Stay Connected: Testing an Intervention to Combat Coronavirus-related Social Isolation Among Older Adults

Study Overview
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Brief Summary
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This study will use the University of Washington's ALACRITY Center's (UWAC) Discover, Design, Build, & Test (DDBT) method to develop and test an intervention to address the mental health health needs of older adults in senior housing (clients) who are forced to not only shelter-in-place but cannot have family or other visitors during this time. Older people (those over 60 years in age) are especially vulnerable and are more likely to have severe - even deadly - coronavirus infection than other age groups. These facts led to the need to have older adults socially isolate in order to protect their health; visits with family and friends are limited, and in senior housing (independent, supported and assisted care residences) have limited such visits by family to one person a day. This necessary practice of social distancing, while addressing an important public health crisis, unintentionally creates social isolation and loneliness, another deadly epidemic amongst the older population. Even before COVID-19, social isolation and loneliness was a prominent mental health and social problem in the aged, one that is associated with increases in other chronic conditions, dementia and suicide. Effective interventions for social isolation exist but are difficult to access and may not address all the concerns older adults have about this particular period of social isolation. The purpose of this proposed study is to deploy an adaptation of Behavioral Activation Therapy called Stay Connected to treat depression in older adults. The adaptation will allow activity directors and staff (clinicians) in these settings and senior centers to deliver the therapeutic elements of the intervention (behavioral activation) in the context of social distancing/shelter-in-place policies. Social workers in these settings will oversee the activity director and staff delivery of the intervention. The investigators are working with a variety of senior housing types (HUD certified and private systems) and senior centers in Skagit county (rural) and King county (urban) in Washington (WA) so that the resulting intervention is not tied to economic levels or access to digital technology.

Detailed Description
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Clinicians and clients from 6 rural and urban senior communities or senior centers will participate in this study. Senior communities or senior centers will be randomized to receive training and materials in either Stay Connected or a resource guide. The investigators will work with 2 staff from each community or senior center and conduct baseline, 4 week and 9 week assessments with clinicians and 20 clients from each community setting (N=12 clinicians and 120 clients).

Official Title
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Stay Connected: Testing an Intervention to Combat COVID-19 Related Social Isolation Among Seattle-area Older Adults

Conditions
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Depression, Anxiety, Loneliness

Intervention / Treatment
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* Behavioral: Stay Connected
* Behavioral: Treatment as usual


Participation Criteria
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Eligibility Criteria
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Older Adult Participants Inclusion Criteria: 60 years of age or older Physical and cognitive ability to complete interviews by phone or using video-chat technology (e.g., Zoom) English speaking Resident of participating Seattle-area senior living communities or member of Seattle-area senior centers Ability to provide consent Score of 5 or higher on Patient Health Questionnaire (PHQ-9) or score of 5 or higher on Generalized Anxiety Disorder Scale (GAD-7) or score of 6 or higher on University of California Los Angeles (UCLA) Loneliness Scale No suicidal ideation Exclusion Criteria: Under the age of 60 Inability to physically and/or cognitively consent and/or participate in study procedures via phone, computer, and/or video call Non-English speaking Scores below inclusion cut-offs on PHQ-9, GAD-7, and UCLA Loneliness Scale Staff Participants Inclusion Criteria English-speaking Staff members in administration, social work, and/or activities department in Seattle area senior living communities or senior centers Physical ability to complete training in intervention and complete questionnaires by phone, computer, or video-chat technology Exclusion Criteria Non-English speaking Unable to physically or cognitively consent and/or participate in study procedures via phone, computer, and/or video call (e.g., Zoom)

