Can the Wonderful Life skills be used for the elderly?
We had the opportunity to have a discussion with Jan Thayer, an expert on aging. She pointed out that we are facing a crisis in care for the elderly. There is nothing effective being done to address the significant mental health issues experienced by many of the elderly.
She commented that the elderly are often just given anti-depressants and expected to “live with it.” She did not have a sense that the anti-depressants were effective. Rather, she saw that they created some very serious side effects (e.g., confusion, falling) that concerned her.
We talked extensively about the Wonderful Life project and what it was intended to do. After some careful consideration, she thought that we could modify the training/coaching materials and do the same type of work with the elderly. She felt so strongly that she gave approval to do the coaching in one of the facilities she owns—her “flagship” facility---Riverside Lodge in Grand Island, Nebraska.
This project began early in 2013. It ended in mid-2014.
What follows is an overview of a second research project—coaching the elderly on Wonderful Life skills.
Enhancing the well-being of the elderly
What is the problem?
A population shift is underway like we have never seen before. Beginning January 1, 2011, the oldest Baby Boomer turned 65. Every day for the next 19 years, roughly 10,000 people will turn 65. By 2030, when all the Boomers are at or over age 65, the proportion of our population age 65 and older will shift from the 13% we currently have in that age category to 18%. This shift will dramatically increase demand for services for the elderly.
Certainly, the demand for health care services will be among the most heavily impacted given that those ages 65 and older are most likely to use health care services. The concern for the expense given this huge increase in demand is certainly appropriate. It is not at all clear how this dramatically increased expense will be funded.
How can we reduce these costs? Clearly, we can cut the amount paid to healthcare providers for services provided. That isn't likely to succeed. Alternatively, we can shift the cost to the elderly. Again, something of a “non-starter” given that this is an age group that is living on retirement income—and the Boomers did not have a good record of preparing financially for retirement. A more viable alternative may be to reduce demand for health care services by enhancing the health of the elderly.
What is the single most expensive health care condition? Depression. The Center for Disease Control and Prevention said that during any two week period there will be 5.4% of us that experience depression.
For the elderly, the National Institute of Mental Health (NIMH) says those living in the community experience roughly the same level of depression (6.7%)—until there is a need for health care. For example, 13.5% of those receiving home health care are depressed. That is almost exactly the same rate for those residing in assisted living facilities---13%.
A study involving assisted living facilities in a four-state area found that over one third had symptoms of depression, including anxious expression, worrying, sad voice, or tearfulness. Those with depression experienced greater social withdrawal, psychosis, agitation, and length of residence in the facility. Those were discharged to nursing homes at a much higher rate—1.5 times those without depression.
NIMH also pointed out that an additional five million elderly have what they have referred to as “subsyndromal depression.” That is, these people show signs of depression but not to such an extent that they will be diagnosed with depression. This is associated with an increased risk of developing major depression. It’s reasonable to anticipate many of these will be residents of independent or assisted living facilities.
Isn’t depression just part of aging? NIMH says it definitely is not. They said that this is a common misperception among health care providers as well as many of the elderly themselves, but they are mistaken. “Depression is not a normal part of the aging process. Emotional experiences of sadness, grief, response to loss, and temporary ‘blue’ moods are normal. Persistent depression that interferes significantly with ability to function is not.” They further argue that this misperception leads to a low rate of diagnosis and treatment of the elderly.
It certainly appears that one way to reduce the cost of health care would be to reduce the risk of depression in independent and assisted living facilities.
The Institute of Medicine has said that the nation’s current system to care for the aging population is not adequately prepared for those suffering from mental illness.
Dan Blazer of Duke University Medical Center said that now is the time to prepare for these demands for the elderly. If we don’t, he argued, the elderly and their families will pay a high price. One way to prepare is to reduce the risk of depression.
The apparent conclusion is there are substantial numbers of people in independent or assisted living facilities that have depression, a second group are showing signs of depression that may be indicating they are on the way to developing depression, we are not prepared to address the depression currently being experienced and—with the huge increase in demand coming as Boomers age—we definitely are not prepared for the future. The question that must be asked is, “Where is the money going to come from to deal with all this depression?”
