Program Planning for an Assisted Living Community
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Scott D. McPhee, MS, DrPH, OTR, FAOTA Timothy Johnson, DA ABSTRACT. Occupational therapy has long had a vested interest in activity programming for the elderly. During the past, this interest has been largely confined to adult day care centers for community dwelling elderly, and to nursing homes for long term care of the elderly. In light of the interest generated by the recent entry of assisted living into the housing continuum, program models and understanding of the population of people who choose this option are of interest. This article introduces one model of wellcare for assisted living residents and describes a population of 626 residents in approximately 30 Morningside assisted living communities dispersed over the Southeast. The Healthy Generation model outlined in this article emphasizes five separate but inter-related domains that have been shown to impact the quality of life of aging individuals. Through the use of a multidimensional instrument, these domains (intellectual, social, physical, spiritual and emotional) are surveyed at the time each resident moves into a Morningside community. The resulting picture of the population is utilized by the assisted living program planners to create a monthly balanced calendar that intentionally engages each domain to support and enhance resident function and well being. This model has a direct bearing on practice of geriatric occupational therapy and this emerging area of practice. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: [email protected] ]
Scott D. McPhee is Associate Dean and Chair, School of Occupational Therapy, Belmont University. Timothy Johnson is Assistant Professor, Department of Physical Education, Health and Wellness, Belmont University. The authors wish to acknowledge the following for their early contributions to the writing of this article: Susan Cheatham, MBA, Director of Programming, LifeTrust America, Inc.; Elaine Blake, MSN, RN, Assistant Professor, Sharon Dowdy, PhD, RN, Assistant Professor, Lynne S. Shores, PhD, RN, Associate Professor, School of Nursing, Belmont University; and Debra B. Wollaber, PhD, RN, Dean, College of Health Sciences, Belmont University. Occupational Therapy in Health Care, Vol. 12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
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KEYWORDS. Gerontology, assisted living, wellcare, activity programming, occupational therapy
‘‘Meeting the wellcare, fitness, nutrition and spiritual needs of our residents will enhance their quality of life and help produce a healthier generation.’’
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R. Clayton McWhorter, 1997 INTRODUCTION The US Census reports that by the year 2000, there will be 35 million people who are older than 65 years, 4.6 million people over 85 years of age, and 61,000 who are over 100 years old (US DHHS, 1992). Independence as one ages has long been a guiding standard for families, healthcare providers and older adults themselves. However, as the number of adults over the age of 65 years increases, providing some assistance in daily living becomes necessary for many. To encourage the independence of these older adults, the concept of an assisted living environment has emerged. Assisted living represents a substantial expansion in the housing market for the older adult. In this environment, older adults can receive a range of assistance with daily living needs without giving up the independence and autonomy as often occurs in nursing homes. The demand for assisted living units is expected to increase from the current 7500 new units annually to over 9000 units per year. Assisted living differs dramatically from a nursing home environment. Whereas the nursing home concept endorses the medical model (dependency, regulations, invasive/clinical, institutionalized), assisted living embraces a social model (independence, flexibility, privacy/dignity, individual choice, homelike, reasonable risk). In this paper, one model for assisted living developed by LifeTrust America, Inc. will be outlined and the population of residents living in this environment will be described. Morningside, the name given to all LifeTrust America assisted living communities, brings a unique blend of hospitality and wellcare to the partnership they offer to older adults and their families. Values central to LifeTrust’s mission include promoting quality of life, staff
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training and fostering teamwork. Core to their philosophy is a holistic approach to the care of their residents. Provided at all Morningside assisted living communities, Healthy Generation is the wellcare program designed to sustain independence and promote a balanced lifestyle for residents. The purpose is to create a culture and environment that enhances the quality of daily living at Morningside. This holistic program is built around five domains of health: social, physical, intellectual, emotional, and spiritual. The philosophy is carried out through a balanced calendar of activities that is developed monthly for each community. Research literature documents that functional capacity and quality of life in old age are associated with multiple dimensions rather than any single descriptive factor. Through systematic application of this approach in an assisted living environment, the Healthy Generation model offers a distinctive advantage toward meeting residents’ needs. Review of the Literature Using descriptive categories to characterize the aging process is not new. George and Fillenbaum (1985) developed the Older Americans Resource and Services (OARS) questionnaire to measure functional capacity in five dimensions: social resources, economic resources, mental health, physical health, and activities of daily