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A Detailed Analysis of the Process and Content Components of the Lifestyle Redesign速 Intervention Dr. Florence Clark, PhD, OTR/L, FAOTA

Overview Healthy Aging Development of the Lifestyle Redesign速 Intervention Implementation of the Lifestyle Redesign速 Intervention

Healthy Aging

Advice Through the Ages

1558-1609 1484-1566

44 B.C.E. • Cicero

• Luigi 1214-1294 Cornaro • Roger Bacon

1903

• Sir Herman • Andre du Weber Laurens

Longevity – 44 B.C.

“We ought to take due care of our Health, and to eat and drink sparingly, and use moderate exercise, that we may be enlivened, and have fresher spirits, not be oppressed, and overloaded.”

Powers of the mind “become more refreshed and invigorated the more they are used.”

- Cicero, A Dialogue On Old Age, 44 B.C.

Longevity – 1500’s “Nothing hastens old age more than idleness.”

- Andre du Laurens (1558-1609)

“A temperate life would enable the body’s finite supply of vital spirits to last until life ebbed peacefully away between the ages of five and six score.”

- Luigi Cornaro (1464-1566)

Longevity – 1903 A.D. “By moderation and abundant exercise of body and mind, including walking, climbing and breathing exercises, I have escaped death from these causes, have greatly prolonged my life, and am now in good health in my 91st year.”

– Case Study from Sir Hermann Weber, On Means for the Prolongation of Life, 1903

Longevity - 2000 “Heath risks such as smoking, physical inactivity, being overweight or obese, consumption of high fat diets, and inadequate fruit and vegetable intake are major determinants of morbidity and mortality.�

Robert Butler, M.D., founder, International Longevity Institute, founding director of the U.S. National Institute on Aging, Pulitzer Prize winner, gerontologist

The White Queen/Tudor Period (Mortality)

Name • • • • • • •

Elizabeth Woodville (White Queen) Edward IV (White Queen’s husband) Elizabeth of York (White Queen’s daughter) Margaret Beaufort (Red Queen) Richard Neville (The Kingmaker) Anne Neville (Kingmaker’s Daughter) The Tudors – Henry VII (Red Queen’s son) – Henry VIII (Henry VII’s son) – Elizabeth I (Henry VIII’s daughter)

Age at Death 55 41 37 66 42 28 52 55 69

Life Span of the Tudor Queens Birth

Age Married

Age of Death

Cause

Catherine of Aragon

1485

24

51

Executed

Anne Boleyn

1504

29

32

Executed

Jane Seymour

1508

28

29

Died

Anne of Cleves

1515

25

42

Died

Kathryn Howard

1521

19

21

Executed

Catherine Parr

1512

31

36

Died

Life Expectancy Today

US: 78.74 years Israel: 81.7 years Japan: 83.1 years Source: World Bank, 2015

Composing a Further Life: The Age of Active Wisdom • Traditional Age - Groups – Childhood – Parenthood – Grandparenthood

• Adulthood I – Very busy, productive time, building careers, raising children

• Adulthood II – Stage of active wisdom preceding old age

From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.

Composing a Further Life: The Age of Active Wisdom Long lives, Better health

Wisdom combined with activity

Adulthood II

Freedom from work and raising a family

Adulthood II is an “improvisational art form calling for imagination and the willingness to learn�

Rich Experiences

From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.

What do older adults believe contribute to their health and well-being?

• Reichstadt et al. (2007) found that older adults attribute successful aging to these factors: – – – –

Positive Attitude and Adaptability to Change Sense of Security and Stability Overall Health and Wellness Engagement and Stimulation

From: Reichstadt, J., Depp, C. A., Palinkas, L. A., Folsom, D. P., & Jeste, D. V. (2007). Building blocks of successful aging: A focus group study of older adults' perceived contributors to successful aging. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 15(3), 194-201.

What factors have economists identified that influence happiness over the life span?

Easterlin, R.A. (2006). Life Cycle Happiness and Its Sources: Intersection of Psychology, Economics, and Demography.

Journal of Economic Psychology/ Elsevier, pp. 463-482.

