CAPABLE trial: a randomized controlled trial of nurse, occupational therapist and handyman to reduce disability among older adults: rationale and design.

BACKGROUND: As the population ages, it is increasingly important to test new models of care that improve life quality and decrease health costs. This paper presents the rationale and design for a randomized clinical trial of a novel interdisciplinary program to reduce disability among low income older adults based on a previous pilot trial of the same design showing strong effect. METHODS: The CAPABLE (Community Aging in Place, Advancing Better Living for Elders) trial is a randomized controlled trial in which low income older adults with self-care disability are assigned to one of two groups: an interdisciplinary team of a nurse, occupational therapist, and handyman to address both personal and environmental risk factors for disability based on participants' functional goals, or an attention control of sedentary activities of choice. Both groups receive up to 10 home visits over 4 months. OUTCOMES: The primary outcome is decreased disability in self-care (ADL). Secondary outcomes are sustained decrease in self care disability as well as improvement in instrumental ADLS, strength, balance, walking speed, and health care utilization. Careful cost tracking and analysis using intervention data and claims data will enable direct measurement of the cost impact of the CAPABLE approach. CAPABLE has the potential to leverage current health care spending in Medicaid waivers, Accountable Care Organizations and other capitated systems to save the health care system costs as well as improving low income older adults' ability to age at home with improved life quality.

Use of the Tailored Activities Program to reduce neuropsychiatric behaviors in dementia: an Australian protocol for a randomized trial to evaluate its effectiveness.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are often considered to be the greatest challenge in dementia care, leading to increased healthcare costs, caregiver burden, and placement into care facilities. With potential for pharmacological intervention to exacerbate behaviors or even lead to mortality, the development and rigorous testing of non-pharmacological interventions is vital. A pilot of the Tailored Activities Program (TAP) for reducing problem behaviors in people with dementia was conducted in the United States with promising results. This randomized trial will investigate the effectiveness of TAP for reducing the burden of BPSD on persons with dementia and family caregivers within an Australian population. This trial will also examine the cost-effectiveness and willingness to pay for TAP compared with a control group. METHODS: This randomized trial aims to recruit 180 participant dyads of a person with dementia and their caregivers. Participants will have a diagnosis of dementia, exhibit behaviors as scored by the Neuropsychiatric Inventory, and the caregiver must have at least 7 h per week contact. Participants will be randomly allocated to intervention (TAP) or control (phone-based education sessions) groups, both provided by a trained occupational therapist. Primary outcome measure will be the revised Neuropsychiatric Inventory - Clinician rating scale (NPI-C) to measure BPSD exhibited by the person with dementia. CONCLUSIONS: This trial investigates the effectiveness and cost-effectiveness of TAP within an Australian population. Results will address a significant gap in the current Australian community-support base for people living with dementia and their caregivers.

Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study.

Although there has been considerable interest in racial differences in family caregiving for persons with dementia, most research to date has either ignored racial diversity or based conclusions on small numbers of caregivers drawn primarily from single site studies. The current study utilized participants from four sites of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) multi-site study to compare well-being, appraisal, and religious coping by race. African-American (n = 295) and Caucasian (n = 425) dementia caregivers from four cities (Birmingham, Memphis, Boston, and Philadelphia) were compared in their demographics, care recipient characteristics, mental and physical health, and psychosocial coping resources including appraisal and religious coping. African-American caregivers reported lower anxiety, better well-being, less use of psychotropic medications, more benign appraisals of stress and perceived benefits of caregiving, and greater religious coping and participation, than Caucasian caregivers. Self-rated health did not differ by race, but African-American caregivers reported more unhealthy behaviors than Caucasian caregivers. Some results were specific to site, possibly due to differences in recruitment strategies, inclusion/exclusion criteria, and regional differences. Adjustment for covariates, including caregiver relationship to the care recipient, gender, age, socioeconomic status, and care recipient behavioral problems, altered few of these differences. Results are discussed in terms of their relevance to psychosocial intervention programs for ethnically diverse caregivers.

Evaluating home environments of persons with dementia: interrater reliability and validity of the Home Environmental Assessment Protocol (HEAP).