living. They emphasized that functioning is associated with multiple, interacting dimensions and not reliant on single factors alone. Krach et al. (1996) examined six domains of functioning with a population of older persons, over the age of 85. They concluded that the domains of physical, mental, social, spiritual, economic, and activities of daily living are important areas of study with this older population. They further found that a multidimensional assessment of these domains is necessary to provide intervention strategies to regain, maintain or enhance functioning in the oldest-old people. Maxson, Berg and McClearn (1997), reporting on their patterned approach to study of the aging process, found that the domains of well being, physical health, functional capacity, cognitive abilities, and social contacts enhance the descriptive efficiency for reporting functional status relative to the aging process. Since functional status spans all domains, the outcome of maintaining activity in all domains contributes to the maintenance of overall functional independence. The Healthy Generation model is aimed at incorporating such a multidi-
OCCUPATIONAL THERAPY IN HEALTH CARE
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mensional approach to interactions and activities that may maintain function and promote quality of life (see Figure 1). The social domain encompasses the ability to communicate, establish relationships and live in harmony with others within the community and the environment. Maintaining interaction with one’s peers has been clearly shown to have a positive effect on quality of life (Russell et al., 1998; Maxson, 1997). Koenig (1994) reports that there is an inter-relatedness among the social, physical, intellectual and spiritual factors associated with the aging process. If one factor is affected, this will affect the performance within and between other factors as well. The physical domain relates to the physiological and functional condition of the body and how it responds to physical activity, nutrition and disease. The physical health of community-dwelling elderly has been studied extensively. Overall, studies have shown that, for the older population, regular physical activity and exercise is associated with positive functional outcomes (Chandler et al., 1998; Brill et al., 1998; Horowitz et al., 1997; Fiatarone et al., 1994; Hamdorf et al., 1992). Further, research shows that there is a positive association between physical activity, social interaction and functional independence (Unger et al., 1997).
FIGURE 1. Elements that Comprise the Healthy Generation Model
Spiritual: Physical: Fitness Functional Capacity Disability Nutrition Safety Self-Care
Meaning and Purpose Values Ethics
Emotional: Relationships Personal Satisfaction Self-esteem Decrease Anxiety & Stress Feelings of well-being Sexuality
Social:
Intellectual:
Social Interactions Interpersonal Relationships Family Community Environment
Mental Health Creative Thinking Informational Skills Decision Making
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The emotional domain emphasizes the exploration of feelings that each individual has toward self, situations, and other people, the awareness of one’s own emotions and how to cope with everyday life and stress. Maxson et al. (1997) found that older adults who have high social scores also did well in the area of cognition, regardless of their level of health status. Looking at patterns associated with the aging process, their data concludes that the greater the number of social contacts maintained, the better older adults perform cognitively, the stronger their feeling of well being, and the greater their level of life satisfaction. The intellectual domain encourages creative thinking and promotes lifelong learning to stimulate an individual’s ability to make sound decisions (Ardelt, 1997; Willis, 1996). Research findings show a modest cognitive decline in performing complex everyday tasks during the ages of 60-69 and a more significant decline in the late 70s and 80s. Ardelt (1997) states that ‘‘. . . successful aging in the later years has to do with both one’s developmental and social pathways. The impact of objective conditions on life satisfaction in old age depends on the specific circumstances of the individual, their vulnerabilities, anxieties, and strengths, whereas a lifelong accumulation of wisdom tends to increase life satisfaction for all people’’ (p. 24). Her research clearly demonstrates the inter-relatedness of the intellectual, social and emotional domains. As defined by the National Interfaith Council on Aging (Thorson, 1980), spiritual well being is the affirmation of life in a relationship with God, self, community, and environment that nurtures and celebrates wholeness. Spiritual elements include the ability to seek purpose and meaning in life, to love, to forgive, to pray, and to worship. Several authors have concluded that involvement with religion has a significant impact upon an older population’s quality of life (Russell et al., 1998; Zorn and Johnson, 1997; Koenig, 1994; Buchanan, 1993; Nelson, 1990). Further, Koenig (1994) reports a positive relationship between cognitive function and spirituality; as cognitive function increases, spirituality increases as well, and as cognitive function decreases, so does spirituality. He further demonstrates that social support, physical activity, and mental alertness impact spirituality. This brief review provides support from the research literature for the inter-relatedness of the social, intellectual, physical, spiritual and emotional domains. Carrying this philosophy into the daily lives of
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residents of assisted living communities is the challenge. Healthy Generation has been designed as the vehicle to accomplish this in the Morningside population described in this paper.
