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Original Investigation
January 7, 2019

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

Author Affiliations
  • 1Johns Hopkins University School of Nursing, Baltimore, Maryland
  • 2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 3Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 4Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
  • 5Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 6Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 7College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania
JAMA Intern Med. Published online January 7, 2019. doi:10.1001/jamainternmed.2018.6026
Key Points

Question  Does a program addressing personal and environmental factors reduce disability among low-income older adults?

Findings  In this randomized clinical trial of 300 low-income older adults with disability, participation in a person-directed program resulted in a 30% reduction in disability scores compared with the results achieved in an attention control group.

Meaning  The findings suggest that disability may be modifiable through addressing both the person and the environment and such an intervention merits consideration for broader implementation.

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, aged 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 the environment.

Trial Registration  ClinicalTrials.gov identifier: NCT01576133

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    1 Comment for this article
    EXPAND ALL
    HEROIC COMMITMENT
    Paul Nelson, M.D., M.S. | Family Health Care, P.C. retired
    The research team screened 1229 persons to select 300 participants to complete a 5 month home intervention or a home minimalist home visit control arm with a respective 12 month f/u analysis. Then, with submission of the report, there was presumably another 1 year of careful editing. The cost per intervention person was $2825 that included up to $1300 for home repairs.

    I wonder whether each person in the study had an assessment of their extended family and next-door neighbor networks at the beginning of enrollment. Secondly, I  wonder whether or not the number
    of hospital days required during the year before enrollment and two years after enrollment were impacted by the study. This information, if available, would generate a much wider impact from the study on healthcare reform. Given the socioeconomic status of these study participants, I dearly hope so.

    During a 40 year career as a primary physician in nearly one location, a home visit was never a wasted effort to more fully understand the complexities of a person's health. I am sure the study team would heartedly agree.
    CONFLICT OF INTEREST: None Reported
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