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!