Rebecca T. Brown’s research while affiliated with University of Pennsylvania and other places

Aging is associated with gradual mobility decline, often undetected until it affects daily life. This study investigates the potential of smartphone-based accelerometry to detect early age-related changes in gait and stair performance in middle-aged adults. Eighty-eight healthy participants were divided into four age groups: young (20–35 years), early middle-aged (45–54 years), late middle-aged (55–65 years), and older adults (65–80 years). They completed single-task, cognitive, and physical dual-task gait assessments and stair negotiation tests. While single-task walking did not reveal early changes, cognitive dual-task cost (DTC) of stride time variability deteriorated in late middle age. A strong indicator of early mobility changes was movement similarity, measured using dynamic time warping (DTW), which declined from early middle age for both cognitive DTC and stair negotiation. These findings highlight the potential of smartphone-based assessments, particularly movement similarity, to detect subtle mobility changes in midlife, allowing for targeted interventions to promote healthy aging.

The Tailored Activity Program (TAP), an intervention for people living with dementia (PLWD) and their caregivers, has been shown to reduce behavioral symptoms for PLWD and caregiver burden. While TAP is proven as an evidence-based practice (EBP), it has yet to be implemented at scale. The Department of Veterans Affairs (VA) has prioritized the Age-Friendly Health System (AFHS) initiative, providing an opportunity to test implementation of TAP in a complex healthcare system. We conducted semi-structured pre-implementation interviews with leaders and clinicians at 6 VA Medical Centers (VAMCs) to engage key implementation partners and understand their unique implementation contexts. We utilized team-based rapid qualitative analysis to identify themes related to implementation determinants. We interviewed 65 unique informants in 58 interviews (5 VAMC leaders, 36 department leaders, and 17 frontline clinical staff). Informants identified 4 key factors critical to consider prior to implementing TAP: (1) alignment with organizational priorities; (2) perceived value and fit with existing clinical workflows; (3) competition with existing organizational and clinical priorities; and (4) considerations about the effect of caregiver burden on participation. We identified key factors to consider for successful implementation of a multicomponent intervention for PLWD and their caregivers within a complex healthcare system. As the AFHS initiative expands, there is a growing need for EBPs focused on the care of PLWD and their caregivers. These factors can guide clinicians, leaders, and implementation scientists in planning for implementation and sustainment of EBPs to bolster AFHS initiatives. Trial Registration Registered 05 May 2021, at ISRCTN #60,657,985. Reporting Guidelines The COnsolidated criteria for REporting Qualitative research (COREQ) checklist was used to ensure proper standards for reporting qualitative studies (see attached).

Aging is associated with gradual mobility decline, often undetected until it affects daily life. This study investigates the potential of smartphone-based accelerometry to detect early age-related changes in gait and stair performance in middle-aged adults. Eighty-eight participants were divided into four age groups: young (20-35 years), early middle-aged (45-54 years), late middle-aged (55-65 years), and older adults (65-80 years). They completed single-task, cognitive, and physical dual-task gait assessments and stair negotiation tests. While single-task walking did not reveal early changes, cognitive dual-task cost (DTC) of stride time variability deteriorated in late middle age. A strong indicator of early mobility changes was movement similarity, measured using dynamic time warping (DTW), which declined from early middle age for both cognitive DTC and stair negotiation. These findings highlight the potential of smartphone-based assessments, particularly movement similarity, to detect subtle mobility changes in midlife, allowing for targeted interventions to promote healthy aging.

Background Maintaining functional status, defined as the ability to perform daily activities such as bathing, dressing, and preparing meals, is central to older adults’ quality of life, health, and ability to remain independent. Identifying functional impairments – defined as having difficulty or needing help performing these activities – is essential for clinicians to provide optimal care to older adults, and on a population level, understanding function can help anticipate service needs. Yet uptake of standardized measurement of functional status into routine patient care has been slow and inconsistent due to the burden posed by current tools. The goal of the Patient-Aligned Care Team (PACT) Functional Status Screening Initiative is to implement and evaluate a patient-centered, low-burden intervention to improve identification and management of functional impairment among older veterans in Veterans Health Administration (VHA) primary care settings. Methods We will conduct a hybrid type 2 implementation-effectiveness cluster-randomized adaptive trial at 8 VHA sites using the Practical, Robust Implementation and Sustainability Model (PRISM) to guide implementation and evaluation. During a Pre-Implementation phase, we will engage clinical partners and develop local adaptations to maximize intervention-setting fit. During an Implementation phase, we will launch a standard bundle of implementation strategies (coalition building, champions, technical assistance) and system-level audit and feedback, identify sites with low uptake, and randomize those sites to receive continued standard vs. enhanced strategies (standard strategies plus clinician-level audit and feedback). The primary implementation outcome is reach (proportion of eligible patients at each site who receive screening/assessment) and the primary effectiveness outcome is appropriate management of impairment (proportion of patients with identified impairments who receive related referrals). Discussion Implementing routine measurement of functional status in primary care has the potential to improve identification and management of functional impairment for older veterans. Improved management includes increasing access to services and supports for veterans and family caregivers, reducing potentially preventable acute care utilization, and allowing veterans to live in the least restrictive setting for as long as possible. Implementation will also provide data to inform the delivery of proactive interventions to prevent and delay development of functional impairment and improve quality of life, health, and independence. Trial registration Registered at ClinicalTrials.gov on May 7, 2024, at NCT06404970 (https://clinicaltrials.gov/). Reporting guidelines Standards for Reporting Implementation Studies (Additional file 1).

