Abstract
OBJECTIVES:
To evaluate the effects of a home-based disability prevention program on life-space and falls efficacy among low-income older adults.
DESIGN:
Single-blind two-arm randomized controlled trial.
SETTING:
Participants’ homes.
PARTICIPANTS:
Participants were low-income cognitively intact older adults (≥65 years old) with restricted daily activities. Our analytic sample for life-space (n=194) and falls efficacy (n=233) varied as the life-space measure was introduced four months after the trial began.
INTERVENTION:
Up to 6 one-hour home visits with an Occupational Therapist (OT); up to 4 one-hour home visits with a Register Nurse (RN); and up to $1300 worth of home repairs, modifications, and assistive devices with a handyman, during a course of 4 months.
MEASUREMENTS:
Life-space was measured by the Homebound Mobility Assessment; falls efficacy was measured using the 10-item Tinetti Falls Efficacy Scale at baseline and 5 months, respectively.
RESULTS:
Participants were on average 75 years, predominantly black (86%) and female (85%-86%). Compared to participants in the control group, participants receiving the intervention were more likely to have improved vs. decreased life-space in areas of bathroom (adjusted odds ratio [OR]: 3.95, 95% CI: 1.20–12.97), front or back porch, patio, or deck (adjusted OR: 2.67, 95% CI: 1.05–6.79), stairs (adjusted OR: 4.09, 95% CI: 1.34–12.48), leaving the house for any reason other than for health care (adjusted OR: 2.40, 95% CI: 1.01–5.73), and overall life-space (adjusted OR: 2.15, 95% CI: 1.10–4.19). Participants who received the intervention also had an 11% improvement in falls efficacy in performing daily activities (exponentiated coefficient: 1.12, 95% CI: 1.04–1.21).
CONCLUSION:
Life-space and falls efficacy were improved through a multi-component, person-directed, home-based disability prevention intervention. Findings suggest that this intervention should be translated into different settings to promote independent aging.
Keywords: disability, falls efficacy, intervention, life-space, physical independence
INTRODUCTION
The ability to move freely and confidently within one’s living environment is essential to maintain older adults’ physical independence and the ability to engage in meaningful daily activities, while minimizing the need for family caregiving.1,2 Life space is a spatial measure of mobility defined by the distance a person routinely travels within a specific time period.3 Constricted life-space is associated with adverse health outcomes, including frailty, nursing home admission, falls, and death.4–7 Falls efficacy measures perceived confidence avoiding falls during essential activities of daily living (ADL).8 Low falls efficacy robustly predicts future falls that can lead to severe consequences such as hip fracture, hospitalizations, and mortality.9–11
Although constricted life-space and reduced falls efficacy independently predict decline in the ability to perform basic ADLs and instrumental ADLs (IADLs),12,13 it is not clear whether and how these constructs may be amenable to intervention.14 Community Aging in Place–Advancing Better Living for Elders (CAPABLE) is an innovative program that reduces disabilities among low-income older adults through an interdisciplinary collaboration of older adults, occupational therapists (OT), and registered nurses (RN) and implementation of home modification/improvement by handymen.15 We have found that participants who received CAPABLE had a statistically significant 30% reduction in ADL disability scores and 17% nonsignificant reduction in IADL disability scores compared to participants in the control group. This study aimed to examine whether CAPABLE also improved life-space and falls efficacy among low-income older adults living with disabilities.
METHODS
Study Overview
CAPABLE was a single-blind 2-arm randomized controlled trial conducted in Baltimore, Maryland. Eligible participants were randomized to receive either CAPABLE or attention control after informed consent. All participants were interviewed in the home at baseline and 5 months by a trained research assistant blinded to the group assignment. The study was approved by the Johns Hopkins University Institutional Review Board.
Participants
Participants were eligible if they a) were ≥ 65 years; b) were cognitively intact based on Mini-Mental State Examination scores;16 c) reported to have difficulty with at least 1 ADL or at least 2 IADLs; d) were able to stand with or without assistance; and e) documented income of 200% or less of the Federal Poverty Level ($22,980 or less for a household of one). Participants were excluded if they a) were hospitalized more than 3 times in the past 12 months; b) were receiving in-home physical therapy, nursing or occupational therapy; c) had expected survival of less than a year; d) were receiving active cancer treatment; e) planned to move houses within 1 year; or f) lived in an apartment or assisted facility. Participants were recruited through collaboration with multiple community partners (e.g., Baltimore Meals on Wheels) and direct mailing by sending study brochures to specific Baltimore City zip codes of high poverty and high proportions of older adults.
