Reducing disability via a bundled bio-behavioral-environmental approach

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DESCRIPTION (provided by applicant): Disability in older adults is a major public health problem, particularly among low-income urban people of color. Most disabled older adults strongly prefer to live at home, but many require nursing home admission due to limitation in basic or instrumental activities of daily living (ADLs or IADLs). Since these costly admissions are preventable, testing novel, cost-effective interventions to improve ADLs should be a public health priority. Previous research has not comprehensively addressed individuals and the environment in which they function yet low income older adults suffer from health disparities in both their function and their home environments. We propose a two-group randomized trial to test the efficacy of our bio-behavioral-environmental intervention, Community Aging in Place - Advancing Better Living for Elders (CAPABLE), which combines evidence-based nursing, occupational therapy, and handyman components. In a randomized controlled pilot trial, the CAPABLE intervention had preliminary effect sizes of 0.63 and 0.62 for reducing difficulty in ADLs and IADLs respectively, when comparing the mean changes in the intervention group to the control group from baseline to follow up. These pilot findings warrant an efficacy trial. We will recruit low-income older (eage 65), principally African-American, adults with e 1 ADL or e 2 IADL limitations from the Baltimore Department of Housing Energy Assistance Program. We will interview them at home and randomize participants to either the treatment (CAPABLE intervention) or control (attention-control) group. Participants in the treatment group will receiv up to 10 in-home sessions -- d6 visits with an occupational therapist and d4 visits from a nurse - and d$1200 in safety and modification services from a licensed handyman. Each treatment participant will receive each intervention component but interventionists will systematically tailo content to the participants' risk profile and goals based on protocols. Participants in the control group will receive an equivalent number of visits, which will consist of sedentary activities with trained research assistant (RA). All participants will be reassessed at 16 and 52 weeks in person by an RA masked to treatment condition. The primary endpoint is the ability to complete ADLs and IADLs without difficulty at 16 weeks post-randomization. Other endpoints include lower extremity mobility, health-related quality of life, and home safety at 16 weeks and ADL and IADL limitations at 52 weeks post-randomization. We will examine moderators of treatment success and mediating mechanisms. We will also evaluate cost-effectiveness based on the cost of the intervention and health care utilization. The study is designed to detect clinically meaningful improvement in ADL or IADL limitations between the intervention and control group with 80 percent power (alpha = 0.05) in an intention to treat analysis. The innovative study will provide economic evidence for a theory-driven intervention that could rein in costs of a growing and increasingly diverse older adult population.