Ages Eligible for Study
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Minimum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Stay Connected<br>Menu-driven set of strategies to combat loneliness, anxiety and depression in older adults | Behavioral: Stay Connected<br>* Stay Connected is a menu-driven set of strategies to combat loneliness, anxiety and depression in older adults based on behavioral activation principles.<br>|
| Active Comparator: Treatment as usual<br>Treatment as usual in these practice settings typically includes regular check-in calls and offering resources and referrals | Behavioral: Treatment as usual<br>* Regular check-ins, resource/referral provision<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient Health Questionnaire (PHQ-9) | The PHQ-9 consists of 9 depression items and one disability item. Each item is associated with a symptom of depression, which the participant rates whether or not they have experienced the symptom over the last two weeks, with severity rating of 0-3. It is one of the few measures that is brief (it takes less than one minute to give) and has been found to have excellent sensitivity to change over time. Older adult participants will complete this measure. Total score ranges from 0 - 27 and higher scores indicate higher levels of depression symptoms. | Baseline, 4-Week Follow-Up, and 9-Week Follow-Up | 
| Generalized Anxiety Disorder (GAD-7) | To assess for co-occurring anxiety, we will use the GAD-7, a 7- item screener for generalized anxiety. It consists of items related to GAD. Participants rate on a scale of 0-3 how much they have experienced in the last two weeks. The scale is a valid screener for GAD. Older adult participants will complete this measure. Total score ranges from 0 - 21, with higher scores mean an increased degree of severity of anxiety symptoms. | Baseline, 4-Week Follow-Up, and 9-Week Follow-Up | 
| Sheehan Disability Scale (SDS) | The SDS will be used as measure of disability/functional status. This is a brief analog disability scale, which uses visual-spatial, numeric and verbal anchors. The scale has been validated in medical and psychiatric populations with a variety of psychiatric diagnoses. Older adult participants will complete this measure. Total score ranges from 0 - 30, with higher scores indicating greater disruptions to their life from mental health symptoms. | Baseline, 4-Week Follow-Up and 9-Week Follow-Up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| University of California Los Angeles (UCLA) Loneliness Scale | A 3-item scale designed to measure one's subjective feelings of loneliness as well as feelings of social isolation. Participants rate each item as either O (I often feel this way), S (I sometimes feel this way), R (I rarely feel this way), N (I never feel this way). Older adult participants will complete this measure. Total scores range from 3 - 9, with higher scores indicating higher levels of loneliness. | Baseline, 4-Week Follow-Up, and 9-Week Follow-Up | 
| Behavioral Activation Scale (BADS) | The Behavioral Activation for Depression Scale (BADS) can be used to track changes weekly in the behaviors hypothesized to underlie depression and specifically targeted for change by behavioral activation. It examines changes in the following areas: activation, avoidance/rumination, work/school impairment, and social impairment. The BADS consists of 25 questions, each rated on a seven-point scale ranging from 0 (not at all) to 6 (completely). Older adult participants will complete this measure. Total scores range from 0 - 150, with higher scores indicating more behavioral activation. | Client participants contributing Baseline, 4-Week Follow-Up, and 9-Week Follow-Up data, excluding cases missing at any timepoint. | 
| Patient Reported Outcome Measurement Information System (PROMIS) Social Isolation - Short Version | The PROMIS Social Isolation item bank assesses perceptions of being avoided, excluded, detached, disconnected from, or unknown by, others. This measure consists of 4 items, each rated on a five-point scale ranging from 1 - 5. Older adult participants will complete this measure. Total scores range from 4 - 20, with higher scores meaning more social isolation. | Baseline, 4-Week Follow-Up, and 9-Week Follow-Up | 
| Acceptability of Intervention Measure (AIM) | This is a four item measure of intervention acceptability, where each item is rated on a 1-5 scale, with 1 = not at all acceptable and 5 = very acceptable, and the total score is a mean item score with minimum score of 1 and maximum of 5. Clinician participants complete this measure. Higher values are considered to be more positive (i.e., a more acceptable intervention). | Baseline and 9 week follow up | 
| Intervention Usability Scale (IUS) | This is a ten item measure of how easy the intervention/system is to use and learn. Used for interventions (e.g., therapeutic modalities). Total scale scores range from 0 to 100, with higher scores considered to be more positive (i.e., a more usable intervention). Scores of 70 and higher are considered to be a usable intervention. Clinician participants complete this measure. | 9 weeks | 
| Intervention Appropriateness Measure (IAM) | This is a four item measure of how suitable an intervention is for the circumstances, where each item is rated on a 1-5 scale, with 1 = not at all appropriate and 5 = very appropriate, and the total score is a mean item score with minimum score of 1 and maximum of 5. Clinician participants complete this measure. Higher values are considered to be more positive (i.e., a more appropriate intervention). | Baseline, 9 week follow up |