PURPOSE: This article reports on an interrater reliability and preliminary validity study of an investigator-developed tool, the Home Environmental Assessment Protocol (HEAP) for use in homes of persons with dementia. METHOD: The HEAP consists of 192 items that are summed into separate indices representing the number of hazards, adaptations, and level of clutter and comfort in eight areas of the home. Interrater reliability was examined among four raters, two environmental experts and two non-experts, who observed 22 dementia households. RESULTS: The Kappa statistic was used to evaluate agreement level for each measured item and found that agreement ranged from slight to almost perfect. Intraclass correlations (ICCs), were used to evaluate agreement level for indices. The hazard index in each room ranged from fair (0.36) to moderate (0.66) for all raters. For the adaptation, clutter and comfort indices in each room, ICCs ranged from 0.51 to 0.90 for all raters. Agreement level between expert and non-expert raters differed minimally for all indices. Adaptations to dining rooms (r= -0.080, p = 0.001), kitchens (r = -0.52, p = 0.02) and bedrooms (r = -0.76, p = 0.001) were associated with patient deficits such that more adaptations were made in homes of dependent persons. Low Mini-Mental Status Examination scores were associated with fewer hazards, more adaptations, and less clutter. CONCLUSION: Findings show that both experts and non-expert raters use the HEAP consistently. Also, measured attributes are related to cognitive and functional status in the expected direction.

A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia.

PURPOSE OF STUDY: The authors determined short-term effects of a home environmental intervention on self-efficacy and upset in caregivers and daily function of dementia patients. They also determined if treatment effect varied by caregiver gender, race, and relationship to patient. DESIGN AND METHODS: Families (N = 171) of dementia patients were randomized to intervention or usual care control group. The intervention involved 5 90-min home visits by occupational therapists who provided education and physical and social environmental modifications. RESULTS: Compared with controls, intervention caregivers reported fewer declines in patients' instrumental activities of daily living (p = .030) and less decline in self-care and fewer behavior problems in patients at 3 months post-test. Also, intervention spouses reported reduced upset (p = .049), women reported enhanced self-efficacy in managing behaviors (p = .038), and women (p = .049) and minorities (p = .037) reported enhanced self-efficacy in managing functional dependency. IMPLICATIONS: The environmental program appears to have a modest effect on dementia patients' IADL dependence. Also, among certain subgroups of caregivers the program improves self-efficacy and reduces upset in specific areas of caregiving.

Factors associated with home environmental problems among community-living older people.

PURPOSE: This paper describes the types of difficulties older people have with their home environments and the factors associated with having such difficulties. METHOD: Data were used from 296 study participants of the University at Buffalo's Consumer Assessments Study that examines the home modification needs and environmental difficulties of older people. A combination of socio-demographic variables, health and functional status indicators and measures of psychosocial well-being were used to predict environmental problems. RESULTS: An average of 13 problems with the environment that posed as a barrier to safe and independent performance was observed in homes. It was found that most difficulties occurred in bathrooms, kitchens, bedrooms and access to entryways and rooms. Hierarchical multiple regression analysis showed that having home environmental problems was most strongly associated with younger age, being female, being of minority status, having pain, and greater physical disability. CONCLUSION: The findings show that a combination of conditions that include demographic and functional conditions place older people at risk for problems with the home environment that impede performance of daily living activities.

Emerging concerns of older stroke patients about assistive device use.

Assistive devices minimize limitations from physical impairment and are integral to rehabilitation. Little is known about older patients' concerns, perceptions, and beliefs about assistive devices. This study used a structured, qualitative approach to describe device perceptions of 103 stroke patients in rehabilitation. Six dimensions of patient concerns were identified, including the operation and utility of devices, social contexts and consequences, and attributions of cultural meanings of use. Initial device use posed cultural value dilemmas originating in discrepancies between sociocultural beliefs and conflicting normative expectations. Knowledge of these dimensions suggests new areas for social science research and refinements to clinical practice.

How occupational therapists teach older patients to use bathing and dressing devices in rehabilitation.

OBJECTIVE: This article describes the methods occupational therapists use to teach bathing and dressing device use to older patients in rehabilitation programs. The relationship of three patient characteristics to five aspects of assistive device instruction was examined. METHOD: The study sample included 86 patients and 19 occupational therapists who provided the assistive device training. Patients were 55 years of age or older and in rehabilitation for an orthopedic deficit, cerebrovascular accident, or lower limb amputation. Therapists recorded information on teaching methods, perceptions of patient knowledge, and expectations for future device use after each treatment session. RESULTS: Patients received an average of three dressing and two bathing devices for home use. Therapists devoted an average of two and a half sessions (10 min average duration) to teach dressing device use and an average of one session (9 min average duration) to teach bathing device use. Teaching occurred mostly in the clinic setting through oral instruction and demonstration. At discharge, patients who evaluated devices positively and were evaluated as having a positive affect were perceived by the therapists as "having greater knowledge of device use." More time was spent teaching those patients with lower Functional Independence Measure scores, less positive evaluations of devices, and lower affect scores. Family caregivers were involved in one or more dressing sessions for 26% of patients and one or more bathing sessions for 36% of patients. CONCLUSION: Assistive device training in rehabilitation centers consists largely of simulated sessions in the occupational therapy clinic, and patients in the study described the instruction they received as "satisfactory." More research is needed to study the long-term effectiveness of assistive device training after patients return home.

