Emotional Distress and Physical Activity Engagement in U.S. Veterans With Chronic Obstructive Pulmonary Disease: A Qualitative Study.

BACKGROUND: Physical activity is recommended as part of guideline-based care for managing chronic obstructive pulmonary disease (COPD) at all stages of the disease. However, physical activity interventions are less effective in individuals with co-occurring emotional distress (i.e., depression and/or anxiety symptoms). Interventions that dually promote improved physical and mental health in COPD are needed. The first step for intervention development is understanding individuals' experience of these factors. PURPOSE: To understand the experience of emotional distress in U.S. Veterans diagnosed with COPD and to explore how emotional distress impacts physical activity engagement. METHODS: Structured interviews informed by the cognitive and behavioral models of psychopathology were conducted with 29 United States Veterans with COPD (89.66% male, age 67.72 ± 6.55 years, 93.10% White) at the VA Boston Healthcare System. Interviews were audio recorded, transcribed, and underwent thematic analysis. RESULTS: Three major themes encapsulating 17 codes emerged through thematic analysis: (i) the experience of emotional distress in Veterans with COPD; (ii) the complex relationship between emotional distress, physical activity engagement, and COPD; (iii) contextual and personal factors. CONCLUSIONS: Veterans' interpretation of their COPD symptoms as unpredictable and uncontrollable and COPD-related physical limitations influenced their experience of emotional distress, while the experience of emotional distress both promoted and deterred physical activity engagement. Veterans were motivated to engage in physical activity despite experiencing emotional distress when they faced a responsibility in daily life. They identified motivational strategies and self-regulation techniques to manage emotional distress and to foster physical activity.

Promoting physical activity is important for maintaining functioning in persons with chronic obstructive pulmonary disease (COPD), but physical activity interventions do not help all individuals. One reason may be the presence of co-occurring clinically significant depression and/or anxiety symptoms (i.e., emotional distress). Behavioral interventions that can address both physical activity and emotional distress at the same time are needed and may translate to improved outcomes. To inform intervention development, the current qualitative study explored the relationship between emotional distress and physical activity engagement, as well as contextual influencers (i.e., social support) in 29 U.S. Veterans with COPD and emotional distress. Participants completed a structured interview guided by the cognitive behavioral model of psychopathology. Three major themes encapsulating 17 codes emerged through thematic analysis: (i) the experience of emotional distress in Veterans with COPD; (ii) the complex relationship between emotional distress, physical activity engagement, and COPD; (iii) contextual and personal factors. The experience of emotional distress both promoted and deterred physical activity. Family, friends, and environmental factors (i.e., seasonal changes) impacted the experience of emotional distress and physical activity engagement. The findings inform intervention development that is patient-centered and dually address physical activity and emotional distress.

Research Protocol Adaptations During the COVID-19 Pandemic: A Process Evaluation.

In general, COVID-19-related adaptations that transitioned in-person assessments and interventions to a virtual format were not routinely evaluated. We aimed to conduct a process evaluation to examine the impact of COVID-19-related adaptations on a behavior change intervention designed to increase exercise adherence among Veterans with mobility difficulty. We used secondary data from a nonrandomized study to complete a process evaluation examining the intervention's reach, recruitment, fidelity, dose delivered by physical therapists, and the dose received by the 14 participating Veterans. The physical therapist delivered 95% (133/140) of the study's 10 sessions. Sessions with the lowest delivery dose included Sessions 1 and 10 (86%; n = 12/14). The elements with the lowest dose received included using an exercise journal and developing a postintervention plan (86%; n = 12/14). Our COVID-19 adaptations allowed us to provide our intervention to the majority (67%) of eligible participants without a negative impact on fidelity, dose delivered, or dose received.

Depression Symptoms and Physical Activity in Veterans With COPD: Insights From a Web-Based, Pedometer-Mediated Physical Activity Intervention.