How are gerontologists conceptualizing the complexity of factors that contribute to healthy aging?

The Model on Agency and Structure Agency (Life Choices)

Structure (Life Chances)

Lifestyle

Hendricks, J. & Hatch, L.R. (2006). Lifestyle and aging. In R. Binstock & L.K. George (Eds.) Handbook of aging and the social sciences (5th ed., pp. 301-319). San Diego, CA: Academic Press.

• • • •

Genetics Staying active Lifelong learning Optimism / Love of Life Helen “Happy” Reichert with her caretaker •

Helen Reichert & Irving Kahn in Time Magazine

Kahn Family – All four siblings lived to be centenarians!

• • • •

Helen “Happy” Reichert, 108 Irving Kahn, 104 Peter Kahn, 100 Lee Kahn passed away in 2005 at the age of 102

Aging Around the World Hippocratic Medicine

Traditional Chinese Medicine

Sardinia Seventh-Day Adventists

Okinawan Secrets

Okinawan Secrets: Japan •

Traditional Okinawan diet

Low in fat and calories High in carbohydrates (e.g. vegetables, grains) and nutrients Lots of vegetables, tofu, seaweed, tea

– – –

•

Modern fast food invasion…

– –

Average life expectancy • Female: 87 years • Male: 79 years (among longest in the world) US Average Life Expectancy = 78.8 years

Increased caloric consumption Lost #1 life expectancy ranking in Japan

•

Low stress and rigorous physical activity

•

Moai - a support network providing financial, social, and emotional help throughout life

•

Ikigai – a reason to wake up in the morning

So how can we optimize the chances of staying healthy during Adulthood II?

Identified a need for in-depth qualitative research to gain critical insights about the needs of the participants and inform protocol refinements

The Qualitative Domain Study • Documented the life domains and adaptive strategies used by older people living in the setting from which the RCT sample would be drawn • Provided a rich database to guide tailoring of the intervention protocol

Task Analysis - Mapping the Well Elderly Intervention Theories: Occupation as Emergent, Dynamic Systems, Meaning through Occupation, Humans as Occupational Beings

Objective #1:

Objective #2:

Enhance the selection of occupations

Enhance the experienced meaning of occupations

Key Activities:

Key Activities:

- Increased occupational balance

- Enactment of flow

- Heightened flexibility

- Improved connections to life course

- More overt strategizing

- Enhanced meaning in daily routine

Treatment Outcomes: Primary Outcomes: Enhanced physical health, Improved mental health, Superior occupational functioning, and Increased life satisfaction

• •

Czaja, Schulz, Lee, C. C., & Belle (2003) Jackson, Carlson, Mandel, Zemke, & Clark (1998)

Adopting a Healthy Lifestyle Later in Life After only 4 years, adopting a healthy lifestyle in middle age can: • Reduce mortality risk by 40% • Reduce cardiovascular disease risk by 35%

Theme:

We become what we have done

Break

Development of the Lifestyle Redesign速 Intervention

Research Base

EVIDENCE-BASED PRACTICE IS… …the integration of: • • • •

the best research evidence clinical expertise the client’s values and circumstances the practice context

Hoffman, T., Bennett, S. & Del Mar, C. (2010). Introduction to evidence-based practice. In T. Hoffman, S. Bennett & C. DelMar (Eds.). Evidence-based practice across the health professions, pp. 1-15. Elsevier Australia: Chastswood, NSW.

Why is Evidence-Based Practice Important?

• Evidence-based practice promotes: – The most effective care – Improved outcomes – An attitude of inquiry – Professional accountability – Appropriate use of resources

Hoffman, T., Bennett, S. & Del Mar, C. (2010). Introduction to evidence-based practice. In T. Hoffman, S. Bennett & C. Del Mar (Eds.). Evidence-based practice across the health professions, pp. 1-15. Elsevier Australia: Chatswood, NSW.