Factors predicting assistive device use in the home by older people following rehabilitation.

The purpose of this article is to (a) describe the pattern of assistive device use by older adults the first 3 months home following rehabilitation, (b) examine factors that predict home use, and (c) describe characteristics of users. The study involved 86 patients 55 years of age or older who were hospitalized for a stroke, orthopedic deficit, or lower limb amputation and discharged home with assistive devices. Of the 642 devices provided in the hospital, 50% were used frequently to always, with those using devices in Month 1 continuing over time. A respondent's expectation while hospitalized to use devices was an independent predictor of actual home use. Although there were no differences between users and nonusers among sociodemographic variables, respondents with a lower limb amputation used devices with greater frequency than those with either a stroke or orthopedic deficit.

Issuing assistive devices to older patients in rehabilitation: an exploratory study.

Occupational therapists play a critical role in determining which assistive devices are provided to older adults and when and how instruction occurs during rehabilitation. This exploratory qualitative study used focus group methodology and Fleming's concept of the therapist with a three-track mind to examine how occupational therapists describe the process of issuing assistive devices to elderly persons in rehabilitation. We identified six interrelated steps involved in issuing an assistive device to an older person with a cerebrovascular accident. These steps were the selection of a device, an activity, a site for instruction, a method of instruction, the time to introduce a device during hospitalization, and reinforcement of its use. Therapists used procedural, interactive, and conditional reasoning to make decisions within each step and individualize device training. The findings from this study underscore the complex series of decisions and skilled clinical judgments involved in issuing assistive devices to older persons. Additionally, the study shows that focus group methodology is a valuable approach by which to identify how therapists reason about specific therapeutic practices.

Reaching consensus on the National Dental Hygiene Research Agenda: a Delphi study. American Dental Hygienists Association Council on Research.

PURPOSE: The purpose of this study was to achieve consensus on specific research topics under the national dental hygiene research agenda categories developed by the ADHA Council on Research. METHODS: A Delphi technique was used to survey a group of 48 dental hygiene experts to gain consensus about the appropriateness of topics for dental hygiene research. The study was carried out in three phases: a development and pilot-testing phase and two rounds of mailed surveys. Responses were analyzed using descriptive statistics. Instrument reliability was analyzed using the Pearson Product-Moment Correlation Coefficient and Cronbach's Alpha for internal consistency. RESULTS: Sixty-six topics reflective of the research agenda categories were identified through the first phase. Return rates of 100% and 94% were achieved for the two survey rounds. Instrument reliability was established at .91 and internal consistency at .94. After two rounds, consensus was reached on 37 of the 66 topics. CONCLUSIONS: Each of the categories comprising the ADHA national dental hygiene research agenda was well represented by the 37 topics. This finding provided evidence that there was consensus on the national agenda. However, reaching consensus is just the first step in the development of a long-range plan to guide research efforts and to promote depth in the development of a body of knowledge based on scientific inquiry.

Understanding the family perspective: an ethnographic framework for providing occupational therapy in the home.

This article presents a framework for providing occupational therapy services to family members caring for elderly persons in the home that is based on four key principles derived from ethnographic methodology: identification of an informant, use of an emic (insider) approach, engagement in self-reflection, and interpretation of information. The underlying strategy is to use these principles to derive an understanding of the personal meaning of caregiving, the way in which care is provided, and the specific aspects of caregiving that are problematic from the perspective of the family member. Services are then developed that reflect individual need as expressed by the caregiver and that fit the fundamental values and belief system of the family unit. A case example is presented to illustrate the framework in action in a home situation with family members caring for an elderly person with dementia.

An exploratory study of how occupational therapists develop therapeutic relationships with family caregivers.