BACKGROUND: Depression is known to limit physical activity (PA) among individuals with chronic obstructive pulmonary disease (COPD). However, whether and how depression influences the effectiveness of PA interventions is unknown. PURPOSE: The study examined the association between baseline depression symptoms and change in daily step count and whether group assignment to a web-based, pedometer-mediated PA intervention moderated the association between baseline depression symptoms and change in daily step count. METHODS: Secondary analysis included two cohorts of U.S. Veterans with COPD (n = 212; 97% male; mean age 69 ± 8 years) assessed at baseline and 3 months. Cohorts 1 and 2 were randomly assigned to the same PA intervention (n = 111) or a control group (n = 101). Multivariate regressions tested the main effects of baseline depression symptoms (BDI-II total and cognitive-affective and somatic subscales) on change in daily steps, as well as the interaction between baseline BDI-II and subscales and group assignment on change in daily steps. RESULTS: Greater BDI-II total score (B = -31.8, SE = 14.48, p = .030) and somatic subscale scores (B = -99.82, SE = 35.76, p = .006) were associated with less improvement in daily step count. There was a significant interaction between baseline cognitive-affective subscale and the intervention predicting change in daily step count (B = -88.56, SE = 42.31, p = .038). When cognitive-affective subscale scores were ≥1 SD above the mean, the intervention was no longer associated with an increase in daily step count (p = .585). CONCLUSIONS: Depression should be routinely assessed and targeted as part of PA promotion efforts.

United States (U.S.) Veterans have high rates of chronic obstructive pulmonary disease (COPD), a progressive lung disease that causes shortness of breath. Promoting physical activity (PA) is an important component to the management of COPD resulting in improved outcomes. Technology-based interventions (i.e., pedometers, websites) are effective at increasing PA in persons with COPD. However, depression symptoms, such as low mood and motivation, may influence their effectiveness. This secondary data analysis examined whether depression symptoms were related to improvement in daily step count. Two cohorts of U.S. Veterans were randomized to either a web-based, pedometer-mediated PA intervention (i.e., pedometer, goal setting and feedback, education and online community) or a control group (i.e., pedometer only or usual care). Daily step count was assessed at baseline and at 3 months. Across both groups, greater overall depression symptoms and greater bodily symptoms of depression (i.e., fatigue) were associated with less improvement in daily step count. Veterans with greater cognitive-affective symptoms of depression (i.e., low mood, loss of interest, or pleasure) who were assigned to the intervention group showed no improvement in daily step count compared with controls. Results highlight the importance of detecting and treating depression as part of PA interventions.

Sleep Continuity, Sleep Related Daytime Dysfunction, and Problem Endorsement: Do These Vary Concordantly by Age?

OBJECTIVES: Sleep continuity (i.e., ability to initiate and/or maintain sleep) worsens with age. It is unclear whether problem endorsement and/or daytime dysfunction show similar age-related trends. Accordingly, a large archival dataset was used to examine age differences in sleep continuity, problem endorsement, and sleep related daytime dysfunction. METHOD: Participants were categorized as: Young Adults (18-29 years); Adults (30-44 years); Middle Aged Adults (45-64 years); and Older Adults (65-89 years). Young Adults, Adults, and Middle Aged Adults were 1:1 matched with Older Adults (n = 233) on the basis of gender, race, ethnicity, and BMI. MANOVA, ANOVAs, and chi-square analysis were performed to assess for age-related differences. RESULTS: In a sample of 932 adults with self-reported sleep continuity disturbance (i.e., insomnia), sleep continuity was significantly worse in older age groups. This effect was limited to middle and late insomnia with middle aged and older adults waking up with greater frequency and for longer durations of time during the night and in the early morning than younger cohorts. Problem endorsement largely increased across age groups (except for sleep latency) but reports of overall sleep-related daytime dysfunction showed no difference by age. CONCLUSION: When evaluating sleep continuity disturbance, assessing whether the patient identifies their sleep continuity disturbance as a problem and whether it affects their daytime function can be informative, particularly in older adults. It may serve to reveal (case-by-case) when there are discordances between incidence/severity of illness and problem endorsement/daytime dysfunction. Such information may better inform if treatment should be initiated.

The Impact of Depression and Exercise Self-Efficacy on Benefits of Pulmonary Rehabilitation in Veterans with COPD.

