Long-term effect on mortality of a home intervention that reduces functional difficulties in older adults: results from a randomized trial.

OBJECTIVES: To evaluate the long-term mortality effect of a home-based intervention previously shown to reduce functional difficulties and whether survivorship benefits differ according to initial mortality risk level. DESIGN: Two-group randomized trial with survivorship followed up to 4 years from study entry. SETTING: Homes of urban community-living elderly people. PARTICIPANTS: Three hundred nineteen adults aged 70 and older with difficulties performing daily activities. INTERVENTION: Occupational and physical therapy sessions to instruct participants in compensatory strategies, home modifications, home safety, fall recovery techniques, and balance and muscle strength exercises. MEASUREMENTS: Survival time was number of days between baseline interview and date of death, as determined using data from the National Death Index or December 31, 2005. Participants were stratified according to baseline mortality risk (low, moderate, high) using a prognostic indicator. RESULTS: At 2 years, intervention participants (n=160) had a 5.6% mortality rate (n=9 deaths) and controls (n=159) a 13.2% rate (n=21 deaths; P=.02). Mortality rates remained lower for intervention participants up to 3.5 years from study entry. At 2 years, intervention participants with moderate mortality risk had a 16.7% mortality rate (n=16 deaths/96), compared with 28.2% for equivalent control group participants (n=24 deaths/85; P=.02). By 3 years, mortality rates were not statistically significantly different between the experimental and control groups. CONCLUSIONS: The intervention extended survivorship up to 3.5 years and maintained statistically significant differences for 2 years. Subjects at moderate mortality risk derived the most intervention benefit. Findings suggest that the intervention could be a low-cost clinical tool to delay functional decline and mortality.

A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults.

OBJECTIVES: To test the efficacy of a multicomponent intervention to reduce functional difficulties, fear of falling, and home hazards and enhance self-efficacy and adaptive coping in older adults with chronic conditions. DESIGN: A prospective, two-group, randomized trial. Participants were randomized to a treatment group or no-treatment group. SETTING: Urban community-living older people. PARTICIPANTS: Three hundred nineteen community-living adults aged 70 and older who reported difficulty with one or more activities of daily living. INTERVENTION: Occupational and physical therapy sessions involving home modifications and training in their use; instruction in strategies of problem-solving, energy conservation, safe performance, and fall recovery techniques; and balance and muscle strength training. MEASUREMENTS: Outcome measures included self-rated functional difficulties with ambulation, instrumental activities of daily living, activities of daily living, fear of falling, confidence performing daily tasks, and use of adaptive strategies. Observations of home hazards were also conducted. RESULTS: At 6 months, intervention participants had less difficulty than controls with instrumental activities of daily living (P=.04, 95% confidence interval (CI)=-0.28-0.00) and activities of daily living (P=.03, 95% CI=-0.24 to -0.01), with largest reductions in bathing (P=.02, 95% CI=-0.52 to -0.06) and toileting (P=.049, 95% CI=-0.35-0.00). They also had greater self-efficacy (P=.03, 95% CI=0.02-0.27), less fear of falling (P=.001, 95% CI=0.26-0.96), fewer home hazards (P=.05, 95% CI=-3.06-0.00), and greater use of adaptive strategies (P=.009, 95% CI=0.03-0.22). Benefits were sustained at 12 months for most outcomes. CONCLUSION: A multicomponent intervention targeting modifiable environmental and behavioral factors results in life quality improvements in community-dwelling older people who had functional difficulties, with most benefits retained over a year.

Effects of the home environmental skill-building program on the caregiver-care recipient dyad: 6-month outcomes from the Philadelphia REACH Initiative.

PURPOSE: We examine 6-month effects of the Environmental Skill-Building Program on caregiver well-being and care recipient functioning and whether effects vary by caregiver gender, race (White or non-White), and relationship (spouse or nonspouse). DESIGN AND METHODS: We enrolled 255 family caregivers of community-residing persons with Alzheimer's disease or related disorders, of whom 190 participated in a follow-up interview. Caregivers were randomized to a usual care control group or intervention group that received five home contacts and one telephone contact by occupational therapists, who provided education, problem-solving training, and adaptive equipment. Baseline and 6-month follow-up included self-report measures of caregiver objective and subjective burden, caregiver well-being, and care recipient problem behaviors and physical function. RESULTS: Compared with controls (n = 101), intervention caregivers (n = 89) reported less upset with memory-related behaviors, less need for assistance from others, and better affect. Intervention spouses reported less upset with disruptive behaviors; men reported spending less time in daily oversight; and women reported less need for help from others, better affect, and enhanced management ability, overall well-being, and mastery relative to control group counterparts. Statistically significant treatment differences were not found for hours helping with instrumental activities of daily living, upset with providing assistance with instrumental activities of daily living and activities of daily living, perceived change in somatic symptoms, White versus non-White caregivers, or care recipient outcomes. IMPLICATIONS: The Environmental Skill-Building Program reduces burden and enhances caregiver well-being in select domains and has added benefit for women and spouses.

Strategies used by families to simplify tasks for individuals with Alzheimer's disease and related disorders: psychometric analysis of the Task Management Strategy Index (TMSI).

PURPOSE: Little is known about the specific behavioral strategies used by families to manage the physical dependency of persons with Alzheimer's disease and related disorders (ADRD). This study reports the psychometric properties of the Task Management Strategy Index (TMSI), a measure designed to identify actions taken by caregivers to simplify everyday self-care tasks for persons with ADRD. Relationships between use of these strategies and caregiver and care-recipient characteristics were also examined. DESIGN AND METHODS: A pool of 20 items was developed and initially tested with 202 family caregivers (Sample 1) recruited for a dementia-management intervention study. Principal axis factor analysis was performed to determine scale structure. Convergent and discriminant evidence was examined using Pearson cor-relation and multiple regression analyses with a separate sample of 255 family caregivers (Sample 2) recruited for the Philadelphia site of the National Institutes of Health multisite initiative, Resources for Enhancing Alzheimer's Caregiver Health. RESULTS: Exploratory principal axis factoring yielded one general factor accounting for 60.2% of variance in the first sample. Nineteen items, loading at.3 or above, constituted the final scale (Cronbach's alpha =.81 in Sample 1 and.74 in Sample 2). In Sample 2, TMSI scores were significantly associated with greater functional dependency of ADRD patients, high self-efficacy, and greater use of positive coping strategies. As expected, caregiver upset with disruptive behaviors and caregiver use of criticism-based strategies were not associated with TMSI scores. Higher caregiver education was significantly associated with greater use of task strategies. IMPLICATIONS: Results provide preliminary evidence that the TMSI is an easily administered, reliable, valid scale. Caregivers with lower education may benefit from instruction in the use of these strategies.