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SURVEY RESULTS The Healthy Generation Assessment Tool is a self-reported, health status survey that contains questions related to each of the five target domains as well as items concerned with clinical and medical data. Each assessment was completed with the help of a Morningside Program Coordinator specifically trained to administer the tool and was assessed by the School of Occupational Therapy at Belmont University. The survey is designed to (1) provide information about each resident’s needs and interests for program planning in each individual community and (2) to provide LifeTrust with a summative picture of its resident population. Statistical Analysis was completed using a SPSS package for descriptive and inferential statistics. The KruskalWallis H test was used to determine whether the independent samples were from the same population. The descriptive results presented here are based on survey reports from a total of 626 assisted living residents from Morningside communities in three southeastern states (Tennessee, Georgia, and Alabama) during 1998 and 1999. The survey was part of routine entry information gathering. Of the 626 residents surveyed to date, 117 were male and 509 were female. The overall average age was 83.3 years (males 81.7 years and females 83.6 years). For the purposes of this study, the ages of residents will be divided into three categories: young-old (60-75 years), old-old (76-84 years), and oldest-old (85 years and older) in keeping with categories commonly used in literature on aging (Neugarten, 1978). Table 1 displays information regarding the health status of Morningside residents. The table is divided into four sections: self-perception of overall state of health, medical problems (diagnosed problems), health-related problems (complaints not specific to established diagnoses), and preventive care. With regards to the self-perception of health status, the young-old differed significantly from the other groups in that they felt that their health was better than a year ago. This group, less than 75 years of age, was also least likely to report their
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TABLE 1. Health Care Status for Morningside Residents (N = 626)
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Condition
< 75 Years (n = 86)
76-84 Years (n = 255)
85+ Years (n = 285)
n (%)
n (%)
n (%)
pa
Self Perception of Health Status Health gets in way of doing things Health is better than 1 year ago Overall Health -- excellent to good
36 (.43) 23 (.27) 48 (.57)
82 (.32) 43 (.17) 169 (.68)
95 (.35) 34 (.13) 204 (.76)
.069 .138 .000
Medical Problems (currently diagnosed) Stomach Problems Circulatory Problems High Blood Pressure Breathing Problems Memory Problems Urinary Problems Heart Problems Parkinson’s Depression Diabetes Arthritis Cancer Stroke
21 (.25) 29 (.35) 36 (.43) 16 (.19) 25 (.30) 21 (.26) 13 (.16) 11 (.13) 25 (.31) 22 (.27) 35 (.44) 4 (.05) 25 (.30)
55 (.22) 54 (.22) 86 (.34) 47 (.19) 90 (.37) 50 (.20) 47 (.19) 12 (.05) 41 (.17) 22 (.09) 128 (.53) 2 (.08) 47 (.19)
63 (.23) 81 (.30) 72 (.27) 35 (.13) 112 (.42) 87 (.32) 74 (.27) 9 (.03) 52 (.19) 21 (.08) 121 (.45) 6 (.02) 46 (.17)
.216 .059 .019 .193 .132 .004 .050 .007 .008 .000 .194 .695 .037
Health Related Problems (non-diagnosed) Decreased appetite Foot/Toe problems Fatigue/Lack of energy Tooth/Denture problems Chronic pain Urinary problems Weight gain/loss
20 (.23) 34 (.40) 49 (.60) 21 (.25) 31 (.37) 25 (.30) 32 (.38)
45 (.18) 86 (.35) 123 (.49) 56 (.23) 71 (.29) 85 (.34) 65 (.26)
51 (.19) 102 (.38) 146 (.55) 48 (.18) 68 (.26) 105 (.40) 61 (.23)
.551 .629 .183 .250 .137 .210 .024
Preventive Care Activities Dental exam in last year Vision exam in last year Hearing exam in last year Flu shot within last year Colonoscopy in last year Pneumonia vaccination Blood pressure check last year
47 (.55) 58 (.69) 24 (.29) 58 (.69) 24 (.29) 40 (.49) 78 (.95)
154 (.62) 168 (.69) 79 (.32) 183 (.75) 72 (.29) 130 (.53) 226 (.94)
149 (.55) 183 (.68) 116 (.43) 206 (.77) 58 (.22) 119 (.46) 240 (.92)
.197 .969 .010 .294 .147 .207 .456
Women only: Pap smear in last year Mammogram in last year Bone density in last year
34 (.53) 36 (.56) 21 (.34)
87 (.44) 87 (.44) 42 (.21)
65 (.28) 80 (.36) 36 (.17)
.000 .012 .011
Men only: PSA/Prostate exam last year
11 (.58)
29 (.57)
30 (.73)