Pulmonary rehabilitation (PR) improves health-related quality of life (HRQoL) and exercise capacity. Little is known about the impact of depression symptoms and exercise self-efficacy on improvements in these key PR outcomes. This study examined the impact of baseline depression status and change in depression symptoms (Beck Depression Inventory-II [BDI-II] score) over the course of PR on change in HRQoL assessed by the Chronic Respiratory Disease Questionnaire-Self Reported (CRQ-SR) and exercise capacity as measured by the 6-Minute Walk Test (6MWT). We also examined whether baseline exercise self-efficacy moderated the association between baseline depression symptoms and change in these key PR outcomes. We studied 112 US veterans (aged 70.38 ± 8.49 years) with chronic obstructive pulmonary disease (COPD) who completed PR consisting of twice-weekly 2-hour classes for 18 sessions. Depressed (BDI-II >13) and nondepressed (BDI-II ≤13) patients at baseline demonstrated comparable and significant improvement in CRQ-SR total score, subscales, and 6MWT. Greater reduction in depression over the course of treatment was significantly associated with greater improvement in CRQ-SR total score and the following subscales: fatigue, mastery, and emotional function. Change in depression did not predict change in 6MWT distance. Baseline exercise self-efficacy moderated the association between baseline depression symptoms and change in CRQ-SR fatigue. Specifically, when baseline exercise self-efficacy was <30.4, greater baseline depression was associated with less improvement in CRQ-SR fatigue. When baseline self-efficacy was >152.0, greater baseline depression was associated with greater improvement in CRQ-SR fatigue. PR programs should address mood and confidence to exercise given their impact on key PR outcomes.

Predictors of Outpatient Pulmonary Rehabilitation Uptake, Adherence, Completion, and Treatment Response Among Male U.S. Veterans With Chronic Obstructive Pulmonary Disease.

OBJECTIVE: To examine predictors of uptake (never start), adherence (drop out), and completion of pulmonary rehabilitation (PR), as well as PR treatment response based on minimal clinically important difference (MCID) on the 6-minute walk test (6MWT) distance and Chronic Respiratory Questionnaire-Self-Report (CRQ-SR). DESIGN: Retrospective, cohort study. SETTING: Veterans Health Administration. PARTICIPANTS: U.S. veterans with chronic obstructive pulmonary disease (COPD) (N=253) referred to PR between 2010 and 2018. INTERVENTIONS: Outpatient PR program. MAIN OUTCOME MEASURES: Participants completed baseline (time 1) measures of depression (Beck Depression Inventory-II), health-related quality of life (CRQ-SR), self-efficacy (Exercise Self-Regulatory Efficacy Scale [Ex-SRES]), and COPD knowledge. Exercise capacity was assessed with the 6MWT. Participants who completed all 18 sessions of PR repeated assessments (time 2). Logistic regression models examined predictors of uptake, adherence, and completion of PR as well as treatment response based on MCID. RESULTS: Participants were referred to PR with 24.90% never starting, 28.90% dropping out, and 46.20% completing. No differences emerged between never starters and dropouts. Having a history of any cancer increased the likelihood of completing PR (vs never starting; odds ratio [OR], 3.18; P=.003). Greater CRQ-SR dyspnea score, indicating less dyspnea, was associated with increased likelihood of completing PR (OR, 1.12; P=.006). Past smoking compared with current smoking was associated with increased likelihood of completion (OR, 3.89; P≤.002). Those without a history of alcohol use disorder had increased likelihood of completing PR (OR, 2.23; P=.048). Greater baseline 6MWT distance was associated with lower likelihood of achieving MCID in 6MWT (OR, 0.99; P<.001). Greater Ex-SRES was associated with decreased likelihood of achieving 6MWT MCID (OR, 0.98; P=.023). CONCLUSIONS: Findings suggest that early psychoeducation on dyspnea management and smoking and alcohol cessation may increase completion of PR.

Cognitive Emotion Regulation Strategies Predict Burnout in Geriatric Nursing Staff.