USC Division of Occupational Science and Occupational Therapy Well Elderly Research Program

The USC Well Elderly Studies 1994-1997: Well Elderly 1 Study National Institute on Aging (R01 AG11810, R01 AG11810-03S1) NIH, AHCPR, NCMRR American Occupational Therapy Foundation (NNPUBS-068-98) PI: Florence Clark, PhD, OTR/L, FAOTA

2004-2008: Well Elderly 2 Study National Institute on Aging (R01 AG 021108) PI: Florence Clark, PhD, OTR/L, FAOTA

USC Well Elderly 1 Study (WE1) Team Florence Clark, PhD Ruth Zemke, PhD Jeanne Jackson, PhD Michael Carlson, PhD Loren G. Lipson, MD Stanley P. Azen, PhD Joel W. Hay, PhD Barbara J. Cherry, PhD Deborah Mandel, OTD Karen Josephson, MD

Occupational Therapy Occupational Therapy Occupational Therapy Social Psychology Geriatric Medicine Preventive Medicine, Biostatistics Pharmaceutical Policy & Economics Cognitive Psychology Occupational Therapy Geriatric Medicine

USC Well Elderly 2 Study (WE2) Team Florence Clark, PhD Jeanne Jackson, PhD Stanley P. Azen, PhD Chih-Ping Chou, PhD Barbara J. Cherry, PhD Maryalice Jordan-Marsh, PhD Brett White, MD Douglas Granger, PhD Robert Knight, PhD Michael Carlson, PhD Rand Wilcox, PhD Deborah Mandel, OTD Jeanine Blanchard, PhD

Occupational Therapy Occupational Therapy Preventive Medicine, Biostatistics Preventive Medicine Cognitive Psychology Nursing Family Medicine Biobehavioral Health, Penn State Psychology, Gerontology Social Psychology Psychology, Statistics Occupational Therapy Occupational Therapy

Well Elderly Study 2: Intent-to-Treat Results Treatment (n=187) vs. Control (n=173) Health Related Quality of Life (SF36V2) Mental Health

0.03

Social Function

0.04

Vitality

0.03

Bodily Pain

0.02

Composite: Mental

0.03

Composite: Physical

0.09

General Health

0.25

Physical Function

0.09

Role Physical

0.18

Role Emotional

0.16

Life Satisfaction (LSI-Z) 0.03 Depression (CES-D)

0.03

Cognition Memory (CERAD) • Immediate Recall

0.20

• Delayed Recall

0.38

• Recognition

0.26

Visual Search

0.49

Psychomotor Speed

0.49

Lifestyle

速 Redesign

Intervention

Lifestyle Redesign速 Lifestyle Redesign速 enables patients to design, practice, and ultimately enact a personalized, sustainable health-promoting daily routine that is tailored to address chronic disease risk factors as well as promote health and well-being more generally.

Age-related Diseases • Can be delayed, even prevented, through lifestyle changes – Coronary heart disease – Certain cancers – Diabetes – Dementia – Arthritis

Lifestyle Redesign Awareness of Activity Patterns

Analysis of Activity Patterns

Lifestyle Redesign Process

Changing Habits and Routines

Development of a Personalized Engagement Plan (PEP)

Key Ideas of the Lifestyle Redesign Program 1. Experience in occupation produces radiating, not linear, change.

2. Occupational self-analysis is possible.

3. When people understand occupation, they can redesign their lives.

4. Occupation is the impetus that propels people forward.

5. Active coping is a learned skill that can positively affect well-being.

Occupation Produces Radiating, Not Linear, Change What changes occur when a participant tries public transportation for the first time?

New positive self-image

New transportati on skills

New sense of social connectedness

Occupational Self-Analysis Is Possible Who are you as an occupational being?

How do your occupations affect your health?

Are you experiencing occupational deprivation?

What occupations do you like best?

What is your plan for healthier living?

How will you enact your plan?

