In the Eyes of Those Who Were Randomized: Perceptions of Disadvantaged Older Adults in a Tai Chi Trial.

BACKGROUND AND OBJECTIVES: Older adults living in subsidized housing have typically been excluded from exercise intervention studies. We conducted a qualitative study to explore the perceived physical, psychological, social, and economic factors that influenced participation in and adherence to a year-long Tai Chi intervention within an ongoing cluster-randomized controlled trial (RCT) for older adults living within subsidized housing facilities. RESEARCH DESIGN AND METHODS: Focus groups were held with participants of the RCT who were allocated to the trial's Tai Chi intervention. Individual phone interviews were conducted with those allocated to Tai Chi who had low adherence or who had withdrawn their participation from the study. Emergent themes were extracted using grounded-theory methods. RESULTS: In this qualitative study, we enrolled 41 participants who were allocated to the RCT's Tai Chi intervention: 38 completed and 3 withdrew from the study. Average Tai Chi class attendance was 64.3%. Pragmatic factors that led to higher adherence and retention included: locating classes within each facility; providing programs at no cost; and deployment of a skilled research support team. In addition, the use of an accessible, simplified Tai Chi program improved confidence, social support, self-efficacy, and self-reported improvements in physical and psychological well-being. DISCUSSION AND IMPLICATIONS: Perceived physical, psychological, social benefits, and self-efficacy likely enhance adherence and retention to research-based Tai Chi interventions for older adults. Delivering an on-site, no cost, and supportive program appears critical to overcoming financial and environmental barriers to participation for those living within subsidized housing.

The Mind Body-Wellness in Supportive Housing (Mi-WiSH) study: Design and rationale of a cluster randomized controlled trial of Tai Chi in senior housing.

Supporting the health of growing numbers of frail older adults living in subsidized housing requires interventions that can combat frailty, improve residents' functional abilities, and reduce their health care costs. Tai Chi is an increasingly popular multimodal mind-body exercise that incorporates physical, cognitive, social, and meditative components in the same activity and offers a promising intervention for ameliorating many of the conditions that lead to poor health and excessive health care utilization. The Mind Body-Wellness in Supportive Housing (Mi-WiSH) study is an ongoing two-arm cluster randomized, attention-controlled trial designed to examine the impact of Tai Chi on functional indicators of health and health care utilization. We are enrolling participants from 16 urban subsidized housing facilities (n=320 participants), conducting the Tai Chi intervention or education classes and social calls (attention control) in consenting subjects within the facilities for one year, and assessing these subjects at baseline, 6months, and 1year. Physical function (quantified by the Short Physical Performance Battery), and health care utilization (emergency visits, hospitalizations, skilled nursing and nursing home admissions), assessed at 12months are co-primary outcomes. Our discussion highlights our strategy to balance pragmatic and explanatory features into the study design, describes efforts to enhance site recruitment and participant adherence, and summarizes our broader goal of post study dissemination if effectiveness and cost-effectiveness are demonstrated, by preparing training and protocol manuals for use in housing facilities across the U.S.

Functional implications of muscle co-contraction during gait in advanced age.

Older adults often exhibit high levels of lower extremity muscle co-contraction, which may be the cause or effect of age-related impairments in gait and associated falls. Normal gait requires intact executive function and thus can be slowed by challenging executive resources available to the neuromuscular system through the performance of a dual task. We therefore investigated associations between lower limb co-contraction and gait characteristics under normal and dual task conditions in healthy older adults (85.4±5.9years). We hypothesized that greater co-contraction is associated with slower gait speed during dual task conditions that stress executive and attentional abilities. Co-contraction was quantified during different phases of the gait cycle using surface electromyography (EMG) signals obtained from the anterior tibialis and lateral gastrocnemius while walking at preferred speed during normal and dual task conditions. Variables included the time difference to complete the Trail Making Test A and B (ΔTMT) and gait measures during normal or dual task walking. Higher co-contraction levels during the swing phase of both normal and dual task walking were associated with longer ΔTMT (normal: R2=0.25, p=0.02; dual task: R2=0.27, p=0.01). Co-contraction was associated with gait measures during dual task walking only; greater co-contraction levels during stride and stance were associated with slower gait speed (stride: R2=0.38, p=0.04; stance: R2=0.38, p=0.04), and greater co-contraction during stride was associated with longer stride time (R2=0.16, p=0.03). Our results suggest that relatively high lower limb co-contraction may explain some of the mobility impairments associated with the conduct of executive tasks in older adults.

