Understanding multi-component interventions
This week, I want to highlight a recent research publication from our team, led by Dr. Melanie Chandler, director of the HABIT program in Florida. For those of you who have followed our newsfeed for a while, you’ve seen our references to the HABIT program already. However, I want to include some description here for any newcomers to our newsfeed. HABIT Healthy Action to Benefit Independence and Thinking ® is Mayo Clinic’s cognitive rehabilitation and wellness program for patients diagnosed with Mild Cognitive Impairment. You can find more detail on our information tab, but briefly, our program has 5 components: cognitive rehabilitation (memory compensation training), cognitive training (brain fitness), yoga, wellness, and support group. There is supportive research literature showing the benefit of each these five components individually, which is why HABIT evolved to include all 5 components in the first place. What we didn’t know, was whether our patients needed all 5 components. That is, could you get just as much benefit from just 4 parts of HABIT because some of the benefits of some pieces of the program overlap? And related to this question is understanding how each of the 5 components is helpful. Which outcomes are helped by which intervention?
For example, perhaps the cognitive rehabilitation piece helps people function better day to day with memory tasks, perhaps cognitive training improves measurements of cognitive function, support group helps improve mood or lessen anxiety, perhaps yoga improves relaxation and physical functioning, and perhaps wellness classes help people change lifestyle habits (e.g. diet and exercise) and also helps with functioning and mood. In our research trial, we attempted to answer these questions.
What is the most important outcome?
We first asked our HABIT alumni to tell us which outcomes were most important, out of 13 possible outcomes that included both patient outcomes (e.g., performance on memory testing, daily functioning in memory related activities, mood, confidence, physical functioning, quality of life, etc.) and partner outcomes (e.g., partner quality of life, burden, mood, anxiety, etc.). That survey showed that the highest priority should be patient quality of life and that all patient outcomes were valued by both patients and partners higher than partner outcomes. Dr. Chandler’s recent publication therefore, focused on this primary outcome as well as mood, self-efficacy (i.e., confidence), and memory-based daily functioning as these were the next most highly rated outcomes.
How do the HABIT pieces contribute to outcomes (so far)?
In this trial, supported by funding from the Patient Centered Outcomes Research Institute, nearly 300 couples agreed to be part of this research study in which they went through the HABIT program, but received just 4 of the components. The 5th component was randomly selected to be left out. The patients did not get to choose or know ahead of time which treatment would be left out. With this type of study, we compared which people had better or worse outcomes by evaluating the cost of not getting the one withheld intervention even if receiving another 4.
In reviewing the primary patient outcomes, Dr. Chandler and our team found that all combinations of four treatments improved quality of life at the end of treatment in our patients. At one year, wellness class had a greater impact on patient mood than cognitive training, and yoga had a greater impact on memory related daily functioning than support groups one year after treatment. Overall, the loss of computerized brain exercise did not negatively impact these primary outcomes. However, the literature on cognitive training suggests that it is most likely to impact cognitive measures, not the measures we’ve evaluated in this study—quality of life, mood, anxiety, or self-efficacy. We collected cognitive measurements in this trial and analyses of those data are ongoing. We also continue to evaluate partner outcomes.
Overall, these results are the first of several making an effort to compare various behavioral interventions (non-medication approaches) for patients with MCI. The topic is complicated, and there is still more to understand, but we can already say that it is likely that no one behavioral intervention is “best”. Different interventions impact different outcomes for patients (and likely partners), such that patients are likely to continue to be best served overall by multi-component interventions like HABIT.
We wish to express our gratitude to the patients and partners who agreed to be a part of this study and follow with us over time!! We could not do this without you, and we are forever thankful and humbled that we get to work with such special and courageous people. We also wish to acknowledge all the sites who participated in the trial, including Mayo Clinic Arizona, Florida, and Minnesota as well as the University of Washington. If you wish to read Dr. Chandler’s full academic paper, you can find that here!