Effect of a Biobehavioral Environmental Approach on Disability Among Low-Income Older Adults

Abstract

IMPORTANCE Disability among older adults is a strong predictor of health outcomes, health service use, and health care costs. Few interventions have reduced disability among older adults. OBJECTIVE To determine whether a 10-session, home-based, multidisciplinary program reduces disability. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial of 300 low-income community-dwelling adults with a disability in Baltimore, Maryland, between March 18, 2012, and April 29, 2016, 65 years or older, cognitively intact, and with self-reported difficulty with 1 or more activities of daily living (ADLs) or 2 or more instrumental ADLs (IADLs), participants were interviewed in their home at baseline, 5 months (end point), and 12 months (follow-up) by trained research assistants who were masked to the group allocation. Participants were randomized to either the intervention (CAPABLE) group (n = 152) or the attention control group (n = 148) through a computer-based assignment scheme, stratified by sex in randomized blocks. Intention-to-treat analysis was used to assess the intervention. Data were analyzed from September 2017 through August 2018. INTERVENTIONS The CAPABLE group received up to 10 home visits over 5 months by occupational therapists, registered nurses, and home modifiers to address self-identified functional goals by enhancing individual capacity and the home environment. The control group received 10 social home visits by a research assistant. MAIN OUTCOMES AND MEASURES Disability with ADLs or IADLs at 5 months. Each ADL and IADL task was self-scored from 0 to 2 according to whether in the previous month the person did not have difficulty and did not need help (0), did not need help but had difficulty (1), or needed help regardless of difficulty (2). The overall score ranged from 0 to 16 points. RESULTS Of the 300 people randomized to either the CAPABLE group (n = 152) or the control group (n = 148), 133 of the CAPABLE participants (87.5%) were women with a mean (SD) age of 75.7 (7.6) years; 126 (82.9%) self-identified as black. Of the controls, 129 (87.2%) were women with a mean (SD) age of 75.4 (7.4) years; 133 (89.9%) self-identified as black. CAPABLE participation resulted in 30% reduction in ADL disability scores at 5 months (relative risk [RR], 0.70; 95% CI, 0.54-0.93; P = .01) vs control participation. CAPABLE participation resulted in a statistically nonsignificant 17% reduction in IADL disability scores (RR, 0.83; 95% CI, 0.65-1.06; P = .13) vs control participation. Participants in the CAPABLE group vs those in the control group were more likely to report that the program made their life easier (82.3% vs 43.1%; P < .001), helped them take care of themselves (79.8% vs 35.5%; P < .001), and helped them gain confidence in managing daily challenges (79.9% vs 37.7%; P < .001). CONCLUSIONS AND RELEVANCE Low-income community-dwelling older adults who received the CAPABLE intervention experienced substantial decrease in disability; disability may be modifiable through addressing both the person and t...

Attention control group activities and perceived benefit in a trial of a behavioral intervention for older adults

“…Baseline participant characteristics are presented in Table . The control group was similar to the intervention group in terms of age, sex, race, education, and whether or not the participant lived alone (Szanton et al, ).…”

“…Behavioral interventions demonstrate efficacy in improving depression, improving the experience of dementia caregiving, and reducing the functional decline in community‐dwelling older adults (Gitlin et al, ; Szanton et al, ). Behavioral intervention trials examine whether those who receive the intervention benefit more than a similar group who receives no care, or a similar group who receives a comparison of interest.…”

“…The team provided participants with support in enhancing individual functional capacity and with home modifications to improve the home environment. We analyze data from the attention control group participants in a randomized trial of the CAPABLE intervention (Szanton et al, ). CAPABLE is designed to improve function among low‐income community‐dwelling older adults by providing time‐limited services focused on functional goals as determined by the older adult participants (Szanton, Leff, Wolff, Roberts, & Gitlin, ).…”

“…Examples of services provided by the team include the occupational therapist developing and facilitating a tailored physical activity program, the registered nurse completing a medication review to reduce fall risk, or the handyman installing handrails to facilitate improved navigation of the home environment. CAPABLE has been widely studied and shows both therapeutic benefits and cost‐effectiveness as an intervention to promote successful aging in place (Szanton et al, ; Szanton et al, ; Szanton et al, ; Szanton et al, ; Szanton et al, ; Szanton & Gitlin, ; Szanton et al, ).…”

“…The goal of the attention control group was to match the amount of attention time provided to the treatment group to determine if CAPABLE provides benefit to intervention participants beyond the benefit of the attention provided by the nurse, occupational therapist, and handyman. The results of the randomized control trial are provided in a different manuscript (Szanton et al, ). Here, we focus on describing and analyzing the attention control group.…”