Systematic Multi-Domain Alzheimer's Risk Reduction Trial (SMARRT): Study Protocol.

This article describes the protocol for the Systematic Multi-domain Alzheimer's Risk Reduction Trial (SMARRT), a single-blind randomized pilot trial to test a personalized, pragmatic, multi-domain Alzheimer's disease (AD) risk reduction intervention in a US integrated healthcare delivery system. Study participants will be 200 higher-risk older adults (age 70-89 years with subjective cognitive complaints, low normal performance on cognitive screen, and ≥ two modifiable risk factors targeted by our intervention) who will be recruited from selected primary care clinics of Kaiser Permanente Washington, oversampling people with non-white race or Hispanic ethnicity. Study participants will be randomly assigned to a two-year Alzheimer's risk reduction intervention (SMARRT) or a Health Education (HE) control. Randomization will be stratified by clinic, race/ethnicity (non-Hispanic white versus non-white or Hispanic), and age (70-79, 80-89). Participants randomized to the SMARRT group will work with a behavioral coach and nurse to develop a personalized plan related to their risk factors (poorly controlled hypertension, diabetes with evidence of hyper or hypoglycemia, depressive symptoms, poor sleep quality, contraindicated medications, physical inactivity, low cognitive stimulation, social isolation, poor diet, smoking). Participants in the HE control group will be mailed general health education information about these risk factors for AD. The primary outcome is two-year cognitive change on a cognitive test composite score. Secondary outcomes include: 1) improvement in targeted risk factors, 2) individual cognitive domain composite scores, 3) physical performance, 4) functional ability, 5) quality of life, and 6) incidence of mild cognitive impairment, AD, and dementia. Primary and secondary outcomes will be assessed in both groups at baseline and 6, 12, 18, and 24 months.

Participation in Older Adult Physical Activity Programs and Risk for Falls Requiring Medical Care, Washington State, 2005-2011.

INTRODUCTION: Physical activity is known to prevent falls; however, use of widely available exercise programs for older adults, including EnhanceFitness and Silver Sneakers, has not been examined in relation to effects on falls among program participants. We aimed to determine whether participation in EnhanceFitness or Silver Sneakers is associated with a reduced risk of falls resulting in medical care. METHODS: A retrospective cohort study examined a demographically representative sample from a Washington State integrated health system. Health plan members aged 65 or older, including 2,095 EnhanceFitness users, 13,576 Silver Sneakers users, and 55,127 nonusers from 2005 through 2011, were classified as consistent users (used a program ≥2 times in all years they were enrolled in the health plan during the study period); intermittent users (used a program ≥2 times in 1 or more years enrolled but not all years), or nonusers of EnhanceFitness or Silver Sneakers. The main outcome was measured as time-to-first-fall requiring inpatient or out-of-hospital medical treatment based on the International Classification of Diseases, 9th Revision, Clinical Modification, Sixth Edition and E-codes. RESULTS: In fully adjusted Cox proportional hazards models, consistent (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.63-0.88) and intermittent (HR, 0.87; 95% CI, 0.8-0.94) EnhanceFitness participation were both associated with a reduced risk of falls resulting in medical care. Intermittent Silver Sneakers participation showed a reduced risk (HR, 0.93; 95% CI, 0.90-0.97). CONCLUSION: Participation in widely available community-based exercise programs geared toward older adults (but not specific to fall prevention) reduced the risk of medical falls. Structured programs that include balance and strength exercise, as EnhanceFitness does, may be effective in reducing fall risk.

Relationships between sitting time and health indicators, costs, and utilization in older adults.

OBJECTIVE: To examine whether self-reported sitting time is related to various health indicators, health costs, and utilization in adults over age 65. METHODS: A retrospective cross-sectional cohort study was conducted using the electronic health record (EHR) from an integrated health system in Washington State. Members who completed an online health risk assessment (HRA) between 2009 and 2011 (N = 3538) were eligible. The HRA assessed sitting time, physical activity, and health status. Diagnosis codes for diabetes and cardiovascular disease (CVD), height and weight for body mass index (BMI) calculations, health care utilization and health costs were extracted from the EHR. Linear regression models with robust standard errors tested differences in sitting time by health status, BMI category, diabetes and CVD, health costs, and utilization adjusting for demographic variables, BMI, physical activity, and health conditions. RESULTS: People classified as overweight and obese, that had diabetes or CVD, and with poorer self-rated health had significantly higher sitting time (p < .05). Total annual adjusted health care costs were $126 higher for each additional hour of sitting (p < .05; not significant in final models including health conditions). CONCLUSION: Sitting time may be an important independent health indicator among older adults.