Lifestyle Redesign Provides a Valuable “Toolkit” “Toolkit” of Lifestyle Redesign 1) Purposeful selection of health-promoting occupations 2) Experienced meaning

Occupation Propels People Forward Technique Collaboration

Occupational Storytelling

Occupational Storymaking

Occupation People Forward EvokingPropels stories of occupation Occupational coaching • • •

Building Empathy

Analysis and synthesis • Time • Value

Inclusion of Ordinary

• •

Joint task interaction with self-interest manifested Identify and meet group norms and goals

Encouraging positive remake Offering occupational strategies Reaffirming and marking progress

Evoking insight (problems and solutions) Broadened view of activities of daily living • Handling emotion • Friendship and intimacy • Symbolic dimension of occupation

Listening

Image reconstruction

Reflection

Cultural place

Active Coping Is a Learned Skill The Stress Response

The Transformative Process of Lifestyle Redesign

Conceptual Foundation • Occupation is essential for human existence • Occupation is transformational • Occupations vary in their degree of meaningfulness (and positive or negative impact on health) • People can reorder their occupational patterns from disequilibrium to stability (dynamic systems theory)

Mechanisms of Change

Knowledge Acquisition Internalization Habit Formation

Goals of Lifestyle

® Redesign

• Assist each participant to develop: – A personally feasible, healthy lifestyle – Sustainable within the fabric of his or her everyday routines

• Increase or maintain: – Independence – Health – Well-Being

Awakening

“I wouldn’t have done it if it weren’t for you!”

Lifestyle Redesign® Intervention • Becoming hyper-cognizant of activity patterns and their impact on health • Activity Pattern Analysis ®

• Lifestyle Redesign

Knowledge: Understanding the Impact of Activity on Health • Notice and name activities • Explore the dimensions of activities

– Physical, cognitive, social, emotional & spiritual

• Learn the relationship of activities to health and well-being • Experience the relationship of activities to health and well-being

Activity Pattern Analysis • Self-reflect • Identify barriers • Identify options and alternatives

El Grupo de Bienestar: Naming Occupations Singing

Dancing

Remembering the old days

Potlucks Praying

Meditating Writing

Doing Puzzles

Exercising Going to Church

Parties Reading the Newspaper Walking

Social Emotion al

Dimensions of Wellness Wellness Mental

Spiritual

Developed by El Grupo de Bienestar

Physical

Parties Potluck Dancing

Remember the old days Yoga Reading Music Meditation Emotional

Social

Wellness Mental Read the Newspaper Write Puzzles Walk Dance Developed by Sing El Grupo de Bienestar Exercise

and

Occupation Spiritual

Physical

Church Mass Pray

Lifestyle Redesign® • Select personalized healthy activity options • Make changes in routines • Practice habits and routines

Preliminary Individual Assessment Investigate: • Medical history • Current daily routines • Functional limitations • Occupational history • Barriers and support systems • Time use/energy management • Stress management • Leisure interests • Long term goals • Diet/exercise

The Personal Engagement Plan (PEP) My Attitudes Customized to fit the participant’s • Attitudes • Needs • Preferences • Capacities • Environmental facilitators and constraints • Health profile

   

My Behaviors    

My Life

My Needs

My Health Status    

   

Other Key Information

   

Making Health Habits and Routines Permanent Sustainable, healthy routines are a main objective of the Lifestyle Redesign program Performed somewhat automatically

Provide daily structure Can counteract the development of chronic disease and disability

Factors that Influence Habits and Routines

Environment Social support

Others

Biological factors

Habits and Routines Influential people

Sleep patterns

Financial security

Adapting Habits and Routines • Reexamine goals and routines periodically, and adjust when necessary • Include caregivers in habit formation and goal setting • Encourage flexibility and set expectation that plans will be modified over time

Intervention Delivery Group Meetings

Individual Sessions

• Didactic Presentation

• Personal goals

• Peer Exchange

• Build new habits

• Direct Experience

• Traditional occupational therapy

• Personal Exploration

• Reinforce and individualize materials from group sessions

USC Well Elderly Program Model Content Areas Aging, Health, and Occupation Transportation Safety Dining Physical and Mental Activity Relationships Cultural Awareness Finances Integrative Summary

Methods of Delivery

Health Related Outcomes

Group and Individual

Enhanced Physical Health

Didactic Presentation

Superior Occupational Functioning

Peer Exchange Direct Experience Personal Exploration

Increased Life Satisfaction

Modules Utilized in WE1 • Occupation, Health, and Aging • Transportation and Occupation • Health Through Occupation: Physical and Mental Activity • Dining as Occupation • Time and Occupation • Home and Community Safety • Relationships and Occupation • Outings, Exploration, and Special Events • Ending a Group