OBJECTIVES: Burnout contributes to high turnover rates, medical errors, and poor patient satisfaction in geriatric nursing staff. Nurses' cognitive emotion regulation (ER) strategies are emerging as an important personal resource related to burnout that are modifiable with intervention. This study examined the association between cognitive ER strategies and burnout among geriatric nursing staff. METHODS: Participants were 54 nurses (RNs, LPNs, CNA/UWs) with a mean age of 43.1 years (SD = 12.2), majority female (96.3%), and racially diverse: Black (20.4%), White (63.0%), and Other (13.0%). RESULTS: After controlling for CVs, cognitive ER strategies accounted for unique variance in depersonalization, but did not account for unique variance in emotional exhaustion or personal accomplishment. Rumination was associated with greater depersonalization, and greater refocus on planning was associated with lower depersonalization. CONCLUSIONS: Findings suggest that depersonalization may be most impacted by ER; however, other ER strategies may be important that were not included in the current study (e.g., experiential avoidance, mindfulness). Future research is needed with additional ER strategies and larger samples. CLINICAL IMPLICATIONS: Findings support the use of person-centered interventions, such as cognitive-behavioral and mindfulness-based techniques, to improve stress management and decrease depersonalization.

Engaging in pleasant events explains the relation between physical disability and mental health outcomes in older adults.

OBJECTIVES: This study expands the body of research examining mediators of the association between physical disability and mental health outcomes. Based on the behavioral model of depression, frequency of pleasant events were examined as a mediator between physical disability and mental health outcomes including depressive symptoms, meaning in life, and positive affect. We predicted that physical disability would have a significant indirect effect on mental health outcomes through the lower frequency of pleasant events. METHODS: Cross-sectional study of 82 community-dwelling adults, Mage = 77.6, SD = 8.0, 64.6% female, was conducted. Self-report instruments measured frequency of pleasant events, physical disability, and mental health outcomes (depression symptoms, positive affect, and meaning in life). RESULTS: Simple mediation analyses demonstrated a significant indirect effect of physical disability on depressive symptoms (unstandardized coefficient = 0.16, 95% bias-corrected CI 0.03, 0.41), positive affect (unstandardized coefficient = -2.65, 95% bias-corrected CI -5.38, -0.88), and meaning in life (unstandardized coefficient = -1.58, 95% bias-corrected CI -3.19, -0.47) through engagement in pleasant events. CONCLUSION: Physical disability was associated with greater depressive symptoms and lower positive affect and meaning in life through reduced frequency of pleasant events. These findings are consistent with the behavioral model of depression and support several applied recommendations for reducing the burden of physical disability on mental health outcomes.

Age differences in cancer-related stress, spontaneous emotion regulation, and emotional distress.

OBJECTIVES: Cancer risk increases with age, cancer-related stress is common and devastating to mental health of patients, yet little work has explored age differences in cancer-related stress. This study investigated sources of stress related to cancer diagnosis and treatment and its association with age and emotional health. Though not an a priori aim of the study, adaptive strategies mentioned within discussions of stress-which we classify as spontaneous emotion regulation (ER) - were also investigated. METHOD: Participants (N = 147, aged 27-88) recruited from the VA (98% male) with oral-digestive cancers participated in semi-structured interviews regarding sources of stress 6-months post-diagnosis (T1) and treatment-related stress at 12-months post-diagnosis (T2). Patients also reported their emotional distress at T2 via the PROMIS-29. Inductive content analysis was used to classify sources of stress and ER into semantic themes and relative frequencies. RESULTS: The greatest source of stress at diagnosis was psychological; physical symptoms were the greatest source of stress at treatment. Older adults less frequently reported psychological uncertainty, social stress, and situational stress, whereas age groups reported similar rates of physical stress. When describing stress, older adults more often made spontaneous references to emotion regulation (ER). Across age groups, those who reported stress without ER in qualitative comments had higher emotional distress on the PROMIS-29 than those reporting stress with ER or no stress. CONCLUSION: ER may be key to psychological adjustment to cancer, especially in later-life. implications for assessment of stress at pivotal visits and mental health referral are discussed.

Capacity assessment training in geropsychology: Creating and evaluating an outpatient capacity clinic to fill a training gap.

