Duke Roybal Center Theme
Mobility is a cornerstone of healthy aging. It encompasses all forms of movement from rolling in bed to walking, completing daily tasks to exercising, and taking a bus to driving. Nearly half of all adults 65 years of age and older — 48% — reported activity limitations that include mobility.1 The impact of mobility limitations extends to physical, mental and social dimensions of health and well-being. Impaired mobility, and also limited mobility without impairment, is associated with poor physical health including cognitive function and many chronic diseases. 2-6 Limited mobility also affects mental health and can result in depression or low mood. Social wellbeing can be negatively affected either in conjunction with low mood or as a result of decreased community participation and social engagement that leads to isolation.7,8 Because aging is associated with functional limitations and disability, the negative effects of limited or impaired mobility are widely studied.9 To advance the science of interventions that address mobility to impact these downstream effects, the Duke Roybal Center will use the WHO International Classification of Functioning, Disability and Health (ICF) to define mobility. Mobility is a domain of activity and participation and can be measured by a person’s capacity (what s/he can do) and performance (what is actually done) in executing a specific task or being involved in a life situation. 10 Applying the ICF framework to define mobility allows us study interventions to address capacity or performance not only at the individual level but also at the institutional service-delivery, community, and societal or policy levels. Duke University has a long history of innovative and translational research addressing mobility to promote older adult independence. For example, our Pepper OAIC collaborators had in the last cycle focused on functional independence and are now studying physical reserve and resilience. Establishing a Roybal Center at Duke University will complement the research in the Pepper center, expand on the research of our Demography and Economics of Aging Center, and create a centralized hub of expertise to stimulate and accelerate behavioral intervention research on aging and mobility.
Justification for the Theme: Mobility
A. The importance of mobility in older adults. With the growth in the population of older adults, there is heightened recognition of the importance of mobility as one critical aspect of maintaining independence and enhancing quality of life. There is also growing agreement that mobility is, among behavioral factors, truly fundamental to active and healthy aging.9 Older adults who are able to initiate and sustain mobility on an everyday basis not only experience a higher quality of life, they also have better health status. Older adults who are mobile are more likely to be able to engage in range of family, social, community, and physical activities that give their lives meaning and value. B. The construct of mobility. One of the most consistent findings is that mobility varies substantial across older adults even among those similar in age or with a similar disease status (e.g., progressive osteoarthritis of the knee).11 One individual with moderate osteoarthritis, for example, might be able to remain active and maintain a rewarding and meaningful lifestyle. Another individual with the same level of osteoarthritis may be restricted to a walker or wheelchair, feel depressed, and develop a sedentary lifestyle in which they are overly dependent on family and friends, and lose a sense of general and health-specific self-efficacy. Conceptual models of mobility shed light on why some older adults are much more mobile than others. The ecological model, for example, views mobility as shaped not only by biological factors (e.g. disease status), but also but behavioral, social, and environmental influences.12 Conceptual approaches that address the challenge of maintaining optimal mobility across the life span are important not only because they help us understand how mobility contributes to independence, but also because they can be used to inform and guide interventions to enhance mobility. For example, they help pinpoint targets for individually-focused behavioral interventions (e.g. engaging in valued activities) and interpersonally focused interventions (e.g. enhancing social support, partner-assisted activity or exercise interventions). Contact PD/PI: Prvu Bettger, Janet Research Strategy Page 144 C. Why is it important to intervene to enhance mobility in older adults? Interventions designed to enhance mobility are important to the nation’s health for a number of reasons.9 First, by becoming more active or simply by moving more each day with fewer limitations, older adults are much more likely to be able to engage in the self-care behaviors needed to remain healthy and remain living independently in the community (e.g. shop for healthy foods, get their medications, keep doctor’s appointments, maintain a health sleep-wake schedule, remain physical fit). Second, with increasing activity come more opportunities to engage in pleasurable and meaningful activities with family, friends, and community members. Third, behavioral activation programs that systematically teach individuals how to increase and maintain a higher level of activity represent one of the most effective (and cost-effective) ways of enhancing self-efficacy and reducing depressive symptoms.13 Finally, improved mobility reduces the risk of falls and other accidents that, in older adults, can cause injuries that lead to hospitalization and early nursing home placement. D. The need for new and refined intervention approaches and programmatic efforts in intervention development. Although there has been progress in interventions to enhance mobility, significant limitations in the existing literature are evident. • The link between basic theory on behavior change and existing interventions could be much stronger. Using theory to identify the underlying mechanisms of behavior change in mobility interventions not only could enhance our understanding of how these mechanisms operate, it could also guide refinement of the interventions themselves. • Although the need is already acute and is growing, there are relatively few nationally funded programs of intervention research to enhance mobility and associated psychosocial and health outcomes in older adults. There is a clear need for programmatic research in which the findings of one study inform the next study (e.g. focus groups to assess needs, small pilot studies to customize the intervention, feasibility and acceptability studies, efficacy trials, and larger scale effectiveness studies). Applying the NIH Stage Model as a framework for translation could improve the rigor of research and accelerate translation. • There has been too little attention on how to boost the effectiveness of interventions as they are being brought to scale, e.g. by identifying the most effective ingredients so as to streamline intervention and make it more readily available to the large number of older adults who might benefit. • Interventions are not always developed in a way that enables them to be implementable, i.e. to be delivered in real-world settings by providers or institutions in the community. • Although improving mobility can have powerful effects on the health of older adults, very few older adults actually receive or participate in empirically validated interventions to enhance their mobility. Although aging researchers and behavioral scientists have significant background and experience in behavioral and social approaches to understanding mobility, to our knowledge, there are very few systematic, cross-disciplinary programs specifically designed to foster the practical skills needed to develop and test effective and implementable behavioral and social interventions to enhance mobility in older adults.