.243
aKruskal-Wallis
H One Way Analysis of Variance test; age divided into three grouping variables
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overall health as excellent to good. This seems to suggest that some illness event preceded their move to assisted living at this early age. There is no significant difference in 6 of the 20 medical and healthrelated problems in the three age groups. Of interest, the young-old category has a higher incidence of specific medical problems such as high blood pressure and diabetes while general complaints of heart and urinary problems were more often reported by the oldest age group. Not surprisingly, the most reported medical condition across all age groups was arthritis; about half the residents acknowledged this as a current complaint. The most frequently reported non-specific healthrelated problem was fatigue and lack of energy (60%, 49% and 55%, respectively, youngest to oldest). Depression was highest in the young-old (31% reported) and modestly lower in older groups (17% and 19%, respectively). Clearly, concern for healthcare issues and accessibility of healthcare resources must be a consideration in planning a successful assisted living model. Further, health related problems have a direct bearing on activity planning for this age population. With a few exceptions, all three age groups report approximately the same involvement in preventive care activities. However, women are less likely to have had regular pap smears, mammograms or bone density measures completed at older ages while men are more likely to have PSA and prostate exams as they age. Table 2 summarizes results of four of five domains studied in the survey (physical, social, cognitive and spiritual domains). The physical domain shows no significant difference in four of its five reported elements across ages. It is noteworthy that there is no reported difference in the percentages of respondents who participate in physical exercise or recreational activities. Yet, the number of residents stating that they walk unassisted drops significantly as they age. Interestingly, with each age category it was reported that approximately one third had fallen during the past year (36%, 33% and 31%, respectively, youngest to oldest). Compare this to annual fall incidence among community dwelling older adults reported to increase from 25% at 70 years to 40% after age 80 (Campbell et al., 1989). Annually, about 50% of nursing home residents are expected to fall (Gryfe et al., 1977; Thapa et al., 1996). The Social domain is revealing about the residents’ outlook on life. There is no significant difference between the three groups in the three elements of this domain. Although each age group reports that less than a third participate in group activities, a small percentage attribute
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TABLE 2. Descriptions of Domains for Morningside Residents; Percents Indicate Those Residents Who Responded Positively to the Category (N = 626) Condition
pa
< 75 Years (n = 86)
76-84 Years (n = 255)
85+ Years (n = 285)
n (%)
n (%)
n (%)
51 (.61) 47 (.57) 47 (.56) 31 (.36) 35 (.44)
158 (.63) 149 (.62) 166 (.67) 81 (.33) 112 (.49)
159 (.59) 156 (.59) 167 (.62) 85 (.31) 77 (.29)
.586 .774 .270 .592 .000
3 (.04) 29 (.34) 40 (.46) 10 (.12) 24 (.28) 29 (.35) 71 (.85) 63 (.77)
25 (.10) 59 (.23) 77 (.30) 28 (.11) 77 (.30) 83 (.33) 214 (.87) 206 (.83)
10 (.04) 66 (.23) 83 (.29) 29 (.10) 80 (.28) 90 (.33) 233 (.87) 199 (.75)
n/a n/a n/a n/a n/a .949 .965 .452
30 (.61) 17 (.35) 0 (.00) 2 (.04)
80 (.43) 54 (.29) 28 (.15) 24 (.13)
76 (.38) 42 (.21) 64 (.32) 18 (.09)
6 (.10) 15 (.25) 7 (.12) 31 (.52)
11 (.07) 40 (.24) 24 (.14) 90 (.54)
1 (.05) 27 (.14) 30 (.16) 131 (.69)
Physical Domain
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Physical exercise or recreation Enjoy exercise or recreation Participate greater than once/week Recent fall to ground or on stairs Unassisted walking Social Domain Social Contacts in the area: Spouse Son Daughter Sibling Other Relatives Participate in group activities Enjoy social interactions Have a best friend
.003
Cognitive Domain Intact mental functioning Mild mental impairment Moderate mental impairment Severe mental impairment Spiritual Domain Belief important to small extent Belief important to moderate extent Belief important to large extent Belief is most important aKruskal-Wallis