Assessment of decision-making capacity of older adults is a growing area of practice but training opportunities are lacking. We present a needs assessment, program characteristics, pilot clinic process (n= 52 referrals) and outcome training (n= 4 interns) data for a capacity training clinic. Process data reveal that the training clinic provided consistent referrals (1 per week) across multiple capacity domains (independent living, treatment consent, and financial capacities), with 27% of referrals providing opportunities for training in protective services. Outcome data found three of the four interns reported proficient skills in capacity assessment, as well as improved skills in six areas related to capacity assessment: knowledge of limitations of assessment methods, person-environment interaction, identifying and applying ethical and legal standards, utilizing cognitive assessments, communicating results and recommendations, and assessing risk. The discussion shares lessons learned for the development of future training rotations and clinics in the capacity assessment.

Pain is associated with continuing depression in cancer survivors.

Depression is common but under-diagnosed in cancer survivors. This study characterized depressive symptoms over one year in cancer survivors and examined disease-related and psychosocial predictors of depression severity. Participants (n = 122; Mage 65.33, SD = 9.17, 98.4% male) with head and neck, esophageal, gastric, or colorectal cancers were recruited through tumor registries at two regional Veterans Administration Medical Centers. Self-report measures assessing depressive symptoms (PHQ-9), combat-related PTSD symptoms (PC-PTSD), and health-related quality of life (PROMIS) were administered at six, twelve, and eighteen months after diagnosis. Symptoms consistent with major depression were endorsed by approximately one-quarter of the sample at six (24%), twelve (22%), and eighteen (26%) months post diagnosis, with 12% of participants reporting consistently significant depressive symptoms. In multivariate modeling, significant predictors of depression at eighteen months included prior depressive symptoms (ß = .446, p < 0.001) and current pain interference (ß = .231, p = .003). The present findings suggest that major depression is common and persistent one year following cancer diagnosis. Attention to pain management and routine monitoring of mood symptoms is critical to reducing risk of depression in cancer survivors.

Program Evaluation of Group-based Cognitive Behavioral Therapy for Insomnia: a Focus on Treatment Adherence and Outcomes in Older Adults with Co-morbidities.

OBJECTIVE: To describe a program evaluation of the interrelationship of adherence and treatment outcomes in a sample of veteran older adults with co-morbidities who participated in group-based cognitive behavioral therapy for insomnia. METHODS: Retrospective data extraction was performed for 14 older adults. Adherence measures and sleep outcomes were measured with sleep diaries and Insomnia Severity Index. Demographic and clinical information was extracted through chart review. RESULTS: Adherence with prescribed time in bed, daily sleep diaries, and maintaining consistent time out of bed and time in bed was generally high. There were moderate, though not significant, improvements in consistency of time in bed and time out of bed over time. Adherence was not significantly associated with sleep outcomes despite improvements in most sleep outcomes. CONCLUSIONS: The non-significant relationship between sleep outcomes and adherence may reflect the moderating influence of co-morbidities or may suggest a threshold effect beyond which stricter adherence has a limited impact on outcomes. CLINICAL IMPLICATIONS: Development of multi-method adherence measures across all treatment components will be important to understand the influence of adherence on treatment outcomes as monitoring adherence to time in bed and time out of bed had limited utility for understanding treatment outcomes in our sample.

Spirituality attenuates the association between depression symptom severity and meaning in life.

OBJECTIVES: This cross-sectional study examined whether spirituality moderates the association between depression symptom severity and meaning in life among treatment-seeking adults. METHOD: Participants were 55 adults (≥60 years of age) newly seeking outpatient mental health treatment for mood, anxiety, or adjustment disorders. Self-report questionnaires measured depression symptom severity (Patient Health Questionnaire-9), spirituality (Spirituality Transcendence Index), and meaning in life (Geriatric Suicide Ideation Scale-Meaning in Life subscale). RESULTS: Results indicated a significant interaction between spirituality and depression symptom severity on meaning in life scores (ß = .26, p = .02). A significant negative association between depression symptom severity and meaning in life was observed at lower but not the highest levels of spirituality. CONCLUSION: In the presence of elevated depressive symptomatology, those participants who reported high levels of spirituality reported comparable levels of meaning in life to those without elevated depressive symptomatology. Assessment of older adult patients' spirituality can reveal ways that spiritual beliefs and practices can be can be incorporated into therapy to enhance meaning in life.

