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

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 the environment.

Trial registration: ClinicalTrials.gov identifier: NCT01576133.

Figure 1.. CONSORT Flow Diagram

Figure 2.. Survey Responses by Intervention and Control Group Participants

At 5 months or program completion, participants were asked to complete a 10-item survey that assesses their satisfaction with aspects of the CAPABLE program, including (1) overall benefit, (2-9) how the program addressed specific functional goals, and (10) whether the program required too much work or effort. Participants could pick 1 of 3 responses for each question: not at all, some, or a great deal.