Study Interventions
A description of the intervention and study protocol has been published elsewhere.14 CAPABLE participants receive up to 6 one-hour home visits with the OT; up to 4 one-hour home visits with the RN; and 1 one-hour visit and a full day’s work from a handyman over 4 months. After assessment, each participant identified 6 goals they wanted to achieve; three with the OT and three with the RN. Strategies for attaining OT-related goals included evaluating home safety, and identifying behavioral and environmental contributors to performance difficulties (e.g., conserving energy during tasks). The RN identified how and whether pain, depression, strength and balance, medication management, and the ability to communicate with primary care practitioners impact daily function. Common repairs/modifications provided by handyman included up to $1,300 worth of structural adaptions and home repairs that the OT orders. Key interventions implemented by interventionists were presented in Supplementary Table S1. Participants in the attention-control group also received 10 visits over 4 months and identified sedentary activities they wanted to do.
Measures
Outcomes
Life-space was assessed by the Homebound Mobility Assessment (HBMA).17 Participants were asked whether they went to each of five specified areas in their house within the last 24 hours (bathroom, living room/den/front room, kitchen/dining room, front/back porch/patio/deck, or stairs) and if they used equipment or help from another person to get there. Additionally, based on prior work that identified homebound older adults and their difficulties,18 we asked whether participants left the house other than for health care. For each area, going independently without any assistance was scored as a 2, with equipment use was 1.5, with personal help was a 1, and not going was a 0. The summing of each area ranged from 0–12, with higher scores indicating larger life-space. We created change status variables by subtracting baseline scores from 5-month scores of each area and the summed score, with negative values indicating a decreased, zeros indicating unchanged, and positive values indicating improved life-space for each area and overall life-space. The HBMA captures variability in mobility among homebound older adults with high levels of ADL and IADL difficulty. It was also correlated with ADLs, IADLs, and bed hours among homebound older adults.17
Falls Efficacy was evaluated with the 10-item Tinetti Falls Efficacy Scale.8 Participants were asked to rate from 0–10 their confidence doing each of 10 activities (e.g., cleaning house, getting dressed and undressed) without falling. Scores were continuous, ranging from 1 to 100 with higher scores indicating higher level of confidence. This measure has a strong relationship to function, mediates fall risk reduction, and has strong reliability and validity.19
Covariates
Participants’ demographics included age, sex, race/ethnicity, education, and living arrangement. Physical function was measured with the Short Physical Performance Battery.20 Pain intensity and distress in the past week, and pain interference with everyday activities were measured by the Brief Pain Inventory (short form).21 A count of self-reported medical conditions was calculated. Participants were asked whether they unusually had low energy, were usually tired, and were usually weak in the last month. Participants were also asked whether they had unintentional weight loss in the past year.
Data Analysis
A total of 300 participants were assessed at baseline; 62 were excluded due to missing data at 5 months. Excluded participants had higher pain intensity than those included. Because we added the HBMA assessment after the trial started, we created two analytic samples for life-space (n=194) and falls efficacy (n=233), separately. Participants who were not evaluated by the HBMA had more chronic conditions than those who were.
All analyses followed the intent-to-treat principle. Two sample t-tests for continuous variables and Chi-squared tests for categorical variables were used to compare baseline characteristics by treatment groups. To examine the concurrent validity of the two outcomes, we created a variable to represent the changes in falls efficacy scores from baseline to 5 months, with positive values indicating improvement. We examined the relationship between this variable and life-space change status using a box plot. To examine intervention effects on life-space, we used multinomial logistic regression models treating life-space change status as outcome and treatment group as main independent variable. Values of falls efficacy were right-skewed indicating that most participants had high falls efficacy at baseline. To accommodate this skewness, generalized linear models with gamma family and log link were used to determine intervention effects on the falls efficacy score. Histograms of baseline and 5-month life-space score, life-space change status and falls efficacy scores were shown in Supplementary Figure S1 and S2.
For both outcomes, two models were estimated. Model 1 examined crude intervention effects. Model 2 adjusted for age, sex, race/ethnicity, and clinically meaningful confounders that were imbalanced between the two treatment groups. Less than five participants reported “not applicable” on certain rooms of life-space, resulting in missing values. We used inverse probability weighting to adjust for study attrition at 5 months. Odds ratio (OR) for life-space, or regression coefficient for falls efficacy, and 95% confidence intervals (CI) were reported. All analyses were performed in Stata 15.0.
