their health and wellness.

METHODS

Eighteen items, each scored with a seven-point rating scale, were initially developed by content experts, covering perceptions of how daily activities contribute to physical and mental health, as well as satisfaction and activity participation in the last six months. Rasch analysis methods were used to refine the scale using the pencil and paper responses of 460 community-living older adults.

RESULTS

Initial Rasch analysis indicated three unlabelled rating scale categories were seldom used, reducing measurement precision. Five items were conceptually different by misfit statistics and principal component analysis. Subsequently, those items were removed and the number of rating scale steps reduced to 4. The remaining 13-item, 4-step scale, termed the Activity Significance Personal Evaluation (ASPEn), formed a unidimensional hierarchy with good fit statistics and targeting. Person separation reliability (2.7) and internal consistency (.91) indicated the tool is appropriate for individual person measurement. Relative validity indicated equivalence between Rasch measures and total raw scores.

CONCLUSIONS

ASPEn is a brief, easily administered assessment of older adults' perception of the contribution of everyday activities to personal health and wellness. ASPEn may facilitate occupational therapy practice by enabling clinicians to assess change in meaning of an older adult's activity over time.

What is occupational therapy's role in addressing sleep problems among older adults?

Sleep problems, prevalent among older adults, are associated with poor outcomes and high health care costs. In 2008, rest and sleep became its own area of occupation in the American Occupational Therapy Association's Occupational Therapy Practice Framework. The current scoping review examined a broad context of sleep research to highlight efficacious interventions for older adults that fall within the occupational therapy scope of practice and present an agenda for research and practice. Four sleep intervention areas clearly aligned with the practice framework, including cognitive behavioral therapy for insomnia, physical activity, multicomponent interventions, and other interventions. Occupational therapy is primed to address sleep problems by targeting the context and environment, performance patterns, and limited engagement in evening activities that may contribute to poor sleep. Occupational therapy researchers and clinicians need to work collaboratively to establish the evidence base for occupation-centered sleep interventions to improve the health and quality of life of older adults.