CAPABLE: A person-environment intervention to improve function and health-related quality of life in disabled, older adults Sarah L. Szanton, PhD CRNP

CAPABLE: A person-environment intervention to improve function and health-related quality

of life in disabled, older adults

Sarah L. Szanton, PhD CRNPAssistant Professor

Johns Hopkins University School of Nursing Center for Innovative Care in Aging

Core FacultyHopkins Center for Health Disparities Solutions

Johns Hopkins Center on Aging and HealthHopkins Population Center Associate

Adjunct Faculty for Johns Hopkins Center for Injury Research and PolicyRobert Wood Johnson Nurse Faculty Scholar 2011-2014

[email protected]

Home

Home as the ultimate translational context

• Lab research• Translation from lab to clinical• Clinical hospital research• Translation to clinics• Outpatient research• Home

Benefits of function in home

• Individual• Family• Societal• Tax-payer or social policy

The problem

• 42% of current older adults report a functional limitation or disability

• Absolute number will increase as the population ages

• These disabilities are the primary modifiable predictor of nursing home admission

• Nursing homes cost $150 billion/year

Disability as a gap

• The gap between a person’s abilities and their environment (Verbrugge and Jette, 1994)

Mrs. B

Clinic visit for Mrs. B

• Focus on her medical problems• But what keeps her out of a nursing

home?

If disability is the gap, how to approach?

Focus on individual: RN or PT

• Many studies that focus on underlying impairments in individuals– Nursing visits decreased mortality but did not

increase independence at home( Elkan et al, 2001)– Functional decline reduced in programs with

clinical evaluation, but inconsistent effects on nursing home admission (Stuck, 2008)

Focus on individual: OT

• Occupational therapists focus on function• Steultjens (2004) meta-analysis some

evidence on enhancing functional ability and quality of life

• ABLE (2006) OT intervention modifies behavior with small focus on environment

Focus on environment only

• Administrations on Aging provide as common sense

• Interventions that use person-environment fit are most successful (Wahl, 2009)

• Benefits of environmental change most likely in combination with functional strategies

Disability gap for low-income older adults

• Significant disparities in housing quality• More likely to have chronic conditions and

more likely to be disabled• Fewer resources to address both

CAPABLE

• 3 pronged intervention• Each catalyst for function separately and

synergistically

CONCEPTUAL FRAMEWORK

STUDY POPULATI

ON

Low income disabled

older urban adults

CONTRIBUTORS TO FURTHER

DISABILITY

ExtrinsicEnvironmental

IntrinsicWhole Individual Physiologic

PROXIMAL OUTCOMES

Disability - ADLs and IADLs

Mobility

Quality of Life

Environmental Safety

DISTAL OUTCOMES Emergency Room visits

Hospitalization

NH Admission

INTERVENTIONBiobehavioral-Environmental Intervention addressing risk factors for functional decline and relocation consisting of:a) home repair and

assistive devicesb) training in use of

compensatory strategies

c) strength and balance training

d) depression education and problem solving treatment

e) medication review and adherence support

P/E fit

P/E fit

Pilot Study design

• Randomized control pilot study (N=41)• Baseline and 6 month follow-up• Low-income functionally vulnerable older adults

(≥ 1 ADL or ≥ 2 IADL limitations)• Cognitively intact• Intervention group received all three

interventions• Control group received equivalent amount of

“attention.”Szanton et al, 2011 JAGS

Pilot Sample

• Recruited through Commission on Aging, Baltimore Housing Department and CHAI

• Living on own, with no services• Approx 80% lived alone• 80% African-American• Average age 79 (range 66-92)• Average ADL limitations were 2.3• Average EuroQOL of 0-100 = 60

Intervention

• Participant-centered, tailored• Goal –centered• First visit for each discipline is assessment and

helping participant decide goals. • Next visits, a combination of following up,

modifying, training etc based on the participants’ goals

• OT: 6 visits, RN:4 visits, Handyman: til done

Treatment strategiesDimensions Target Area Strategies and Techniques

Extrinsic Housing safety: Make safe built environment

1) OT assesses house for safety risks. Creates prioritized list for Handyman examples of which are: replace leaky gas stove, fill in holes in floors, stabilize shaky banisters, caulk holes, control pests, lower microwave, install tailored bathroom safety equipment


Intrinsic: whole individual Self-care:Enhance ability to independently conduct ADLs and IADLs

1) For each participant-identified area of concern, the OT a. observes performance; b. problem solves priority areas with participant, c. orders, installs, and trains in adaptive devices. This includes bathing, toileting, dressing, meal preparation, seating, walking. The handyman installs adaptive devices such as raised toilet seats and shower chairs


Intrinsic: whole individual Communication with PCP:Enhance connection between participant and PCP to facilitate safe management

1) Health passport 2) medication simplification 3) letters from study team to PCP 4) refer participants to new PCP if have none or Housecalls PCP if unable/unwilling to leave home.