Characteristics of older adult physical activity program users.

OBJECTIVES: Physical activity levels are low among older adults. Many Medicare members have access to low-cost programs including Silver Sneakers (SS) and EnhanceFitness (EF) at no additional cost, however, utilization of these programs is low. We aimed to compare characteristics of people using SS and EF to nonusers of these programs to better understand the characteristics of these 2 populations and to guide future physical activity promotion program design. STUDY DESIGN: Cross-sectional. METHODS: We used 2010 and 2011 electronic health records including demographic, health condition, Charlson comorbidity score, healthcare cost and utilization, and SS and EF program utilization data from 37,492 Medicare members from a large integrated health care system. Models were fit using logistic and negative binomial regression adjusting for age, gender, race, ethnicity, BMI category, and primary care clinic location. RESULTS: Compared with nonusers (N = 30,733; 82%), SS users (N = 6200; 16.5%) were younger and less likely to be male, obese, or have diabetes or cardiovascular disease; they also had lower Charlson scores and fewer hospital admissions than nonusers. EF users (N = 721; 2%) were older, were less likely to be male, had lower Charlson scores, and had fewer hospital admissions compared to nonusers. CONCLUSIONS: Low-cost, evidence-based physical activity programs are vastly underused by Medicare members. Our data suggest that targeting more chronically ill and obese older adults for physical activity programs might help improve the reach of existing evidence-based programs.

Barriers to and facilitators of physical activity program use among older adults.

OBJECTIVE: Regular physical activity (PA) is important for maintaining long-term physical, cognitive, and emotional health. However, few older adults engage in routine PA, and even fewer take advantage of programs designed to enhance PA participation. Though most managed Medicare members have free access to the Silver Sneakers and EnhanceFitness PA programs, the vast majority of eligible seniors do not utilize these programs. The goal of this qualitative study was to better understand the barriers to and facilitators of PA and participation in PA programs among older adults. DESIGN: This was a qualitative study using focus group interviews. SETTING: Focus groups took place at three Group Health clinics in King County, Washington. PARTICIPANTS: Fifty-two randomly selected Group Health Medicare members between the ages of 66 to 78 participated. METHODS: We conducted four focus groups with 13 participants each. Focus group discussions were audio-recorded, transcribed, and analyzed using an inductive thematic approach and a social-ecological framework. RESULTS: Men and women were nearly equally represented among the participants, and the sample was largely white (77%), well-educated (69% college graduates), and relatively physically active. Prominent barriers to PA and PA program participation were physical limitations due to health conditions or aging, lack of professional guidance, and inadequate distribution of information on available and appropriate PA options and programs. Facilitators included the motivation to maintain physical and mental health and access to affordable, convenient, and stimulating PA options. CONCLUSION: Older adult populations may benefit from greater support and information from their providers and health care systems on how to safely and successfully improve or maintain PA levels through later adulthood. Efforts among health care systems to boost PA among older adults may need to consider patient-centered adjustments to current PA programs, as well as alternative methods for promoting overall active lifestyle choices.

Integrated medical care management and behavioral risk factor reduction for multicondition patients: behavioral outcomes of the TEAMcare trial.

PURPOSE: The purpose of the study was to compare behavioral outcomes (physical activity, sedentary behavior, smoking cessation, diet) between the intervention and usual care conditions from the TEAMcare trial. METHODS: TEAMcare was a randomized trial among 214 adults with depression and poorly controlled diabetes and/or coronary heart disease that promoted health behavior change and pharmacotherapy to improve health. Behavioral outcomes were measured with the International Physical Activity Questionnaire (physical activity, sitting time) and the Summary of Diabetes Self-Care Activities Measure (smoking, diet, exercise). Poisson regression models among completers (N=185) were conducted adjusting for age, education, smoking status and depression. RESULTS: Intervention participants had more days/week following a healthy eating plan [relative rate=1.2, 95% confidence interval (CI)=1.1-1.4] and more days of participation in 30 min of physical activity (relative rate=1.2, 95% CI=1.1-2.0) compared to usual care. Intervention participants were more likely to meet physical activity guidelines (7.5% increase) compared to usual care (12% decrease; P=.053). CONCLUSION: Diet and activity generally improved for those receiving the intervention, while there were no differences in some aspects of diet (fruit and vegetable and high-fat food intake), smoking status and sitting time between conditions in the TEAMcare trial.