RESULTS
Participants were on average 75 years of age, predominantly black (85.6%) and female (84.6%-86.3%) (Table 1). All baseline characteristics including life-space and falls efficacy were balanced between two groups except for pain experience. More participants in the treatment group experienced improvement (48.2 % vs. 39.3%) in life-space and falls efficacy (from a mean of 64.9 to 74.7) compared to those in the control group (63.6 to 67.2).
Table 1.
Baseline characteristics and outcomes at follow-up by treatment group for two analytic samples
| Variables | Sample for life-space | Sample for falls efficacy | ||||
|---|---|---|---|---|---|---|
| Total | Control (n = 101) | Intervention (n = 93) | Total | Control (n = 119) | Intervention (n = 114) | |
| Age, mean (SD), y (65–95) | 75.8 (7.5) | 75.0 (7.1) | 76.6 (7.8) | 75.2 (7.2) | 74.6 (7.0) | 75.8 (7.5) |
| Female sex, No. (%) | 164 (84.6) | 85 (84.2) | 79 (85.0) | 201 (86.3) | 102 (85.7) | 99 (86.8) |
| Race/ethnicity, No. (%) | ||||||
| White | 27 (13.9) | 10 (9.9) | 17 (18.3) | 33 (14.2) | 12 (10.1) | 21 (18.4) |
| Black | 166 (85.6) | 90 (89.1) | 76 (81.7) | 199 (85.4) | 106 (89.1) | 93 (81.6) |
| Asian | 1 (0.5) | 1 (1.0) | 0 | 1 (0.4) | 1 (0.8) | 0 |
| Education, No. (%) | ||||||
| < 12 y | 62 (32.0) | 34 (33.7) | 28 (30.1) | 79 (33.9) | 43 (36.1) | 36 (31.6) |
| = 12 y | 94 (48.4) | 44 (43.5) | 50 (53.8) | 114 (48.9) | 53 (44.6) | 61 (53.5) |
| > 12 y | 38 (19.6) | 23 (22.8) | 15 (16.1) | 40 (17.2) | 23 (19.3) | 17 (14.9) |
| Living alone, No. (%) | 106 (54.6) | 53 (52.5) | 53 (57.0) | 121 (53.3) | 58 (48.7) | 63 (58.3) |
| SPPB score, mean (SD) (0–12) | 5.1 (3.1) | 5.0 (3.3) | 5.2 (2.9) | 5.1 (3.0) | 5.1 (3.2) | 5.1 (2.9) |
| Pain in the last week, mean (SD) | ||||||
| Intensity (0–10) | 5.3 (2.8) | 5.1 (3.3) | 5.5 (2.6) | 5.5 (2.8) | 5.2 (3.0) | 5.7 (2.6) |
| Distress (0–10) | 5.1 (3.0) | 4.7 (3.4) | 5.3 (2.9) | 5.2 (3.0)* | 4.8 (3.1) | 5.6 (2.9) |
| Interference (0–10) | 4.7 (3.1) * | 4.3 (3.2) | 5.3 (2.9) | 4.8 (3.0) ** | 4.3 (3.1) | 5.3 (2.9) |
| No. of medical conditions, mean (SD) (0–8) | 3.7 (1.5) | 3.7 (1.5) | 3.7 (1.5) | 3.8 (1.5) | 3.8 (1.4) | 3.8 (1.5) |
| Energy in past month, No. (%) | ||||||
| Unusually low energy | 110 (56.7) | 56 (55.5) | 54 (58.1) | 124 (58.5) | 65 (58.0) | 59 (59.0) |
| Usually tired | 121 (62.4) | 62 (61.4) | 59 (63.4) | 134 (63.2) | 70 (62.5) | 64 (64.0) |
| Usually weak | 88 (45.4) | 40 (39.6) | 48 (51.6) | 100 (47.2) | 48 (42.9) | 52 (52.0) |
| Unintentional weight loss in the past year, No. (%) | 138 (71.1) | 74 (73.3) | 64 (68.8) | 154 (72.6) | 83 (74.1) | 71 (71.0) |
| Baseline total life-space scores | ||||||
| Mean (SD) | 8.6 (2.9) | 8.8 (2.9) | 8.5 (2.9) | - | - | - |
| Range | 0–12 | 0–12 | 1.5–12 | - | - | - |
| Life-space change by 5 months | ||||||
| Decreased | 65 (36.3) | 42 (44.7) | 23 (27.1) | - | - | - |
| Unchanged | 36 (20.1) | 15 (16.0) | 21 (24.7) | - | - | - |
| Improved | 78 (43.6) | 37 (39.3) | 41 (48.2) | - | - | - |
| Baseline falls efficacy scores | ||||||
| Mean (SD) | - | - | - | 64.2 (20.3) | 63.6 (20.8) | 64.9 (19.8) |
| Range | - | - | - | 0–90 | 0–90 | 5–90 |
| 5-month falls efficacy scores | ||||||
| Mean | - | - | - | 70.9 (20.1) | 67.2 (20.9) | 74.7 (18.6) |
| Range | - | - | - | 7–90 | 7–90 | 13–90 |
Notes: SD-standard deviation; SPPB-Short Physical Performance Battery;
p<0.05;
p<0.01.