Family members, who provide 70% to 80% of all long-term care, have often been perceived by occupational therapists as a barrier to, rather than a partner in, effective care for elderly persons. This perception suggests that in order to build effective partnerships to manage complex issues, occupational therapists working with elderly persons must develop effective strategies for involving family members in the therapeutic process. This article describes a pilot study that examined how occupational therapists engage family caregivers of elderly persons receiving home care services. A qualitative descriptive approach was used to explore the behaviors demonstrated by two occupational therapists when working with family caregivers. The findings point to four primary types of occupational therapist-caregiver interaction, categorized as: caring, partnering, informing, and directing. These interaction styles were compared with current literature describing state-of-the-art occupational therapy practices with older adults and family caregivers. An emphasis was placed on examining how therapeutic interactions can evoke different caregiver responses and influence the development and maintenance of collaborative therapeutic relationships. The results of this pilot study can serve as a framework for further exploration of interactive strategies that promote caregiver empowerment and ultimately influence the ability of families to assume responsibility for the long-term care required by many chronically disabled older adults.

Review of the literature on African American caregivers of individuals with dementia.

Despite the large body of literature on caregivers for relatives with dementia, few studies have included minority caregivers. This paper examines research studies on African American caregivers of relatives with dementia and provides recommendations for future research.

Adaptive device use by older adults with mixed disabilities.

A key strategy in rehabilitation with the elderly is the selection and training in the use of adaptive devices to improve the ability to perform self-care and other activities of daily living. Two descriptive pilot studies were conducted to determine home use of equipment from the perspective of older adults with mixed disabilities and home care therapists. The first study examined home equipment use over a three-month period by 13 elderly patients discharged from a hospital rehabilitation unit. The second study surveyed 31 home therapists to evaluate their perceptions of device use by their elderly clients. The findings indicate that older adults and home care therapists share similar perspectives as to why devices are not frequently used. Home care therapists perceived that additional training in a person's home may increase safety, maximize functional performance, and reduce some caregiver responsibilities. The implications of these findings for service delivery are discussed.

A model to promote activity competence in elders.

This paper describes an occupational therapy home-based intervention in which purposeful activities were used to promote adaptation and competence in older adults with chronic disabilities. Seven home care therapists visited 17 randomly selected, community-living elders who were chronically disabled and who volunteered to participate in the program. The number of visits ranged from 3 to 10 and occurred over a 3-month period according to clients' needs and wishes. Therapists enhanced their ability to enter the client's social and cultural system by using participant-observation techniques and collaboratively identified activities. Therapists documented each home visit with a structured fieldnote form. An analysis of 112 field-notes indicated that therapists were able to understand a client's needs; this understanding resulted in small qualitative gains in areas identified as important by the client. Reilly's concept of an activity continuum was a useful framework from which to work with this population. The implications for program development, treatment outcomes, and accountability with this approach promote improved future treatment planning with the elderly with chronic disability.

Dementia management: an occupational therapy home-based intervention for caregivers.

This paper describes an occupational therapy intervention designed for family caregivers of persons with dementia. The intervention, based on the framework of a competence-environmental press model and the principle of collaboration, was implemented during 5 home visits. Each visit was designed to build caregiving skills through collaboration in identifying problem areas, developing and implementing environmental strategies, and modifying management approaches. A case vignette illustrates the therapeutic process and outcomes. The theoretical rationale and structure of the intervention and innovative documentation for evaluation of the theoretic process are also presented.

Effects of exercise training in the elderly on the occurrence and time to onset of cardiovascular diagnoses.

To examine the long-term effects of aerobic exercise on the occurrence and time to onset of cardiovascular diagnoses, 184 initially healthy older subjects were randomized into either a long-term exercise group (Group A, n = 80), a short-term exercise group (Group B, n = 42), or a contract control group (Group C, n = 62). After completion of two years in the study, data on new cardiovascular diagnoses and time to onset of these diagnoses in each of the three groups were compared. The occurrence rates for new onset diagnoses were as follows: Group A, 2.5%; Group B, 2%; and Group C, 13%; the average time to onset was greatest for the long-term exercisers and shortest for the contact control group (P less than or equal to .02). The results suggest that a regular program of exercise may have cardiovascular benefits for those over 60 years of age.

Early intervention.

This paper provides an overview of the critical nced for early intervention services, the specific role of occupational therapists in early intervention settings, and the training implications for the preparation of occupational Therapists with expanded roles, responsibilities and skills. An intervention approach that is multidisciplinary, culturally relevant, and family centered in nature is proposed as one way of redefining the occupational therapist's contribution and strategy in early intervention settings. Recommendations are presented regarding the education and preparation of occupational thera ists for their new directions in early intervention and the potenliarincrease in demands for their services.