Program Adaptations (WE1  WE2) • Intervention shortened from 9 months to 6 months • More diverse participants • Research sites expanded to include senior centers and 1 continuous care retirement community • Modules were updated and modified

Lunch

Implementation of the Lifestyle Redesign速 Intervention

How to Use the Modules Occupation, health, and aging

Community mobility, transportation, and occupation

The building blocks of longevity: physical, mental, spiritual, social, and productive activity

Stress and inflammation management

Dining and nutrition

Time and occupation

Home and community safety

Relationships and occupation

Thriving

Navigating health care

Hormones, aging, and sexuality

Ending a group

Module 1: Occupation, Health, and Aging • Goals – Enable participants to: – Describe occupation (homeostasis, routine, balance, circadian rhythms) – Understand the relationship of occupation to health and apply concepts in their own lives – Develop their individual preliminary Personalized Engagement Plans (PEP)

Module 2: Community Mobility, Transportation and Occupation • Goals – Enable participants to: – Develop an understanding of mobility challenges – Plan and enact solutions to challenges in preparation for community outings

• Focus varies depending on population – Driving – Public transportation – Having multiple options

Module 3: The Building Blocks of Longevity: Various Types of Activity • Goals – Enable participants to:

– Understand that health and wellbeing requires engagement in a diverse range of meaningful and health-promoting activities (in addition to avoidance of illness) – Employ practical approaches for incorporating healthy occupations into daily lives – Recognize different types of activity: • • • • •

Physical Mental Spiritual Social Productive

– Utilize strategies for dealing with factors that impede activity engagement (e.g., urinary incontinence)

What is Occupation?

Cognitive Physical Social Productive Spiritual

30%

engage in sexual activity at least once per month

Module 4: Stress and Inflammation Management • Goals – Enable participants to:

– Understand the relationship of stress and sleep deprivation on inflammation – Recognize the impact of stress on their minds and bodies and explore healthy ways to decrease stress – Utilize active coping • Problem-focused coping

– Acting – Planning – Suppressing distracting activities

– Develop strategies for managing sleep Heckhausen & Schulz (1995), Schulz & Heckhausen (1996)

Homeostasis and Occupation Homeostasis is a state of balance within the body.

Sometimes we use occupation to help achieve homeostasis.

Circadian Rhythm and Occupation

Module 5: Dining and Nutrition • Goals – Enable participants to: – Describe what constitutes “healthy eating” – Recognize the relationship of food intake to activity engagement – Engage in a group cooking and dining activity based on themes of nutrition and understanding food labels – Explore the social dimension of eating – Enact methods for organizing medication intake according to a schedule

Module 6: Time and Occupation • Goals – Enable participants to: – Analyze their lives in terms of pace, past, present, anticipated future, and degree of forward progression – Reflect upon the experience of time – Implement strategies for taking control of time through activity orchestration/management – Chart circadian rhythms

Module 7: Home and Community Safety • Goals – Enable participants to: – Explore small changes that could prevent an unwanted attack or improve personal safety at home and in community – Take appropriate risks, develop friendships, and use available resources to be more comfortable exploring community – Modify their home environments to eliminate hazards and to promote safe activity engagement – Employ strategies for fall prevention

Module 8: Relationships and Occupation • Goals – Enable participants to: – Explore the topics of community and communication and the impact of loneliness on health – Discuss cultural and personal strategies for coping with loss or death and dying – Recognize the importance of end-of-life planning

Module 9: Thriving • Goals – Enable participants to: – Recognize and exercise their own potential by • • • •

Exploring what they care about most Engaging in life more profoundly Discovering their deepest priorities and potentials Pursuing new forms of meaning

Module 10: Navigating Healthcare • Goals – Enable participants to: – Increase their health literacy by reviewing and discussing pertinent content which has been tailored to the particular healthcare system concerns of their group

