Advertisement

Improving Social Connectedness for Homebound Older Adults: Randomized Controlled Trial of Tele-Delivered Behavioral Activation Versus Tele-Delivered Friendly Visits

Published:March 02, 2020DOI:https://doi.org/10.1016/j.jagp.2020.02.008

      Highlights

      • Would lay-coach-facilitated Tele-BA be more effective than Tele-FV in increasing social connectedness among socially isolated and lonely homebound older adults?
      • Both Tele-BA and Tele FV were highly acceptable to participating older adults.
      • Tele-BA was more effective than Tele-FV in improving social connectedness and decreasing depressive symptoms and disability.
      • Short-term Tele-BA by lay providers is a promising intervention for the growing number of homebound older adults.

      ABSTRACT

      Objective

      To test the acceptability and effectiveness of a lay-coach-facilitated, videoconferenced, short-term behavioral activation (Tele-BA) intervention for improving social connectedness among homebound older adults.

      Methods

      We employed a two-site, participant-randomized controlled trial with 89 older adults (averaging 74 years old) who were recipients of, and initially screened by, home-delivered meals programs. All participants reported loneliness; many reported being socially isolated and/or dissatisfaction with social support. Participants received five weekly videoconference sessions of either Tele-BA or Tele-FV (friendly visits; active control). Three primary outcomes were social interaction (Duke Social Support Index [DSSI] Social Interaction Subscale), subjective loneliness (PROMIS Social Isolation Scale), and DSSI Satisfaction with Social Support Subscale. Depression severity (PHQ-9) and disability (WHODAS 2.0) were secondary outcomes. Mixed-effects regression models were fit to evaluate outcomes at 6- and 12-weeks follow-up.

      Results

      Compared to Tele-FV participants, Tele-BA participants had greater increase in social interaction (t [81] = 2.42, p = 0.018) and satisfaction with social support (t [82] = 2.00, p = 0.049) and decrease in loneliness (t [81] = −3.08, p = 0.003), depression (t [82] = −3.46, p = 0.001), and disability (t [81] = −2.29, p = 0.025).