Development and preliminary evaluation of the anxiety in cognitive impairment and dementia (ACID) scales.

BACKGROUND: Although rates of anxiety tend to decrease across late life, rates of anxiety increase among a subset of older adults, those with mild cognitive impairment (MCI) or dementia. Our understanding of anxiety in dementia is limited, in part, by a lack of anxiety measures designed for use with this population. This study sought to address limitations of the literature by developing a new measure of anxiety for cognitively impaired individuals, the anxiety in cognitive impairment and dementia (ACID) Scales, which includes both proxy (ACID-PR) and self-report (ACID-SR) versions. METHODS: The ACID-SR and ACID-PR were administered to 45 residents, aged 60 years and older, of three long-term care (LTC) facilities, and 38 professional caregivers at these facilities. Other measures of anxiety, and measures of depression, functional ability, cognition, and general physical and mental health were also administered. RESULTS: Initial evaluation of its psychometric properties revealed adequate to good internal consistency for the ACID-PR and ACID-SR. Evidence for convergent validity of measures obtained with the ACID-SR and ACID-PR was demonstrated by moderate-to-strong associations with measures of worry, depressive symptoms, and general mental health. Discriminant validity of measures obtained with the ACID-SR and ACID-PR was demonstrated by weak correlations with measures of cognition, functional ability, and general physical well-being. CONCLUSIONS: The preliminary results suggest that the ACID-SR and ACID-PR can obtain reliable and valid measures of anxiety among individuals with cognitive impairment. Given the subjective nature of anxiety, it may be prudent to collect self-report of anxiety symptoms even among those with moderate cognitive impairment.

Exploring physical therapists' approach to addressing home exercise program-related low self-efficacy: knowledge, strategies, and barriers.

PURPOSE: Self-efficacy is the strongest predictor of completing home exercise programs (HEPs). How physical therapists address low levels of self-efficacy is unknown. Our objectives were to determine (1) knowledge and confidence in addressing patients' self-efficacy; (2) strategies used to address low self-efficacy; and (3) barriers. MATERIAL AND METHODS: Licensed physical therapists who are actively treating patients in the United States participated in our mixed-methods study consisting of: (1) a survey on knowledge, barriers, and confidence; and (2) interviews on strategies used to address low self-efficacy. Descriptive statistics were calculated on all quantitative data. Braun and Clarke's 6-phase thematic analysis was used for the qualitative data. RESULTS: All 37 participants believed that self-efficacy impacts HEP completion. The majority (72.9%) reported addressing low self-efficacy. Barriers that impacted the ability to address low self-efficacy (Theme 1) included lack of knowledge, confidence, tools, guidance, and community resources, patients' past experiences and complexities, inability to follow-up with patients, and reimbursement. Due to these barriers, participants primarily addressed patients' low self-efficacy via communication (Theme 2) and ensuring successful exercise completion (Theme 3). CONCLUSION: Instead of using Bandura's fours sources of self-efficacy (i.e., mastery experiences, verbal persuasion, vicarious experiences, physiological state), participants verbalized addressing low self-efficacy via communication and successful exercise completion. Thus, implementation studies evaluating strategies to overcome the identified barriers are needed.

Self-efficacy is the strongest predictor of completing home exercise programs (HEPs) as prescribed.Instead of using evidence-informed strategies, physical therapists primarily address low self-efficacy via communication and ensuring that patients complete exercises successfully by simplifying the exercises and repeating the exercises until able to do them without cues.Barriers that keep physical therapists from using evidence-informed strategies include lack of knowledge, confidence, tools, guidance, and community resources, patients' past experiences and complexities, inability to follow-up with patients, and reimbursement.Physical therapists' ability to address low self-efficacy and increase HEP completion, can be improved by resolving clinical barriers (i.e., lack of knowledge) with implementation strategies (i.e., training).

Obstructive respiratory disease in U.S. veterans: Prevalence, characteristics, and health burden.