Module 11: Hormones, Aging, and Sexuality • Goals – Enable participants to: – Understand the effects of aging on hormones and sexuality for both men and women – Discuss lifestyle, social, and pharmacological factors affecting sexuality in later life

Module 12: Ending a Group – Finalizing Personal Engagement Plans (PEPs) • Goals – Enable participants to: – Finalize their PEPs • Health promoting habits, routines, and strategies for sustaining enactment of plan over time

– Engage in a ritual/ceremony which marks their transition to a healthy lifestyle independent of group involvement

Personal Engagement Plan (PEP) Select Content Recommendations for Participants

Plans must be customized to be sustainable But they should include these components‌

1. Learning to listen to your body • Follow your circadian rhythms • Become mindful of when you are at homeostasis • Use technology to track your biomarkers and activity pattern From: Agus, D. B. (2011). The end of illness. New York: Free Press.

2. Trying to avoid chronic inflammation • Through simple everyday practice – i.e., avoid wearing high heels, carrying heavy purchases, wearing uncomfortable or binding clothes, using heavy suitcases, etc.

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

3. Trying to eat a healthy aging diet • As much as possible, try to eat…

– On a regular schedule – Cold water fish (i.e. trout, tuna, halibut) 3x per week – A multi-colored diet – Red wine (if you wish) 5 nights per week • Unless you are at high risk for cancer

– A good-fat diet – Natural, non-processed food From: Agus, D. B. (2011). The end of illness. New York: Free Press.

4. Minimizing your stress • Some stress is normal and adaptive • Chronic stress is health-compromising

– Becoming aware of sources of chronic stress is important

• Ways of managing stress: – – – – – – –

Finding ways to rest Avoiding chronic stressors (as much as possible) Spacing Taking breaks Just saying no Escape Personal therapeutic activities that are enjoyable, soothing

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

5. Knowing your risk factors • Genetic risk factors – Predisposition to common conditions

• Lifestyle factors can counteract these risks – Physical exercise changes gene expression

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

6. Incorporating health-promoting practices • Eat, sleep, and exercise at predictable times every day • Engage in the social, productive, and spiritual activities you value • Choose physical activities you enjoy (as much as possible) – Consistent physical activities such as walking or dancing can be very health-promoting

• Take time to rest • Avoid sedentary activity as much as feasible From: Agus, D. B. (2011). The end of illness. New York: Free Press.

7. Developing in new ways • Explore what you care most about – Engage in life more profoundly – Explore your deepest priorities and potentials – Pursue new forms of meaning

From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.

8. Getting started • Taking action is self-perpetuating

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

What’s really happening in those groups?

Safe Place

Someone was there to trust.

You will love us, accept us, who we are.

You can make mistakes.

There will be no judgment.

Affirmation that they were on a journey together.

You did your best to get us where to be.

We could be ourselves.

Touched each other in different ways.

Talked to each other.

There was nowhere they could talk at this level.

They grew and changed as a person.

They experienced it and no one can take that away.

So what did the intervention provide overall?

®

Lifestyle Redesign

• Select personalized healthy activity options • Make changes in routines • Practice habits and routines

References • • • • • •

•

Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.

Easterlin, R.A. (2006). Life Cycle Happiness and Its Sources: Intersection of Psychology, Economies, and Demography. Journal of Economic Psychology, 27, 463-482.

Heckhausen, J. & Schulz, R. (1995). A life-span theory of control. Psychological Review, 102, 284304.

Hendricks, J. & Hatch, L.R. (2006). Lifestyle and aging. In R. Binstock & L.K. George (Eds.) Handbook of Aging and the Social Sciences (5th ed., pp. 301-319). San Diego, CA: Academic Press.

Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: The Well Elderly Study occupational therapy program. American Journal of Occupational Therapy, 52, 326-336.

Reichstadt, J., Depp, C. A., Palinkas, L. A., Folsom, D. P., & Jeste, D. V. (2007). Building blocks of successful aging: A focus group study of older adults' perceived contributors to successful aging.

The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 15(3), 194-201.

Schulz, R., & Heckhausen, J. (1996). A life span model of successful aging. American Psychologist, 51, 702-714.

Thank you!