What can we do about it?
Maybe there is an alternative. Maybe we won’t have to come up with funding at the level currently expected. What if a method were developed that would reduce the risk of depression? If we can reasonably conclude that increased well-being reduces the risk of depression, then taking steps to enhance the well-being of those in independent or assisted living may be one way to reduce future incidence of depression.
Based on the suggestions of Jan Thayer and the staff at Riverside Lodge, a collection of coaching programs from the Wonderful Life project were modified for use for residents in independent or assisted living facilities. These topics include:
Others coaching topics were designed just for this project:
How was effectiveness evaluated?
To assess the impact of the coaching, measures were identified that were completed by participating residents at the Riverside Lodge facility. A group of residents at Northridge (the control facility) in Kearney, Nebraska, also completed the measures; however, they were not provided any training. In effect, the comparison between measures at the two sites was used to evaluate the effectiveness of the training.
These measures assess life satisfaction, depression, mental functioning, personality, self-esteem, and activities of daily living for residents. High functioning residents, as identified by the staff of each of the facilities, who are in assisted living or are in independent living were given the opportunity to participate in the study.
Anyone who was not able to attend, understand, or participate in the coaching sessions was not included in the study. For example, individuals with sight or hearing deficits were not asked to participate due to their limitations for learning the information. Residents who are able to participate in the study and wished to do so—participation is voluntary--were asked if they wanted to participate in the study and appropriate consent was obtained.
Survey packets were completed by residents at the beginning of the project and near the conclusion. The surveys were completed by the residents and returned in a sealed envelope. If the resident needed assistance in filling out the surveys, the researchers provided help by reading and/or marking responses for the resident.
The survey packet for the residents includes:
All survey packets remain anonymous. Only the aggregate data were used in the analyses for the study. There was no apparent risk to anyone involved in the project. Even so, the project was reviewed and approved by the Institutional Review Board of the University of Nebraska at Kearney to ensure proper procedures were maintained for the safety of the residents.
What were the results?
The results were quite apparent. Residents of Northridge, the facility that did not experience the training, experienced a 12% decline in their ability to perform activities of daily living (ADLs). Those who lived at Riverside and did experience the training saw no decline whatsoever. Neither group saw changes in cognitive impairment, personality or self-esteem during this time. As such, the results are credible. There was no apparent significant change in mental functioning that lead to the changes in the ADLs; it was due to the training.
The numbers of participants was not large and, as such, these results are not conclusive. Even so, they do suggest that the coaching
What this indicates is that through this coaching we may be able to make it possible for elders to live independently for longer periods of time. In doing so, they will have greater control of their lives, a greater sense of dignity, less likelihood of depression, and the cost of their care will be less. Certainly, this work warrants additional research.
Who are the partners in this effort?
The primary partners included the management and staff of Riverside Lodge; Deb Friend is executive director.
The scientists responsible for ensuring the training was appropriate are Robert Rycek, Ph.D., and Krista Fritson, Ph.D. Both work at the University of Nebraska at Kearney (UNK). Krista is a clinical psychologist with a strong interest in the tools being used in this project. Robert is a development psychologist and teaches human development and aging. Students from UNK will be involved in coordinating the surveys noted above. Krista and Robert will conduct the evaluation of the data generated by the project to determine its effectiveness.
Diann Muhlbach, a retired college instructor, conducted the one-on-one coaching for the residents at Riverside Lodge.
She commented that the elderly are often just given anti-depressants and expected to “live with it.” She did not have a sense that the anti-depressants were effective. Rather, she saw that they created some very serious side effects (e.g., confusion, falling) that concerned her.
We talked extensively about the Wonderful Life project and what it was intended to do. After some careful consideration, she thought that we could modify the training/coaching materials and do the same type of work with the elderly. She felt so strongly that she gave approval to do the coaching in one of the facilities she owns—her “flagship” facility---Riverside Lodge in Grand Island, Nebraska.
