Determine If Pathways Are Modifiable

A related consideration is to determine whether the identified pathway(s) of the selected problem area are amenable to change; and if so, what type and magnitude of change might be expected. Of importance is identifying triggers or contributors of the problem that are modifiable and thus can be addressed by an intervention. If a problem is due to factors that are intractable or not modifiable, and it is not possible to mitigate the problem, then an intervention is obviously not possible.

For example, certain personality types are a risk factor for negative or inappropriate behaviors; but personality is trait-based and not modifiable. However, the circumstances that elicit negative behavioral responses for specific personality types could be targeted through an intervention to mitigate inappropriate behaviors. More specifically, being male and having a history of aggressive behaviors are known risk factors for aggressive forms of behaviors in persons with dementia (Kunik et al., 2010). However, neither sex nor previous history or experiences are modifiable and thus cannot be targeted in an intervention. Yet an intervention could target other modifiable contributors such as reducing caregiver stress, increasing their understanding of dementia, and heightening awareness of the risk for aggressive behaviors.

The identification of modifiable factors in this stage of intervention development is critical. Through this identification process, it might be discovered that certain problems are due to multiple factors, some of which reflect “low-hanging fruit” or which could be addressed simply and if so, mitigate the problem. Alternately, an identified problem area may be rooted in individual behaviors, which in turn are supported by environmental forces. Take, for example, a weight loss intervention for low-income middle-aged adults that focuses on cooking and eating appropriate foods only. However, healthy foods may not be easily available in low-income neighborhoods of study participants. An intervention that focuses on individuals’ behaviors exclusive to their living context may have an immediate benefit but not long-term impact on desired outcomes. Thus, a multimodal (e.g., targeting different pathways) and multicomponent (e.g., different strategies) intervention may be a preferred approach.

As to the ABLE Program (shown in Table 3.1), functional limitations may be due to an underlying pathology (e.g., irreversible arthritic processes) and impairments that are not necessarily modifiable. Although functional limitations may be partially addressed through exercise or reducing inflammation, the impact of functional limitations on quality of life is due primarily to the mismatch between persons’ functional abilities and the physical and social environmental demands they confront. These latter factors can be modified. For example, persons with difficulty ambulating may not be able to ascend stairs easily to use a bathroom. They may compensate by restricting their living space to one floor, and/or they may choose to limit their fluid intake or discontinue a diuretic to reduce their need to use the bathroom. We may be able to enhance their balance and strength through exercise, but that may still not enable them to ascend stairs routinely to use a bathroom. However, installing a stair glide or creating a first floor powder room may address this mismatch. The ABLE Program was designed to optimize the fit between abilities, tasks, and environmental home features. The reduction of everyday difficulties in task performance was the primary outcome chosen to demonstrate intervention efficacy. Furthermore, it was hypothesized that reducing daily functional difficulties would result in enhanced engagement, quality of life, less health care costs, and a reduced risk for mortality. These are all outcomes that were demonstrated for the ABLE Program in a Phase III efficacy trial (Gitlin et al., 2006, 2009). Furthermore, examining the primary pathways will lead to identifying appropriate measures, which may serve as descriptors, modifiers, mediators, or primary or secondary outcomes of an intervention (see Chapters 14 and 15).

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