Functional benefits of tai chi training in senior housing facilities.

OBJECTIVES: To determine the effects of tai chi training on functional performance and walking with and without the addition of the performance of a cognitive task, in older adults living in supportive housing facilities. DESIGN: Secondary data analysis comparing a single-blind, randomized controlled trial of tai chi training with an attention-matched educational control intervention with crossover to tai chi. SETTING: Two supportive housing facilities. PARTICIPANTS: Sixty-six men and women living in supportive housing facilities entered the study, and 57 aged 87±7 completed all study procedures. INTERVENTION: Interventions consisted of two 1-hour-long instructor-led group sessions per week for 12 weeks. Tai chi training consisted of movements based upon the Yang-style short form. Educational sessions consisted of lectures and discussions of age-related health topics. MEASUREMENTS: Subjects were tested for physical function (Short Physical Performance Battery, SPPB), balance (Berg Balance Scale, BBS), mobility (timed up-and-go, TUG), and walking speed under normal and cognitive dual-task conditions. RESULTS: The tai chi group exhibited greater improvement in SPPB scores (baseline 8.1±2.9, follow-up 9.0±2.6) than controls (baseline 8.2±2.6, follow-up 8.2±2.6) (P=.005). Tai chi also increased normal and dual-task walking speed (P<.001) yet did not affect BBS (P=.02) or TUG (P=.02) after accounting for multiple comparisons. The dual-task cost (percentage change) to walking speed was unaffected. After the crossover tai chi intervention, the control group improved performance in the SPPB, BBS, and TUG, and increased walking speed under normal and dual-task conditions (P=.008). CONCLUSION: Tai chi training may be a safe and effective therapy to help improve physical function and dual-task walking in very old adults living in supportive housing facilities.

Optimizing the tracking of falls in studies of older participants: comparison of quarterly telephone recall with monthly falls calendars in the MOBILIZE Boston Study.

Tracking falls among elders is challenging. In this reliability study, which took place between October 2007 and February 2008, the authors compared participants' daily recordings of falls on calendars with a telephone survey of recall of falls over the previous 3 months within the population-based MOBILIZE Boston Study cohort, a cohort of 765 elders. From the cohort, 218 participants were randomly selected. Falls were tracked prospectively on daily calendars (mailed back monthly). Telephone recalls of falls over the previous 3 months were conducted in January and February 2008. Agreement, sensitivity, and specificity were calculated to compare the occurrence of falls as determined by 3-month recall with falls recorded by daily calendar (gold standard) during the same 3-month period. Results showed good agreement between recall and calendars: 27 persons reported a fall by both methods. However, while the 3-month recall correctly classified persons who did not fall (164 persons by both methods), it missed 25% of participants who fell (of 36 participants with a calendar-reported fall, 9 did not report a fall by telephone recall). Kappa was 0.74 (95% confidence interval: 0.68, 0.80), sensitivity was 75%, and specificity was 96%. Retrospective 3-month recall of falls resulted in underreporting of falls by as much as 25% compared with daily calendars. Calendars should be considered the preferred method of ascertaining falls in longitudinal studies.

Issues in conducting epidemiologic research among elders: lessons from the MOBILIZE Boston Study.

Conducting research in elderly populations is important, but challenging. In this paper, the authors describe specific challenges that have arisen and solutions that have been used in carrying out The MOBILIZE Boston Study, a community-based, prospective cohort study in Massachusetts focusing on falls among 765 participants aged 70 years or older enrolled during 2005-2007. To recruit older individuals, face-to-face interactions are more effective than less personal approaches. Use of a board of community leaders facilitated community acceptance of the research. Establishing eligibility for potential participants required several interactions, so resources must be anticipated in advance. Assuring a safe and warm environment for elderly participants and offering a positive experience are a vital priority. Adequate funding, planning, and monitoring are required to provide transportation and a fully accessible environment in which to conduct study procedures as well as to select personnel highly skilled in interacting with elders. It is hoped that this paper will encourage and inform future epidemiologic research in this important segment of the population.