This project began early in 2013. It ended in mid-2014.
What follows is an overview of a second research project—coaching the elderly on Wonderful Life skills.
Enhancing the well-being of the elderly
What is the problem?
A population shift is underway like we have never seen before. Beginning January 1, 2011, the oldest Baby Boomer turned 65. Every day for the next 19 years, roughly 10,000 people will turn 65. By 2030, when all the Boomers are at or over age 65, the proportion of our population age 65 and older will shift from the 13% we currently have in that age category to 18%. This shift will dramatically increase demand for services for the elderly.
Certainly, the demand for health care services will be among the most heavily impacted given that those ages 65 and older are most likely to use health care services. The concern for the expense given this huge increase in demand is certainly appropriate. It is not at all clear how this dramatically increased expense will be funded.
How can we reduce these costs? Clearly, we can cut the amount paid to healthcare providers for services provided. That isn't likely to succeed. Alternatively, we can shift the cost to the elderly. Again, something of a “non-starter” given that this is an age group that is living on retirement income—and the Boomers did not have a good record of preparing financially for retirement. A more viable alternative may be to reduce demand for health care services by enhancing the health of the elderly.
What is the single most expensive health care condition? Depression. The Center for Disease Control and Prevention said that during any two week period there will be 5.4% of us that experience depression.
For the elderly, the National Institute of Mental Health (NIMH) says those living in the community experience roughly the same level of depression (6.7%)—until there is a need for health care. For example, 13.5% of those receiving home health care are depressed. That is almost exactly the same rate for those residing in assisted living facilities---13%.
A study involving assisted living facilities in a four-state area found that over one third had symptoms of depression, including anxious expression, worrying, sad voice, or tearfulness. Those with depression experienced greater social withdrawal, psychosis, agitation, and length of residence in the facility. Those were discharged to nursing homes at a much higher rate—1.5 times those without depression.
NIMH also pointed out that an additional five million elderly have what they have referred to as “subsyndromal depression.” That is, these people show signs of depression but not to such an extent that they will be diagnosed with depression. This is associated with an increased risk of developing major depression. It’s reasonable to anticipate many of these will be residents of independent or assisted living facilities.
Isn’t depression just part of aging? NIMH says it definitely is not. They said that this is a common misperception among health care providers as well as many of the elderly themselves, but they are mistaken. “Depression is not a normal part of the aging process. Emotional experiences of sadness, grief, response to loss, and temporary ‘blue’ moods are normal. Persistent depression that interferes significantly with ability to function is not.” They further argue that this misperception leads to a low rate of diagnosis and treatment of the elderly.
It certainly appears that one way to reduce the cost of health care would be to reduce the risk of depression in independent and assisted living facilities.
The Institute of Medicine has said that the nation’s current system to care for the aging population is not adequately prepared for those suffering from mental illness.
Dan Blazer of Duke University Medical Center said that now is the time to prepare for these demands for the elderly. If we don’t, he argued, the elderly and their families will pay a high price. One way to prepare is to reduce the risk of depression.
The apparent conclusion is there are substantial numbers of people in independent or assisted living facilities that have depression, a second group are showing signs of depression that may be indicating they are on the way to developing depression, we are not prepared to address the depression currently being experienced and—with the huge increase in demand coming as Boomers age—we definitely are not prepared for the future. The question that must be asked is, “Where is the money going to come from to deal with all this depression?”
What can we do about it?
Maybe there is an alternative. Maybe we won’t have to come up with funding at the level currently expected. What if a method were developed that would reduce the risk of depression? If we can reasonably conclude that increased well-being reduces the risk of depression, then taking steps to enhance the well-being of those in independent or assisted living may be one way to reduce future incidence of depression.
