Older adults living in low-income communities face tremendous economic and health-related challenges that diminish their ability to ‘age in place’ [30]. Insufficient access to care, particularly in rural areas, exacerbates these challenges and their effects on health. Advances in technology may help to overcome these barriers through increased access to integrated mHealth and physical health interventions focused on improving mood, mobility, and overall well-being [31] that negatively affect ‘aging in place’. The present pilot study examined the feasibility of introducing varied levels of integration for existing interventions addressing physical [32], functional [33], and psychological [34] factors that might help independently residing, albeit resource-poor older adults, successfully age in place. We hypothesized that this integrated treatment would not only satisfy our feasibility criteria related to recruitment, enrollment, and retention, but would also be viewed as particularly welcome when delivered via telemedicine, with patients reporting high satisfaction with the program. Our results support the feasibility of the mHealth-delivered intervention and its component parts, insofar as lower income older adults agreed to be randomized to condition, accept conditions of treatment components, and complete 6 or more sessions. Satisfaction with the mHealth component of the Activate for Life intervention was also high.
Overall, about three quarters of study participants reported high satisfaction with the OG physical exercise components of treatment, while participants reporting severe pain were more likely to drop out of the study. Experience with the iPad varied widely within the arms of this study. The main complaints were not related to the technology per se, but rather how the technology was performing due to connectivity issues such as poor Wi-Fi signal for some of the participants. This prevented a few participants from full participation in the televideo sessions or made operating the mHealth app more cumbersome (i.e., the activity tracker would not synchronize with the app or videos would run slower or with pauses). Indeed, participants did enjoy using the blood pressure monitor and were more tolerant when experiencing technical issues with this device because they clearly understood that the information it provided was important (note, the majority of these patients were taking antihypertensive medications). This underscores the importance of clearly explaining why certain devices and exercises are being used in the study to participants, since insufficient information combined with technical difficulties resulted in frustration.
Impressively, many of those who completed treatment reported that they continued to perform the exercises they had learned after they finished the study, with at least twice a week engagement in those activities. Exercise routines for older adults may require more than 12 weeks of training, particularly if the exercises are new [35, 36]. Some evidence indicates that older adults feel more comfortable doing things they enjoy and have already experienced in the past [37], so interventions that modify existing exercise patterns are likely advisable for increasing adherence to physical regimens in this patient population. Another positive observation was the enthusiasm reported by the older adults who learned that other people in their community were participating in the study. Social support and social connection are highly important for all age groups but may be particularly so for older adults engaging in novel activities to sustain motivation [38]. Because most activities were conducted individually and within the home, we might have increased satisfaction and retention if we had included opportunities to engage in treatment components with other participants, perhaps virtually and in group settings.
Study Limitations / Identified Issues of Treatment Implementation. Limitations of this study include its small sample size, limited representation of participants from minority and rural populations, limited follow-up periods post intervention, and issues with technology in terms of internet connectivity. We encountered problems that were related to the community-based nature of our implementation, including issues of internet connectivity. This issue seemed to drive dropout, despite the fact that the study team tried to provide solutions for connectivity issues. Because the Otago component of the treatment is more commonly used in residential settings [31], it will be important to anticipate and prevent these problems in future studies with lower-income older adults to avoid negative experiences or discontinuation.
We also perceived that our participants may not have been able to form fully effective therapeutic relationships with our young therapists in Arm 3 to the extent that an older provider might have. Indeed, participants expressed this to our therapists and noted the large gap in age (of about 50 years). The preference of older adults with respect to matching with a provider similar to themselves appeared to extend beyond age, to also include preferences for matching in terms of appearance, gender and culture. Specifically, a recurring theme our team noted was participant lack of engagement with the GYYB component of treatment and with Behavioral Activation therapists. As this was a small, localized sample with limited representation of older adults, we believe that engagement may vary depending on the region of the country. Future considerations should include assurances that exercises are presented considering age, gender and cultural background similar to the specific target sample, to increase engagement with the activity.
The COVID-19 pandemic and subsequent public health advisory restrictions made it particularly difficult for older adults to engage with study personnel. The justifiable concern of older adults regarding close contact with study personnel such as during visits for resolving technical issues, or saliva sample collection was a major issue. Nonetheless, both the research team and participants showed extraordinary motivation to complete measures and to overcome these obstacles/restrictions, particularly concerning saliva sample collection (for example, use of additional protective gear). We believe this indicates that, under normal conditions, far fewer difficulties would be encountered. Unrelated to this, another limitation was underrepresentation of minority groups. Better representation would have been preferable.
Implications for Physical, Functional and Behavioral Health. Future studies of sufficient sample size should address lessons learned in this feasibility study, particularly with respect to attention to cultural / geographical issues, broadband connectivity issues, and efforts to increase social interaction during treatment components. Consideration of cultural and age representation, and appropriate language, for instance, using simpler wording to refer to activities for breathing or to support mood in video and print / tablet applications may increase engagement, participation, and adherence to treatment. Peers may also be a useful addition to treatment components and can help to address many of the aforementioned issues, such as resolving technical issues (to avoid frustration), personal contact to motivate oneself to complete the activities, or seeing/interacting with people they know in their community who successfully have completed treatment or know how to do the most challenging activities such as the GYYB or following the planned activities of Behavioral Activation. Finally, as pain was reportedly related to dropout in this small sample, future studies should consider implementing integrated strategies to address pain in combination with components of the Activate for Life treatment to increase retention. As COVID-19 was an unexpected event that challenged participants, research teams, and housing agencies, high levels of innovation and flexibility were brought to bear, and these modifications, along with mHealth and telehealth may help address the challenges noted in delivering this type of multidimensional treatment to older adults.