Development and Feasibility of a Behavioral Activation Intervention to Support Independence in Older Veterans at Risk for Functional Decline

背景：一半的退伍军人年龄在65岁或以上。年龄和相关的慢性疾病会增加风险 对于功能限制，定义为执行日常活动困难。这不仅意义重大 因为年长的退伍军人高度重视维持机能，还因为 限制意味着不良后果的风险增加。需要有效的干预措施来帮助老年人 退伍军人在社区中保持独立。该项目将采用经验性支持的 抑郁症的心理社会治疗--行为激活(BA)--促进身体、认知和社交 居住在社区的有功能衰退风险的老年退伍军人的功能。作为一次简短的干预， 通过增加与价值观一致的活动的参与度，BA是一种很有前途的支持运作的方法。 具体目标和方法：我们将开发和试点为期六周的远程健康提供的BA干预， “老年退伍军人的独立行为激活”(ACTIVE)。此次干预的目的是 根据个人价值观，更多地参与有意义的活动。目标人群年龄较大 参加退伍军人初级保健的退伍军人(年龄≥65岁)有功能衰退的风险，定义为≥3分 关于弱势老年人调查(VES-13)。这将通过三个目标来实现： 目标1.适应：我们将基于现有的BA模型(简要行为激活)开发Actify 抑郁症治疗-修订)通过VA视频向有功能衰退风险的老年退伍军人提供服务 连接(VVC)。我们之前与英航合作的经验将为最初的适应提供参考，并纳入各种观点 来自初级保健、老年心理学和职业治疗。我们将就初步方案征求意见。 通过与退伍军人事务部心理学家的半结构化访谈(n=5)，职业手册和参与者练习册 治疗师(n=5)和退伍军人(n=5)，根据发现进一步修改材料。 目标2.改进：我们将通过VVC在10名有风险的老年退伍军人中进行激活的公开试验 功能减退，采用混合方法确定干预的初步可接受性。进一步 将根据定性访谈的结果和满意度对干预措施进行改进 使用可接受性理论框架进行调查。 目标3.测试：我们将在48名患有VES的老年退伍军人中进行激活与注意力控制的试验性随机对照试验 从初级保健中招募的13分≥-3。我们将在基线、6周和12周收集临床测量结果， 使用急救后护理的动态测量(AM-PAC)和促进对社会角色和 作为身体、认知和社会功能的主要衡量标准的活动。我们还将进行半 以满意度和忠诚度为基础，对有目的的参与者进行有目的的访谈。可行性 将由注册人数和保留率决定，可接受性将由遵守和 满意度，以及定性访谈的主题。对AM-PAC和PROMIS Will的初步影响 通过组内和组间混合效应线性回归模型和比例被探索 在结果中实现最小临床重要变化的参与者。 影响：该项目将调整一种基于证据的抑郁症干预(BA)，以实现一个新的目的： 促进老年退伍军人的功能独立。通过VVC交付，它具有可扩展性和 对与世隔绝的和农村退伍军人的影响。数据将被用来为未来全面疗效的设计提供信息 试验(RR&D功勋奖)。除了我的研究目标，我还将接受行为和康复方面的培训。 科学、方法论(临床试验设计和分析技术)、拨款撰写和学术传播， 和领导力。同时支持开发创新的、与价值观一致的治疗靶向 发挥作用，这个CDA-2也将促进我成长为一名独立资助的退伍军人事务部内科研究员 在初级保健、行为健康和康复方面进行创新。

Background: Half of all Veterans are aged 65 or older. Age and associated chronic conditions increase risk for functional limitations, defined as difficulty performing day-to-day activities. This is significant not only because older Veterans place a high priority on maintaining function, but also because the manifestation of limitations signifies elevated risk for adverse outcomes. Effective interventions are needed to help older Veterans maintain independence in the community. This project will adapt an empirically-supported psychosocial therapy for depression – behavioral activation (BA) – to promote physical, cognitive, and social functioning in community-dwelling older Veterans at risk for functional decline. As a brief intervention that increases engagement in values-aligned activities, BA is a promising approach to support functioning. Specific Aims and Methods: We will develop and pilot test a six-week telehealth-delivered BA intervention, “Behavioral Activation for Independence in Older Veterans” (ACTIVaTE). The intervention will be designed to increase engagement in meaningful activities in line with individual values. The target population is older Veterans (age ≥65) enrolled in VA primary care who are at risk for functional decline, defined as a score of ≥3 on the Vulnerable Elders Survey (VES-13). This will be accomplished over three aims: Aim 1. Adapt: We will develop ACTIVaTE based on an existing BA model (Brief Behavioral Activation Treatment for Depression-Revised) for delivery to older Veterans at risk for functional decline via VA Video Connect (VVC). Our previous experience with BA will inform the initial adaptation, incorporating perspectives from primary care, geropsychology, and occupational therapy. We will seek feedback on the preliminary manual and participant workbook via semi-structured interviews with VA psychologists (n=5), occupational therapists (n=5), and Veterans (n=5), using findings to further modify the materials. Aim 2. Refine: We will conduct an open trial of ACTIVaTE delivered via VVC in 10 older Veterans at risk for functional decline, using mixed methods to determine preliminary acceptability of the intervention. Further refinements will be made to the intervention based on findings from qualitative interviews and a satisfaction survey using the Theoretical Framework of Acceptability. Aim 3. Test: We will conduct a pilot RCT of ACTIVaTE versus attention control in 48 older Veterans with VES- 13 score ≥3 recruited from primary care. We will collect clinical measures at baseline, 6 weeks, and 12 weeks, using the Ambulatory Measure for Post-Acute Care (AM-PAC) and PROMIS Satisfaction with Social Roles and Activities as primary measures of physical, cognitive, and social functioning. We will also conduct semi- structured interviews with a purposive sample of participants based on satisfaction and adherence. Feasibility will be determined by enrollment and retention and acceptability will be determined by adherence and satisfaction, as well as by themes from qualitative interviews. Preliminary impact on AM-PAC and PROMIS will be explored through within and between groups mixed-effects linear regression models and proportions of participants who achieve minimal clinically important change in outcomes. Impact: This project will adapt an evidence-based intervention for depression (BA) for a novel purpose: promoting functional independence in older Veterans. Through VVC delivery, it has potential for scalability and implications for isolated and rural Veterans. Data will be used to inform the design of a future full-scale efficacy trial (RR&D Merit Award). In parallel with my research aims, I will obtain training in behavioral and rehabilitation science, methodology (clinical trials design and analytic techniques), grant writing and scholarly dissemination, and leadership. While supporting the development of an innovative, values-aligned treatment targeting functioning, this CDA-2 will also promote my growth into an independently-funded VA physician investigator innovating at the interface of primary care, behavioral health, and rehabilitation.