Figure 1 shows the increase of falls efficacy scores from baseline to 5 months by life-space change status. Participants with improved life-space had the greatest increase in falls efficacy scores with a median of 12.0, followed by those with unchanged (median=4.5) and decreased life-space (median=1.0).
Figure 1.
The variable of the Y axis represents the increase of falls efficacy scores from baseline to 5 months and a positive value indicates improvement (N=194). Participants with improved life-space had greatest improvement in falls efficacy scores with a median of 12.0, followed by those with unchanged (median=4.5) and decreased life-space (median=1.0).
Table 2 presents intervention effects on life-space by home area and falls efficacy. Compared to participants in the control group, CAPABLE participants were more likely to have improved vs. decreased life-space in areas of stairs (adjusted OR: 4.09, 95% CI: 1.34–12.48), leaving the house other than for health care (adjusted OR: 2.40, 95% CI: 1.01–5.73), and overall life-space (adjusted OR: 2.15, 95% CI: 1.10–4.19). CAPABLE participants tended to have improved life-space in independently using bathrooms (adjusted OR: 3.95, 95% CI: 1.20–12.97) and front or back porch, patio, or deck (adjusted OR: 2.67, 95% CI: 1.05–6.79). The intervention also significantly improved falls efficacy in both the crude and adjusted models (adjusted exponentiated coefficient: 1.12, 95% CI: 1.04, 1.21).
Table 2.
Effects of the intervention on life-space and falls efficacy from baseline to 5 months
| Outcomes | n | Model 1 (Crude) OR or Exponentiated Coefficient (95% CI) |
Model 2 (adjusted)a OR or Exponentiated Coefficient (95% CI) |
|---|---|---|---|
| Life-spaceb | |||
| Bathroom | 193 | ||
| Decreased | 23 | 1.00 | 1.00 |
| Unchanged | 141 | 1.50 (0.60–3.79) | 1.55 (0.60–4.00) |
| Improved | 29 | 3.19 (1.00–10.14) | 3.95 (1.20–12.97)* |
| Living room/den/front room | 194 | ||
| Decreased | 23 | 1.00 | 1.00 |
| Unchanged | 140 | 1.11 (0.45–2.76) | 1.00 (0.37–2.57) |
| Improved | 31 | 2.84 (0.91–8.82) | 2.93 (0.91–9.48) |
| Kitchen | |||
| Decreased | 27 | 1.00 | 1.00 |
| Unchanged | 142 | 1.15 (0.50–2.66) | 1.09 (0.44–2.69) |
| Improved | 25 | 2.41 (0.78–7.44) | 2.55 (0.77–8.47) |
| Front/back porch/patio/deck | 188 | ||
| Decreased | 38 | 1.00 | 1.00 |
| Unchanged | 111 | 1.55 (0.72–3.34) | 1.56 (0.70–3.44) |
| Improved | 39 | 2.43 (0.97–6.11) | 2.67 (1.05–6.79)* |
| Stairs | 188 | ||
| Decreased | 25 | 1.00 | 1.00 |
| Unchanged | 120 | 2.71 (1.01–7.31)* | 2.66 (0.97–7.31) |
| Improved | 43 | 4.08 (1.35–12.34)* | 4.09 (1.34–12.48)* |
| Leave the house for any reason other than for health care | 191 | ||
| Decreased | 41 | 1.00 | 1.00 |
| Unchanged | 97 | 1.47 (0.69–3.13) | 1.33 (0.60–2.94) |
| Improved | 53 | 2.53 (1.09–5.90)* | 2.40 (1.01–5.73)* |
| Overall change | 179 | ||
| Decreased | 65 | 1.00 | 1.00 |
| Unchanged | 36 | 1.96 (0.88–4.37) | 2.03 (0.82–4.98) |
| Improved | 78 | 1.91 (1.00–3.65)* | 2.15 (1.10–4.19)* |
| Total falls efficacy | 233 | 1.11 (1.03–1.20)** | 1.12 (1.04–1.21)** |
Notes:
Model 1 presented crude effects. Model 2 for life-space adjusted for age sex, race/ethnicity, and pain interference. Model 2 for falls efficacy adjusted for baseline falls efficacy score, age, sex, race/ethnicity, distress pain last week, and pain interference.