Intrinsic: whole individual Medication Management:Increase ability to manage medication

Nurse problem solves re medication management including 1)need for medication, 2)timing of doses, 3)physical reminders,4) medications with balance implications


Intrinsic: physiologic factors

Strength/balance:Increase ability to stand, balance, and recover from falls and near-falls

1)Implement NIA exercise strategies and moves. Practice with participant. 2) Assess participant’s interest in TaiChi Have DVD’s and tailored number of home visits from Tai Chi instructors 3) Assess interest in exercise bands. Procure and practice with if interested. 4)OT and Nurse reinforce chosen strength and balance strategies at each visit



Depression:Enhance skills for mood management

A problem solving intervention based on the PEARLS depression intervention



Pain:To decrease pain to facilitate function

1) Thorough assessment of pain and its patterns.2) Advocacy with PCP re pain medication 3) education and provision of other pain management techniques such as topical gel, distraction, mobility, heat

Attention control

• Mirror the amount of social attention, empathy and engagement provided to experimental group

Attention control

• Participants reminisce with RAs about lives• Sedentary activities of choice (e.g. scrapbooks,

pictures, cookbooks)• Also receive printed material on exercise, fall

prevention, home modification

CAPABLE pilot participants’ evaluation

How much did participation in CAPABLE….

Control Intervention

“a great deal” “some” “a great deal” “some”

Helped them take care of selves 53% 15% 72% 17%

Made life easier 15% 38% 83% 11%

Benefited them 31% 62% 83% 17

Believe CAPABLE would help others 31% 38% 78% 22%

CAPABLE pilot results

Control Intervention

Baseline 24 week Change Baseline 24 week Change

Difficulty with ADLs (0-5 possible score) 2.6 (1.4) 2.1 (2.3)

Improve (19%)

2.1(1.2) 0.7 (0.8)Improve

(67%)

Difficulty with IADL (0-5 possible score)

2.0 (1.1) 1.8 (1.9)Improve

(10%)2.3 (1.4) 1.2(1.3)

Improve (48%)

EuroQOL 5-D (out of 100) 63 55

Decline (13%)

57(18.7) 78(15.8)Improve

(37%)

(average change by group) from 0-24 weeks

Szanton et al, JAGS, 2011

Participant re CAPABLE study

• “I can go up and down the steps better. I do. I do everything better. Like I said, I’m not 40! But, I’m a whole lot better than I was. And, I believe that if I continue to do this that I won’t lose. Do you understand? I can only get better. I’m not trying to get to 40 again. But, I want to have a quality seniorhood. And, I think this is helping.”

Community Support

• Baltimore City Commission on Aging• Baltimore City Housing Authority• Baltimore Deputy Health Commission for Healthy

Homes• Civic Works, Americorps• CHAI• Rebuilding Together• GEDCO• Meals on Wheels

Larger CAPABLE RCT currently

• R01 from NIH• Planned N= 300• Same design but also measuring 52 week

outcomes and health care costs for both arms

CMS innovation grant

• Planned N = 500• No control group, only comparison group• Working with CMS to pick comparison group• If deemed successful, can become national

policy

Further Policy Implications

• Community involvement in maintaining older adults houses – civic works, Americorps

Mrs. J.

Acknowledgements

• Study participants• 1KL2RR025006-01 • Johns Hopkins Population Center Early Career

Award • The John A. Hartford Building Academic

Geriatric Nursing Capacity Program• 1R01AG040100: National Institute on Aging

Study staff and students

• Alice Delaney, Jill Roth, Laura Fisher, Allyson Evelyn-Gustave, Allysin Bridges, Wanda Clark-Smith, Karen Harrison, Jerry Shorb, Elizabeth Spradley

• CivicWorks

Co-investigators

• Laura Gitlin Jack Guralnik• Emily Agree Ibby Tanner• Carlos Weiss Cynthia Boyd• Bruce Leff Roland Thorpe• David Bishai Jeri Allen

Discussion and Questions

Documents

CAPABLE: A person-environment intervention to improve function and health-related quality of life in disabled, older adults Sarah L. Szanton, PhD CRNP