      Conclusion

      A short-term, lay-coach-facilitated Tele-BA is a promising intervention for the growing numbers of homebound older adults lacking social connectedness. The intervention holds promise for scalability in programs that already serve homebound older adults. More research is needed to solidify the clinical evidence base, cost-effectiveness and sustainability of Tele-BA delivered by lay coaches for homebound and other older adults.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Geriatric Psychiatry
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Durkheim E
        Suicide: A Study in Sociology.
        The Free Press, New York1897 (1951). ISBN 0-684-83632-7
        • Berkman LF
        • Glass T
        • Brissette I
        • et al.
        From social integration to health: Durkheim in the new millennium.
        Soc Sci Med. 2000; 51: 843-857
        • Cacioppo JT
        • Hawkley LC
        • Thisted RA
        Perceived social isolation makes me sad: 5-year cross-lagged analyses of loneliness and depressive symptomatology in the Chicago Health, Aging, and Social Relations Study.
        Psychol Aging. 2010; 25: 453-463https://doi.org/10.1037/a00117216
        • Cornwell EY
        • Waite LJ
        Social disconnectedness, perceived isolation, and health among older adults.
        J Health Soc Behav. 2009; 50: 31-48
        • Courtin E
        • Knapp M
        Social isolation, loneliness and health in old age: a scoping review.
        Health Soc Care Community. 2017; 25: 799-812https://doi.org/10.1111/hsc.12311
        • Donovan NJ
        • Wu Q
        • Dorene M
        • et al.
        Loneliness, depression and cognitive function in older U.S. adults.
        Int J Geriatr Psychiatry. 2017; 32: 564-573
        • Shankar A
        • McMunn A
        • Demakakos P
        • et al.
        Social isolation and loneliness: prospective associations with functional status in older adults.
        Health Psychol. 2017; 36: 179-187https://doi.org/10.1037/hea0000437
        • Shaw JG
        • Farid M
        • Noel-Miller C
        • et al.
        Social isolation and Medicare spending: among older adults, objective social isolation increases expenditures while loneliness does not.
        J Aging Health. 2017; 29: 1119-1143https://doi.org/10.1177/0898264317703559
        • Steptoe A
        • Shankar A
        • Demakakos P
        • et al.
        Social isolation, loneliness, and all-cause mortality in older men and women.
        Proc Natl Acad Sci U S A. 2013; 110: 5797-5801https://doi.org/10.1073/pnas.1219686110
        • Valtorta NK
        • Moore DC
        • Barron L
        • et al.
        Older adults’ social relationships and health care utilization: a systematic review.
        Am J Public Health. 2018; 108: e1-e10https://doi.org/10.2105/AJPH.2017.304256
        • Hughes ME
        • Waite LJ
        • Hawkley LC
        • et al.
        A short scale for measuring loneliness in large surveys: results from two population-based studies.
        Res Aging. 2004; 26: 655-672
        • AARP Foundation
        A national survey of adults 45 and older: Loneliness and social connections.
        2018 (Available at:) (Accessed November 15, 2019)
        • Rosso AL
        • Taylor JA
        • Tabb LP
        • et al.
        Mobility, disability, and social engagement in older adults.
        J Aging Health. 2013; 25: 617-637https://doi.org/10.1177/0898264313482489
        • Meek KP
        • Bergeron CD
        • Towne SD
        • et al.
        Restricted social engagement among adults living with chronic conditions.
        Int J Environ Res Public Health. 2018; 15https://doi.org/10.3390/ijerph15010158
        • Szanton SL
        • Roberts L
        • Leff B
        • et al.
        Home but still engaged: participation in social activities among the homebound.
        Qual Life Res. 2016; 25: 1913-1920https://doi.org/10.1007/s11136-016-1245-2
        • Xiang X
        • Chen J
        • Kim M
        Trajectories of homebound status in Medicare beneficiaries aged 65 and older.
        Gerontologist. 2020; 60: 101-111https://doi.org/10.1093/geront/gnz023
        • Musich S
        • Wang SS
        • Hawkins K
        • et al.
        Homebound older adults: prevalence, characteristics, health care utilization and quality of care.
        Geriatr Nurs. 2015; 36: 445-450https://doi.org/10.1016/j.gerinurse.2015.06.013
        • Cohen-Mansfield J
        • Perach R
        Interventions for alleviating loneliness among older persons: a critical review.
        Am J Health Promot. 2015; 29: e109-e125https://doi.org/10.4278/ajhp.130418-LIT-182
        • Gardiner C
        • Geldenhuys G
        • Gott M
        Interventions to reduce social isolation and loneliness among older people: an integrative review.
        Health Soc Care Community. 2018; 26: 147-157https://doi.org/10.1111/hsc.12367
        • Choi NG
        • Wilson NL
        • Sirrianni L
        • et al.
        Acceptance of home-based telehealth problem-solving therapy for depressed, low-income homebound older adults: qualitative interviews with the participants and aging-service case managers.
        Gerontologist. 2014; 54: 704-713https://doi.org/10.1093/geront/gnt083
        • Institute of Medicine
        The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?.
        The National Academies Press, 2012 (Available at:) (Accessed July 2013)
        • Freshour JS
        • Amspoker AB
        • Yi M
        • et al.
        Cognitive behavior therapy for late-life generalized anxiety disorder delivered by lay and expert providers has lasting benefits.
        Int J Geriatr Psychiatry. 2016; 31: 1225-1232https://doi.org/10.1002/gps.4431
        • Dias A
        • Azariah F
        • Anderson SJ
        • et al.
        Effect of a lay counselor intervention on prevention of major depression in older adults living in low- and middle-income countries: a randomized clinical trial.
        JAMA Psychiatry. 2019; 76: 13-20https://doi.org/10.1001/jamapsychiatry.2018.3048
        • Kroenke K
        • Spitzer RL
        • Williams JB
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-813
        • Katzman R
        • Brown T
        • Fuld P
        • et al.
        Validation of a short orientation-memory-concentration test of cognitive impairment.
        Am J Psychiatry. 1983; 140: 734-739
        • Lejuez CW
        • Hopko DR
        • Hopko SD
        A brief behavioral activation treatment for depression. Treatment manual.
        Behav Modif. 2001; 25: 255-286
        • Lejuez CW
        • Hopko DR
        • Acierno R
        • et al.
        Ten year revision of the brief behavioral activation treatment for depression: revised treatment manual.
        Behav Modif. 2011; 35: 111-161https://doi.org/10.1177/0145445510390929
        • Mulligan MA
        • Bennett R
        Assessment of mental health and social problems during multiple friendly visits: the development and evaluation of a friendly visiting program for the isolated elderly.
        Int J Aging Hum Dev. 1977-1978; 8: 43-65
        • Barber JP
        • Stratt R
        • Halperin G
        • et al.
        Supportive techniques: are they found in different therapies?.
        J Psychother Pract Res. 2001; 10: 165-172
      1. ALSWH Data Dictionary Supplement Section 2 Core Survey Dataset; 2.7 Psychosocial Variables; Duke Social Support Index (DSSI). 2004.

