Matthew J. Miller

Background: Multidomain interventions may reduce the risk of cognitive decline among older adults with modifiable risk factors, but most existing programs are resource-intensive and difficult to scale. To address this barrier, we developed and pilot-tested Brain Health Together (BHT), a 12-week, virtual group program to reduce dementia risk by targeting modifiable risk factors in older adults with subjective cognitive decline. Methods: We used two phases to develop (Phase 1), pilot-test, and refine (Phase 2) the BHT program. During Phase 1, we collected semi-structured interview data and used an iterative human-centered design approach to identify program opportunities, user needs, and guiding design principles to develop the virtual BHT program. In Phase 2, we refined the BHT program based on participant feedback and assessed preliminary BHT feasibility and acceptability through measures of participant retention, session attendance, and survey-based perceived usefulness of program elements, educational content, and subjective changes since starting the program. We also explored participant experiences with the BHT program through semi-structured interviews. Results: In Phase 1, our iterative human-centered design identified four opportunities for BHT development (e.g., holistic support for participants, personalized feedback) and three user archetypes that informed the development of the 12-week BHT framework. In Phase 2, six of seven participants attended > 90% of sessions during weeks 1–4. At week 4, BHT program delivery was adapted based on participant feedback (e.g., education was simplified and covered a larger range of topics). During weeks 5–12 of Phase 2, 7 enrolled participants (6 retained, 1 new) attended 86% of sessions. Participants reported the most useful program elements were individual brain health coaching sessions (mean ± SD: 4.9 ± 0.4, max score: 5), sharing progress with group (4.3 ± 0.8). All participants self-reported feeling “somewhat” or “much” better compared to baseline. Participant qualitative data suggest subjectively beneficial effects of BHT classes, brain health education, and brain health coaching on confidence and motivation. Conclusions: The BHT program, a multidomain intervention with virtual brain health coaching, was developed to address cognitive decline risk reduction among those with cognitive impairment. Our 12-week pilot suggests that BHT is feasible and acceptable among older adults with cognitive decline. Trial Registration: This study was retrospectively registered as a clinical trial at ClinicalTrials.gov (NCT06914947) on 04/04/2025.

Background: Chronic pain (CP) is among the most common medical conditions, is the leading cause of disability, and is often refractory to medical treatment. The CDC and the American College of Physicians recommend nonopioid and nonpharmacologic treatment as first-line strategies, including cognitive-behavioral therapy (CBT), mindfulness-based interventions (MBI), and movement-focused interventions (MFI); however, only 3% of people with chronic pain (CP) have access to these evidence-based treatments. Patients from historically minoritized populations and those speaking languages other than English are particularly underserved and may go untreated. Stigma regarding CP and interventions to manage it present additional obstacles. Methods: The Integrating Nonpharmacologic Strategies for Pain with Inclusion, Respect, and Equity (INSPIRE) study evaluates a blend of these non-pharmacologic, evidence-based interventions using a pragmatic, parallel, two-arm RCT comparing intervention participants with wait-list controls. The INSPIRE intervention includes a 12-week curriculum delivered via a multilingual mobile app paired with weekly telehealth coaching. The primary outcome will be the “Pain, Enjoyment, and General Activity (PEG)” scores at 3 months. Secondary outcomes include PEG scores at 6 and 12 months, physical functioning, quality of life, sleep, depression, anxiety, and global satisfaction with treatment at 3, 6, and 12 months. Primary mediators to be examined include pain cognitions and health behaviors. Secondary mediators may include stigma and isolation, trust in healthcare providers, and both engagement and satisfaction with the INSPIRE intervention. The intention-to-treat primary analysis will be conducted with covariates including baseline measures of pain, anxiety, and physical function. Discussion: The full RCT protocol and intervention details are provided following the SPIRIT guidelines. Implications for improving treatment access via culturally and linguistically tailored digital health interventions are discussed along with the potential for health coaching to drive mobile app engagement. Trial registration: ClinicalTrials.gov ID NCT06183281. Trial registration data set can be found here: https://clinicaltrials.gov/study/NCT06183281 and in Additional file 1.