All reference groups are decreased life-space groups; OR-odds ratio; CI-confidence interval;
p<0.05;
p<0.01.
DISCUSSION
Our study found that low-income older adults randomized to a home-based disability reduction intervention improved in other areas of functioning critical to wellbeing. Life-space, like disability, is a product of the interaction between individuals’ intrinsic abilities and the environment. Intervention participants’ life-space significantly improved likely because of CAPABLE’s focus on the participant’s goals and environment, and improving the person-environment fit. The intervention also increased the life-space outside of participants’ homes. This may be due to some participants’ goals involved leaving their home and intervention strategies, such as adding handrails to facilitate that goal. Evidence on improving life-space in older adults using interventions has been limited and mixed.22–25 Prior studies show disparities in life-space restriction by race and gender with black women having high restriction.26 This study, with a predominantly black female sample, provides key evidence that life-space among older black females can be improved through a multi-component, person-directed, home-based disability prevention program.
CAPABLE also significantly improved participants’ falls efficacy. CAPABLE participants received home modifications/repairs based on their preferences and needs in meeting their functional goals. Participants in this study had lower falls efficacy than a general community-dwelling older population and those with previous falls;19,27,28 thus fear of falling might be an important threat to their physical independence at baseline. Our study also found that participants with improved life-space had the greatest increase in falls efficacy.
One major strength of the intervention is the interdisciplinary coordination among the older adult, OT, RN, and the handyman. This study included low-income older adults, and more than half of them lived alone which is higher than the national average of 29%.29 Our results suggest that this high-risk group living with disabilities can improve and become able to traverse their home independently with confidence.
The study has several limitations. First, the availability of validated life-space measures for homebound older adults is limited.30 The measure we used has only preliminary validation,17 but our study provided additional support on its concurrent validity with falls efficacy. Second, our study focused on low-income and predominately black women and the results may not be generalizable. We note, however, that this population is generally understudied and at high risk of experiencing negative consequences of disability and functional impairment.
In conclusion, our study extends the results of the original trial to show that other areas of function were positively enhanced through CAPABLE. An intervention delivered by the older adult, an OT, a RN, and a handyman significantly improved life-space and falls efficacy among low-income older adults who were predominantly African American. These findings provide more evidence for the effectiveness of CAPABLE to address functional challenges in older adults using a person-directed and interdisciplinary approach. It suggests that CAPABLE should be part of routine care of older adults living at home with functional challenges.
Supplementary Material
Supplementary Figure S1. Histograms of overall life-space change status from baseline to 5 months (N=179).
Supplementary Figure S2. Histograms of baseline and 5-month falls efficacy total score (N=233).
Supplementary Table S1. Key interventions implemented by CAPABLE interventionists
ACKNOWLEDGMENTS
Financial Support:
This study was supported by grant R01AG040100 from the National Institutes of Health.
Sponsor’s Role:
The sponsor had no role in the design, methods, subject recruitment, data analysis, or preparation of the article.
Footnotes
Conflict of Interest: Drs Szanton and Gitlin are inventors of the CAPABLE training program, for which the Johns Hopkins University is entitled to fees. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies.
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Supplementary Materials
Supplementary Figure S1. Histograms of overall life-space change status from baseline to 5 months (N=179).
Supplementary Figure S2. Histograms of baseline and 5-month falls efficacy total score (N=233).
Supplementary Table S1. Key interventions implemented by CAPABLE interventionists