Based on the suggestions of Jan Thayer and the staff at Riverside Lodge, a collection of coaching programs from the Wonderful Life project were modified for use for residents in independent or assisted living facilities. These topics include:
- Forgiveness--getting rid of grudges
- Happiness
- Trust
- Positive emotions, resilience, and hope
- Stress management
- Fulfillment
- Life planning---focus on life review and planning
Others coaching topics were designed just for this project:
- Shifting family relationships—role transitions
- Redefining oneself
- Health and aging--both physical and mental
- Managing profound change/dealing with loss
- The coaching was provided one-on-one to each of 26 residents in Independent Living or Assisted Living at Riverside Lodge. Each sessions lasted approximately one hour and continued at the rate of one per month for eleven months.
How was effectiveness evaluated?
To assess the impact of the coaching, measures were identified that were completed by participating residents at the Riverside Lodge facility. A group of residents at Northridge (the control facility) in Kearney, Nebraska, also completed the measures; however, they were not provided any training. In effect, the comparison between measures at the two sites was used to evaluate the effectiveness of the training.
These measures assess life satisfaction, depression, mental functioning, personality, self-esteem, and activities of daily living for residents. High functioning residents, as identified by the staff of each of the facilities, who are in assisted living or are in independent living were given the opportunity to participate in the study.
Anyone who was not able to attend, understand, or participate in the coaching sessions was not included in the study. For example, individuals with sight or hearing deficits were not asked to participate due to their limitations for learning the information. Residents who are able to participate in the study and wished to do so—participation is voluntary--were asked if they wanted to participate in the study and appropriate consent was obtained.
Survey packets were completed by residents at the beginning of the project and near the conclusion. The surveys were completed by the residents and returned in a sealed envelope. If the resident needed assistance in filling out the surveys, the researchers provided help by reading and/or marking responses for the resident.
The survey packet for the residents includes:
- The Instrumental Activities of Daily Living (IADLS) is a 20-item self-report measure that examines functional abilities in everyday living.
- The Mini-mental Status Exam (MMSE) which is a 30-point questionnaire used to screen cognitive impairment (dementia). This is a screening device commonly used in assisted living, nursing home, and hospital settings to assess dementia.
- Big Five Personality Traits. This is a shortened version of the Big Five Personality Assessment. Participants rate themselves on a 5-point scale on 15 adjective pairs.
- The Rosenberg Self-Esteem Scale. A ten-item self-report measure designed to measure global feelings of self-worth or self-acceptance.
All survey packets remain anonymous. Only the aggregate data were used in the analyses for the study. There was no apparent risk to anyone involved in the project. Even so, the project was reviewed and approved by the Institutional Review Board of the University of Nebraska at Kearney to ensure proper procedures were maintained for the safety of the residents.
What were the results?
The results were quite apparent. Residents of Northridge, the facility that did not experience the training, experienced a 12% decline in their ability to perform activities of daily living (ADLs). Those who lived at Riverside and did experience the training saw no decline whatsoever. Neither group saw changes in cognitive impairment, personality or self-esteem during this time. As such, the results are credible. There was no apparent significant change in mental functioning that lead to the changes in the ADLs; it was due to the training.
The numbers of participants was not large and, as such, these results are not conclusive. Even so, they do suggest that the coaching
What this indicates is that through this coaching we may be able to make it possible for elders to live independently for longer periods of time. In doing so, they will have greater control of their lives, a greater sense of dignity, less likelihood of depression, and the cost of their care will be less. Certainly, this work warrants additional research.
Who are the partners in this effort?
The primary partners included the management and staff of Riverside Lodge; Deb Friend is executive director.
The scientists responsible for ensuring the training was appropriate are Robert Rycek, Ph.D., and Krista Fritson, Ph.D. Both work at the University of Nebraska at Kearney (UNK). Krista is a clinical psychologist with a strong interest in the tools being used in this project. Robert is a development psychologist and teaches human development and aging. Students from UNK will be involved in coordinating the surveys noted above. Krista and Robert will conduct the evaluation of the data generated by the project to determine its effectiveness.
Diann Muhlbach, a retired college instructor, conducted the one-on-one coaching for the residents at Riverside Lodge.
Copyright©Wonderful Life Project, LLC (2013)