OBJECTIVE: To examine the psychiatric and physical health burden of obstructive respiratory disease in a nationally representative sample of U.S. Veterans. METHODS: Secondary data analyses were conducted using data from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. Veterans. Participants self-reported health professional-diagnosed obstructive respiratory disease (i.e., asthma, chronic bronchitis or chronic obstructive pulmonary disease). Veterans who reported obstructive respiratory disease (n = 502) were compared to veterans without this disease but with at least one or more other medical conditions-controls (n = 3169) on measures of sociodemographic, trauma, psychiatric, and physical health characteristics. Multivariable regression analyses examined independent associations between obstructive respiratory disease and psychiatric conditions and physical characteristics. RESULTS: A total 12.5% of the sample reported a diagnosis of obstructive respiratory disease. Compared to controls, veterans with obstructive respiratory disease were more likely to be female, unmarried/partnered, lower income, residing in the Midwest, receiving VA healthcare, and had greater lifetime and childhood trauma burden. In adjusted analyses, veterans with respiratory disease had 47-91% greater odds of screening positive for current posttraumatic stress, major depressive, and generalized anxiety disorders, and had 48% greater odds of current suicide ideation. They were also more likely to have lifetime nicotine use disorder and had more medical comorbidities and more severe somatic symptoms. CONCLUSIONS: Obstructive respiratory disease is prevalent among U.S. veterans and associated with significant mental and physical health burden. Results highlight the need for timely screening and treatment for psychiatric and medical conditions that are highly comorbid with obstructive respiratory disease in this population.

Rural disparities impact response to a web-based physical activity self-management intervention in COPD: A secondary analysis.

PURPOSE: This secondary exploratory analysis examined rural-urban differences in response to a web-based physical activity self-management intervention for chronic obstructive pulmonary disease (COPD). METHODS: Participants with COPD (N = 239 US Veterans) were randomized to either a multicomponent web-based intervention (goal setting, iterative feedback of daily step counts, motivational and educational information, and an online community forum) or waitlist-control for 4 months with a 12-month follow-up. General linear modeling estimated the impact of rural/urban status (using Rural-Urban Commuting Area [RUCA] codes) on (1) 4- and 12-month daily step-count change compared to waitlist-control, and (2) intervention engagement (weekly logons and participant feedback). FINDINGS: Rural (n = 108) and urban (n = 131) participants' mean age was 66.7±8.8 years. Rural/urban status significantly moderated 4-month change in daily step counts between randomization groups (p = 0.041). Specifically, among urban participants, intervention participants improved by 1500 daily steps more than waitlist-control participants (p = 0.001). There was no difference among rural participants. In the intervention group, rural participants engaged less with the step-count graphs on the website than urban participants at 4 months (p = 0.019); this difference dissipated at 12 months. More frequent logons were associated with greater change in daily step counts (p = 0.004); this association was not moderated by rural/urban status. CONCLUSIONS: The web-based intervention was effective for urban, but not rural, participants at 4 months. Rural participants were also less engaged at 4 months, which may explain differences in effectiveness. Technology-based interventions can help address urban-rural disparities in patients with COPD, but may also contribute to them unless resources are available to support engagement with the technology.

Association Between Depression Symptoms and Disability Outcomes in Older Adults at Risk of Mobility Decline.

Objective: To assess the association between depression symptoms and physical functioning and participation in daily life over 2 years in older adults at risk of mobility decline. Design: A secondary analysis of 2-year observational data from the Boston Rehabilitative Impairment Study of the Elderly. Setting: Nine primary care clinics within a single health care system. Participants: Participants (N=432; mean age ± SD, 76.6±7.0y; range, 65-96y; 67.7% women) were community-dwelling adults (>65y) at risk of mobility decline. Interventions: Not applicable. Main Outcome Measures: Secondary data analyses of the Late Life Function and Disability Instrument (primary outcome), Short Physical Performance Battery (secondary outcome), and Patient Health Questionnaire-9 (PHQ-9) (predictor). Measures were administered at baseline, 12 months, and 24 months. Participants completed a self-report survey asking about 16 medical comorbidities, and demographic information was collected at baseline. Results: Participants had an average ± SD PHQ-9 score of 1.3±3.1, ranging from 0 to 24 at baseline. Twenty-nine percent of participants reported a history of depression. Greater depression symptoms were associated with lower physical functioning (unstandardized beta [B]=-0.14, SE=0.05, P=.011) and restricted participation (frequency subscale: B=-0.21, SE=0.11, P=.001; limitation subscale: B=-0.45, SE=0.04, P<.001) cross-sectionally over 2 years. PHQ-9 was not significantly associated with the rate of change in Late Life Function and Disability Instrument score over 2 years. Conclusions: Treating depression in primary care may be an important strategy for reducing the burden of functional limitations and participation restrictions at any 1 time. Further research is needed on treatment models to cotarget depression and physical functioning among at-risk older adults.