Background: Preoperative physical activity (PA) levels persist in patients following total knee arthroscopy (TKA), despite improved function and mobility following rehabilitation. Long‐standing activity behaviors and preexisting psychosocial characteristics may explain suboptimal PA post‐TKA. Objective: To (1) confirm latent constructs from outcome measures capturing symptoms, function, psychosocial factors, and mobility and (2) examine relationships between constructs measured pre‐TKA and their influence on post‐TKA outcomes using factor analyses and structural equation modeling. Design: Secondary analysis of a randomized clinical trial. Setting: Veterans Administration medical center. Patients: U.S. military Veterans ( n = 113; age 67.3 ± 7.3; mean ± SD; body mass index 29.0 ± 3.5 kg/m ² ; 90% male) scheduled for TKA. Intervention: Participants received TKA postoperative rehabilitation and were randomized to a PA behavior‐change intervention targeting increased walking exercise or control group. Main Outcome Measures: The Western Ontario Measurement Arthritis, Falls Efficacy Scale International, Functional Comorbidity Assessment, Veterans RAND‐12 Health Survey, Multidimensional Scale for Perceived Social Support, Geriatric Depression Scale, Self‐Efficacy for Exercise scale, Timed‐Up and Go, 6‐minute walking test, and Life‐Space Assessment (LSA) score. Results: A direct relationship was observed between pre‐TKA physical characteristics and pre‐TKA psychosocial characteristics ( β = .734, z = 7.871, p < .001). Pre‐TKA psychosocial characteristics were directly associated with post‐TKA LSA scores ( β = −.627, z = 2.924, p = .003). Pre‐TKA psychosocial characteristics explained 53.8% of the variability in post‐TKA LSA scores and mediated the pre‐post relationship between physical characteristics and LSA scores ( β = −0.460, z = −2.455, p = .014). No significant relationship was observed between pre‐TKA physical characteristics and post‐TKA LSA scores. Conclusions: Latent constructs representing physical health and psychosocial traits were directly related in veterans scheduled for TKA. Elevated psychosocial characteristics observed before TKA were associated with decreased life space mobility at 12 weeks post‐TKA. Our findings support addressing psychosocial factors before and throughout TKA rehabilitation as these may have implications on postoperative life space mobility.

Objective: To identify whether depression, resilience, and perceived control of health are related to 2.5-year mortality and instrumental activities of daily living (IADL) decline among older adults after surgery. Background: The relationships of psychosocial factors with postoperative mortality and IADL decline among older adults are understudied. Methods: We identified 3778 community-dwelling older adults in the health and retirement study with Medicare claims for surgery [mean (SD) age: 75.4 (7.8) years, 53.9% women, and 86.0% non-Hispanic White]. We assessed associations of depression, resilience, and perceived control of health with 2.5-year postoperative mortality and IADL decline using Cox and modified Poisson regression analyses, adjusting for sociodemographic and health variables. Results: The incidence of 2.5-year postoperative mortality was 18.5%, and IADL decline was 9.4%. Depression was associated with a higher incidence and adjusted hazard (95% CI) of mortality [26% vs 16%, adjusted hazard ratio: 1.2 (0.9, 1.5)], but high resilience was associated with a lower incidence and adjusted hazard of mortality [9% vs 21%, adjusted hazard ratio: 0.6 (0.5, 0.8)]. Those with depression had higher incidence and adjusted relative risk (95% CI) of IADL decline [17% vs 7%, aRR: 1.6 (1.2, 2.2)], but the lower incidence and adjusted relative risk of IADL decline were identified for those with high resilience [4% vs 11%, aRR: 0.6 (0.4, 1.0)] and high perceived control of health [7% vs 10%, aRR: 0.6 (0.4, 1.0)]. Conclusions: While depression confers a greater risk of mortality and IADL decline, higher resilience and perceived control of health may be protective. Addressing psychosocial factors in the perioperative period may improve outcomes among older adults.