Background and Objectives The Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program provides rental subsidies, case management, and supportive services to Veterans who are currently or formerly homeless, 77% of whom are aged ≥50. Few interventions have been developed to address the needs of older Veterans in HUD-VASH. Research Design and Methods We conducted a 2-stage study to inform the development of an intervention to promote aging in place in HUD-VASH. First, we completed qualitative interviews with 21 older Veterans in HUD-VASH and focus groups with 13 staff members to identify unmet needs for supporting aging in place. Second, we used a modified Delphi process with 9 staff and 1 Veteran to prioritize 66 intervention elements based on perceived feasibility and importance. Results We identified 4 main themes: need for services to support aging in place, expanding the HUD-VASH workforce, focus on home delivery, and importance of trust. The top-rated intervention elements spanned 5 categories: (1) staffing (by social workers, primary care providers, nurses, home health aides); (2) focus (on geriatric needs, mental health needs, dementia care, medication management); (3) modality (in the home or medical center); (4) timing (delivery of the intervention when Veterans have functional impairment, memory impairment, mental health problems, trouble caring for themselves, or are new to HUD-VASH); and (5) duration (regularly scheduled or ongoing as needed). Discussion and Implications Veterans and staff members identified key intervention elements which can help inform Veterans Affairs (VA) efforts to develop and implement interventions to enhance aging in place in HUD-VASH.

Age-friendly care integrates the 4Ms (what Matters, Medication, Mentation, Mobility) to promote evidence-based care for older adults. The Safer Aging through Geriatrics-Informed Evidence-Based Practices Quality Enhancement Research Initiative (SAGE QUERI) is a hybrid type-III implementation-effectiveness trial comparing an implementation strategy bundle to dissemination as usual. We implemented four evidence-based practices (EBPs) aligned with the 4Ms across 9 VA Medical Centers. We used descriptive statistics and qualitative interviews with 30 implementing clinicians to report mixed-methods outcomes for reach, adoption, implementation, and maintenance across 39 implementation instances. Reach to Veterans varied widely across EBPs: Mobility n=30; Mentation n=37; Medication n=184; what Matters n=8000+. Eligibility criteria impacted reach; clinicians reported the ease of enrolling Veterans in an EBP with wide eligibility (e.g., every Veteran who is a candidate for surgery) versus an EBP with strict eligibility (e.g., “all the moons have to be aligned” to identify/enroll Veterans). Across 39 implementation instances, 77% (n=31) initially adopted the EBP, with a total of 169 clinicians trained (what Matters n=21; Mobility n=29; Medication n=30; Mentation n=89). Clinicians described training requirements, alignment of EBPs with current practices, and organizational support as key factors influencing adoption. Implementation fidelity varied by EBP: 34% what Matters; 80% Mobility; 100% Mentation and Medication. Clinicians noted the wider impact of EBP-related practice changes, including using new skills with Veterans ineligible for the full EBPs. Across 39 implementation instances, 51% (n=20) reached full maintenance; an additional 23% (n=9) achieved implementation. Sites that had successfully integrated EBPs into practice expressed intentions to sustain EBPs.

Background Urgency urinary incontinence (UUI), a risk factor for falls, affects 40% of women over the age of 70 years. Multicomponent interventions have the potential to decrease the risk of falls and urinary symptoms in women. We previously designed and conducted a pilot study of a multicomponent, theory-driven intervention in women with UUI. The Mobility and Voiding Exercises in Older Women with Urinary Incontinence (MoVEonUp) Trial will assess the efficacy of this intervention to decrease falls and urinary incontinence in community-dwelling older women. Methods In the MoVEonUp Trial, 314 women ages ≥ 70 years with UUI will be randomized to the intervention group or an attention control group. Women randomized to the intervention will participate in a home-based multicomponent program consisting of strength and balance training, bladder training with urge suppression strategies, and a home hazard assessment by an occupational therapist. Women in the control group will receive an educational booklet on falls prevention and behavioral treatment for urinary incontinence. Outcomes of falls, urinary incontinence, physical function, functional limitations, and mobility will be measured at 3, 6, 9, and 12 months. Discussion This study will determine if a home-based multicomponent program reduces the risk of falls and improves incontinence among older women with UUI. If the intervention is efficacious, it will help address the critical need to reduce falls in this population via an intervention that can be implemented in the home setting. Clinical trial registration NCT05375344