      2. Patient-Reported Outcomes Measurement Information System. Social isolation: A brief guide to the PROMIS Social Isolation instruments. Available at:http://www.healthmeasures.net/images/PROMIS/manuals/PROMIS_Social_Isolation_Scoring_Manual.pdf. Accessed April 2, 2017

        • Goodger B
        • Byles J
        • Higganbotham N
        • et al.
        Assessment of a short scale to measure social support among older people.
        Aust N Z J Public Health. 1999; 23: 260-265
        • Simonsick EM
        • Kasper JD
        • Phillips CL
        Physical disability and social interaction: factors associated with low social contact and home confinement in disabled older women (The Women's Health and Aging Study).
        J Gerontol B Psychol Sci Soc Sci. 1998; 53: S209-S217
      3. World Health Organization. WHODAS 2.0. Available at:https://www.who.int/classifications/icf/whodasii/en/index3.html. Accessed April 3, 2017

        • Choi NG
        • Teeters M
        • Perez L
        • et al.
        Severity and correlates of depressive symptoms among recipients of meals in wheels: age, gender, and racial/ethnic difference.
        Aging Ment Health. 2010; 14: 145-154https://doi.org/10.1080/13607860903421078
        • Gelman A
        • Hill J
        Data Analysis Using Regression and Multilevel/Hierarchical Models.
        Cambridge University Press, New York, NY2007
        • Raudenbush SW
        • Bryk AS
        Hierarchical Linear Models: Applications and Data Analysis Methods.
        Sage, Thousand Oaks, CA2001
        • Bates D
        • Maechler M
        • Bolker B
        • et al.
        lme4: Linear Mixed-Effects Models Using 'Eigen' and S4.
        2019 (Available at:) (Accessed October 1, 2019)
        • Kuznetsova A
        • Brockhoff PB
        • Christensen RHB
        lmerTest: Tests in Linear Mixed Effects Models.
        2015 (Available at:) (Accessed October 1, 2019)
        • Rosseel Y
        lavaan: An R package for structural equation modeling.
        J Stat Softw. 2012; 48: 1-36https://doi.org/10.18637/jss.v048.i02
        • Feingold A
        Effect sizes for growth-modeling analysis for controlled clinical trials in the same metric as for classical analysis.
        Psychol Method. 2009; 14: 43-53
        • Grabovich A
        • Lu N
        • Tang W
        • et al.
        Outcomes of subsyndromal depression in older primary care patients.
        Am J Geriatr Psychiatry. 2010; 18: 227-235https://doi.org/10.1097/JGP.0b013e3181cb87d6
        • Bruce ML
        • Ten Have T
        • Reynolds CF
        • et al.
        A randomized trial to reduce suicidal ideation and depressive symptoms in depressed older primary care patients: The PROSPECT Study.
        JAMA. 2004; 291: 1081-1091
        • Bruce ML
        • Raue PJ
        • Reilly CF
        • et al.
        Clinical effectiveness of integrating depression care management into medical home health: the Depression CAREPATH cluster-randomized trial.
        JAMA Intern Med. 2015; 175: 55-64https://doi.org/10.1001/jamainternmed.2014.5835
      4. (Edited by)
        • Peplau LA
        • Perlman D
        Perspectives on loneliness.
        in: Peplau LA Perlman D Loneliness: A Sourcebook of Current Theory, Research and Therapy. Wiley, New York1982: 1-8 (Edited by)
        • Sirey JA
        • Franklin AJ
        • McKenzie SE
        • et al.
        Race, stigma, and mental health referrals among clients of aging services who screened positive for depression.
        Psychiatr Serv. 2014; 65: 537-540