Disability in older adults is a major public health problem, particularly among low-income urban people of color. Most older adults strongly prefer to live at home, but limitation in multiple basic or instrumental activities of daily living (ADLs or IADLs) is the leading modifiable predictor of nursing home admission. Because of the high cost of nursing home care, testing novel, cost-effective interventions to enhance ADLs is a public health priority. Most research has addressed either the individual or the environment, but not both.
Our goal is to address this gap in research by intervening at both the individual and environmental level. To do so, 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 change in the intervention group to the mean change in the control group from baseline to follow up. These pilot findings warrant an efficacy trial.
We will recruit low-income older (≥age 65), principally African-American, adults with ≥ 1 ADL or ≥ 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 activity) group. Participants in the treatment group will receive up to 10 in-home sessions -- ≤6 visits with an occupational therapist and ≤4 visits from a nurse – and ≤$1200 in safety and modification services from a licensed handyman. Each treatment participant will receive each component of the intervention but interventionists will systematically tailor content to the participants’ risk profile and goals based on protocols. Participants in the control group will receive an equivalent number and length of visits, which will consist of sedentary activities with a 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 limitations 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 intervention mechanisms by mediation analyses. 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 burgeoning and diverse older adult population.