Objectives Early diagnosis of Alzheimer’s disease (AD) using brain scans and other biomarker tests will be essential to increasing the benefits of emerging disease-modifying therapies, but AD biomarkers may have unintended negative consequences on stigma. We examined how a brain scan result affects AD diagnosis confidence and AD stigma. Methods The study used a vignette-based experiment with a 2×2×3 factorial design of main effects: a brain scan result as positive or negative, treatment availability and symptom stage. We sampled 1,283 adults ages 65 and older between 11 June and 3 July 2019. Participants (1) rated their confidence in an AD diagnosis in each of four medical evaluations that varied in number and type of diagnostic tools and (2) read a vignette about a fictional patient with varied characteristics before completing the Modified Family Stigma in Alzheimer’s Disease Scale (FS-ADS). We examined mean diagnosis confidence by medical evaluation type. We conducted between-group comparisons of diagnosis confidence and FS-ADS scores in the positive versus negative brain scan result conditions and, in the positive condition, by symptom stage and treatment availability. Results A positive versus negative test result corresponds with higher confidence in an AD diagnosis independent of medical evaluation type (all p<0.001). A positive result correlates with stronger reactions on 6 of 7 FS-ADS domains (all p<0.001). Discussion A positive biomarker result heightens AD diagnosis confidence but also correlates with more AD stigma. Our findings inform strategies to promote early diagnosis and clinical discussions with individuals undergoing AD biomarker testing.

Background Nearly 2.9 million older Americans with lower incomes live in subsidized housing. While regional and single‐site studies show that this group has higher rates of healthcare utilization compared to older adults in the general community, little is known about healthcare utilization nationally nor associated risk factors. Methods We conducted a retrospective cohort study of Medicare beneficiaries aged ≥65 enrolled in the National Health and Aging Trends Study in 2011, linked to Medicare claims data, including individuals living in subsidized housing and the general community. Participants were followed annually through 2020. Outcomes were hospitalization, short‐term skilled nursing facility (SNF) utilization, long‐term care utilization, and death. Fine–Gray competing risks regression analysis was used to assess the association of subsidized housing residence with hospitalization and nursing facility utilization, and Cox proportional hazards regression analysis was used to assess the association with death. Results Among 6294 participants (3600 women, 2694 men; mean age, 75.5 years [SD, 7.0]), 295 lived in subsidized housing at baseline and 5999 in the general community. Compared to older adults in the general community, those in subsidized housing had a higher adjusted subdistribution hazard ratio [sHR] of hospitalization (sHR 1.21; 95% CI, 1.03–1.43), short‐term SNF utilization (sHR 1.49; 95% CI, 1.15–1.92), and long‐term care utilization (sHR 2.72; 95% CI, 1.67–4.43), but similar hazard of death (HR, 0.86; 95% CI, 0.69–1.08). Individuals with functional impairment had a higher adjusted subdistribution hazard of hospitalization and short‐term SNF utilization and individuals with dementia and functional impairment had a higher hazard of long‐term care utilization. Conclusions Older adults living in subsidized housing have higher hazards of hospitalization and nursing facility utilization compared to those in the general community. Housing‐based interventions to optimize aging in place and mitigate risk of nursing facility utilization should consider risk factors including functional impairment and dementia.

Despite its importance for clinical care and outcomes among older adults, functional status–the ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)–is seldom routinely measured in primary care settings. The objective of this study was to pilot test a person-centered, interprofessional intervention to improve identification and management of functional impairment among older adults in Veterans Affairs (VA) primary care practices. The four-component intervention included (1) an interprofessional educational session; (2) routine, standardized functional status measurement among patients aged ≥75; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; and (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment. Surveys, semi-structured interviews, and electronic health record data were used to measure implementation outcomes (appropriateness, acceptability and satisfaction, feasibility, fidelity, adoption/reach, sustainability). We analyzed qualitative interviews using rapid qualitative analysis. During the study period, all 959 eligible patients were screened (100% reach), of whom 7.3% (n = 58) reported difficulty or needing help with ≥1 ADL and 11.8% (n = 113) reported difficulty or needing help with ≥1 IADL. In a chart review among a subset of 50 patients with functional impairment, 78% percent of clinician notes for the visit when screening was completed had content related to function, and 48% of patients had referrals ordered to address impairments (e.g., physical therapy) within 1 week. Clinicians highly rated the quality of the educational session and reported increased ability to measure and communicate about function. Clinicians and patients reported that the intervention was appropriate, acceptable, and feasible to complete, even during the COVID pandemic. These findings suggest that this intervention is a promising approach to improve identification and management of functional impairment for older patients in primary care. Broader implementation and evaluation of this intervention is currently underway.