Development, adaptation, and clinical implementation of the Later-Adulthood Trauma Reengagement (LATR) group intervention for older veterans.

Later in life Veterans may report increased thoughts and memories of traumatic military experience in the context of age-related changes, a process called Later-Adulthood Trauma Reengagement (LATR); this process may lead to resilience or distress. We describe the development of a 10-session group intervention with goals of providing psychoeducation about LATR, enhancing stress management and coping skills, and fostering meaning making. We characterize implementation and outcome characteristics for seven group cohorts over 5 years; groups were completed in-person or virtually. Outcomes were measured with the Connor-Davidson Resilience Scale, Meaning in Life Scale, Satisfaction with Life Scale, Positive Appraisals of Military experience (PAMES), Posttraumatic Stress Disorder Checklist-5, and Patient Health Questionnaire-9. Forty-seven Veterans (aged 65-93) began the group, 37 (87%) completed at least six sessions. These 37 Veterans reported an average of eight stressful events in the prior year, mostly major illness, death of a friend, and decline in memory and enjoyable activities, which may have set the stage for LATR. Veterans resonated with the LATR concept on standardized scales and qualitative comments. In pre-post comparisons, participants reported higher levels of PAMES (η² = .225), resilience (η² = .208), and meaning in life (η² = .145), with fewer symptoms of PTSD (η² = .199) and depression (η² = .124). There were no significant differences in outcomes for those who completed the group in-person or virtually. The LATR protocol may provide a framework for working with older adults reporting emergence or exacerbation of thoughts and memories of earlier trauma in later life, fostering positive adaptation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Chronic Obstructive Pulmonary Disease Access and Adherence to Pulmonary Rehabilitation Intervention (CAPRI): Protocol for a randomized controlled trial and adaptations during the COVID-19 pandemic.

BACKGROUND: Pulmonary rehabilitation (PR) is the standard of care for chronic obstructive pulmonary disease (COPD) management. However, significant barriers limit access and adherence to PR and alternatives are needed. The purpose of this randomized controlled trial is to test the efficacy of a web-based, pedometer-mediated intervention to increase physical activity (PA) for persons with COPD who decline PR or meet U.S. guidelines for referral to PR but have not participated (CAPRI-1). In addition, we will test whether the intervention maintains PA following PR in an exploratory aim (CAPRI-2). METHODS: Participants with COPD (N = 120) will be recruited and randomized 1:1 to a 12-week web-based, pedometer-mediated intervention or usual care (UC) (CAPRI-1). The intervention provides: 1) objective monitoring of walking and iterative feedback, 2) individualized step-count goals, 3) motivational messages and educational content, and 4) an online community. The primary outcome is change in daily step count from baseline to 12 weeks. Secondary outcomes include: (a) exercise capacity; (b) self-reported PA; (c) PA intensity; (d) exercise self-regulatory efficacy, (e) health-related quality of life, (f) dyspnea, (g) depression symptoms, and (h) healthcare utilization. CAPRI-2 will test whether participants (N = 96) assigned to the intervention following PR completion show greater maintenance of daily step count compared to UC at 3, 6, 9, and 12 months. DISCUSSION: If the intervention is efficacious, it may be an alternative for those who cannot attend PR or a maintenance program following completion of conventional PR. We also present adaptations made to the protocol in response to the COVID-19 pandemic.