Background: The prevalence of cognitive impairment in home health physical therapy (HHPT) is unknown. We sought to identify the prevalence of cognitive impairment, including cognitive impairment no dementia (CIND) and dementia, among older adults who used HHPT, and if cognitive impairment prevalence was higher among those with HHPT‐relevant characteristics. Methods: For our cross‐sectional analysis, we identified 963 fee‐for‐service Medicare beneficiaries with HHPT claims (>85 years old: 28.8%, women: 63.7%, non‐Hispanic White: 82.1%) in the 2014 and 2016 waves of the Health and Retirement Study (HRS) and used a validated algorithm to categorize cognitive status as normal, CIND, or dementia. We estimated the population prevalence and calculated age, gender, race/ethnicity adjusted odds ratio (aOR) of CIND and dementia for characteristics relevant to HHPT service delivery including depression, walking difficulty, fall history, incontinence, moderate‐vigorous physical activity (MVPA) ≤1x/week, and community‐initiated HHPT using multinomial logistic regression. Results: The population prevalence of cognitive impairment was 46.4% (CIND: 27.3%, dementia: 19.1%). The prevalence of cognitive impairment was greater among those with depression (46.7% vs. 39.5%), difficulty walking across the room (58.9% vs. 41.8%), fall history (49.1% vs. 42.9%), MVPA ≤1x/week (50.0% vs. 38.0%), and community‐initiated HHPT (55.2% vs. 40.2%). Compared to normal cognitive status, the odds of cognitive impairment were greater for those with MVPA≤1x/week (CIND: aOR = 1.57 [95% CI: 1.05–2.33], dementia: aOR = 2.55 [95% CI: 1.54–4.22]), depression (dementia: aOR = 1.99 [95% CI: 1.19–3.30]), difficulty walking across the room (dementia: aOR = 2.54 [95% CI: 1.40–4.60]), fall history (dementia: aOR = 1.85 [95% CI: 1.20–2.83]), and community‐initiated HHPT (dementia: aOR = 1.72 (95% CI: 1.13–2.61]). Conclusion: There is a high prevalence of CIND and dementia in HHPT, and no characteristics had a low prevalence of cognitive impairment. Physical therapists should be ready to identify cognitive impairment and adapt home health service delivery for this vulnerable population of older adults.

Objective: The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. Methods: Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. Results: Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. Conclusion: System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. Impact: A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.

Objective: The objective of this study was to estimate the prevalence of cognitive impairment (including cognitive impairment no dementia [CIND] and dementia) among Medicare fee-for-service beneficiaries who used outpatient physical therapy and to estimate the prevalence of cognitive impairment by measures that are relevant to rehabilitation practice. Methods: This cross-sectional analysis included 730 Medicare fee-for-service beneficiaries in the 2016 wave of the Health and Retirement Study with claims for outpatient physical therapy. Cognitive status, our primary variable of interest, was categorized as normal, CIND, or dementia using a validated approach, and population prevalence of cognitive impairment (CIND and dementia) was estimated by sociodemographic variables and Charlson comorbidity index score. Age-, gender- (man/woman), race-/ethnicity-adjusted population prevalence of CIND and dementia were also calculated for walking difficulty severity, presence of significant pain, self-reported fall history, moderate-vigorous physical activity (MVPA) ≤1×/week, and sleep disturbance frequency using multinomial logistic regression. Results: Among Medicare beneficiaries with outpatient physical therapist claims, the prevalence of any cognitive impairment was 20.3% (CIND:15.2%, dementia:5.1%). Cognitive impairment was more prevalent among those who were older, Black, had lower education attainment, or higher Charlson comorbidity index scores. The adjusted population prevalence of cognitive impairment among those who reported difficulty walking across the room was 29.8%, difficulty walking 1 block was 25.9%, difficulty walking several blocks was 20.8%, and no difficulty walking was 16.3%. Additionally, prevalence of cognitive impairment among those with MVPA ≤1×/week was 27.1% and MVPA >1×/week was 14.1%. Cognitive impairment prevalence did not vary by significant pain, self-reported fall history, or sleep disturbance. Conclusion: One in 5 older adults who use outpatient physical therapist services have cognitive impairment. Furthermore, cognitive impairment is more common in older physical therapist patients who report worse physical function and less physical activity. Impact: Physical therapists should consider cognitive screening for vulnerable older adults to inform tailoring of clinical practice toward a patient’s ability to remember and process rehabilitation recommendations.

Background: Mobility assessments are commonly used among older adults as risk stratification for falls, preoperative function, frailty, and mortality. We determined if gait speed and self‐reported difficulty walking are similarly associated with social isolation and loneliness, which are key markers of social well‐being and linked to health outcomes. Methods: We used 2015–2016 data from the National Social life Health and Aging Project (NSHAP), an in‐person nationally‐representative survey of 2640 community‐dwelling adults ≥65 years old. We measured gait speed (timed 3‐m walk: unable to walk, ≥5.7 s, and p < 0.05): social isolation (much difficulty: 26% vs no difficulty: 18%), low socializing (33% vs 19%), low volunteering (67% vs 53%), low community participation (54% vs 43%), low religious participation (51% vs 46%), and loneliness (25% vs 14%). Difficulty walking across the room was similarly strongly associated with social isolation and individual activities. The association between self‐reported difficulty walking and social isolation was stronger at older ages ( p ‐value of interaction <0.001). Conclusions: Self‐reported mobility difficulty is a widely used clinical assessment that is strongly associated with loneliness and social isolation, particularly at older ages. Among persons with limited mobility, clinicians should consider a careful social history to identify social needs and interventions addressing mobility to enhance social connections.