.011
H One Way Analysis of Variance test; age divided into three grouping variables
this to being unable for health reasons. This is true for both male and female respondents. Given this finding, each age group shows a high percentage of respondents who would like to be socially involved and report having a best friend. Dividing this factor by age and gender, the response was constant across all age groups for both genders. Table 2 lists the relatives that live near the Morningside residents. As expected, few report spouse as the relative close by. The percentage having a son or daughter in the community is near 50% in young old
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residents but dwindles considerably in the old-old (sons-- 24%; daughters-- 31%). Report of ‘‘other relatives’’ in the community remains relatively constant as residents age. The Cognitive domain was measured using the Short Portable Mental Status Questionnaire (Pfeifer, 1975). After adjusting for education, results indicated a significant difference between the three age categories (H = 16.13; p = .000), particularly between the youngest-old and the other two categories. Overall, the data shows that as the population ages, there is a decrease in mental capacity for both the male and female groups. When dividing the data by age and gender, results show that the female population maintained intact cognition during most of the aging process (63%, 43%, and 40% for the three age groups, respectively). However, for the male population, the decrease was more dramatic as they aged (54%, 45%, and 27%, respectively). The Spiritual Domain was measured by the Religious Coping Index (Koenig, 1994). This index was designed to generate an overall spirituality score for an elderly population. Koenig defines spirituality as belief in God and reliance on prayer as a way of coping with difficult times. The overall mean spirituality score was 21.44 (score of 30 possible). Separated by gender, the scores were 17.47 for males, and 22.53 for females. The mean spirituality score by category is as follows: youngest-old, 19.61; old-old, 20.33; oldest-old, 22.98 (H = 15.28; p < .000). The biggest difference in spirituality scores is between the youngest-old and the oldest-old categories. Russell et al. (1998) found, in their longitudinal study of individuals 65 and older, that physical health is significantly related to church involvement. In their study of rural older adults in Iowa, those who reported attending church regularly during their baseline interviews were less likely to die over the subsequent 12 to 13 years. Our findings show support for Russell’s study in that a strong association was found between age and spirituality (rho = .195; p = .000). This indicates that the older the population, spirituality is given more importance. Further, a significant positive correlation exists between spirituality and life satisfaction (rho = .119; p = .017), interest in life (rho = .156; p = .000). These findings indicate that the stronger the spiritual scores, the more satisfied they are with their lives. Table 3 displays information about the Emotional domain. The Philadelphia Geriatric Center Morale Scale (Lawton, 1975) is the tool used to measure the emotional domain in the Healthy Generation
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TABLE 3. Emotion Domain Results for Morningside Residents; Mean Response by Year Group (N = 626) < 75 Years (n = 86)
76-84 Years (n = 255)
85+ Years (n = 285)
mean (SD)
mean (SD)
mean (SD)
4.34 (1.52) 2.43 (1.34) 4.35 (1.40) 11.13 (3.27)
3.98 (1.78) 2.13 (1.36) 4.04 (1.48) 10.14 (3.67)
pa
PGCMSb Subscales
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Factor 1: Agitation scale Factor 2: Attitude toward aging scale Factor 3: Lonely dissatisfaction scale Overall Morale Score
3.65 (1.88) 2.34 (1.12) 3.87 (1.81) 10.00 (3.65)
.012 .037 .044 .012
aKruskal-Wallis
H One Way Analysis of Variance test; age divided into three grouping variables Geriatric Center Morale Scale The mean score (standard deviation) for the PGCMS for factor 1 is 4.28 (1.65), factor 2 is 2.17 (1.56), factor 3 is 4.81 (1.50), and total is 11.35 (3.76).
bPhiladelphia
survey. This scale has been found to be a good measure of global life satisfaction (Liang and Bollen, 1983). The scale divides into three factors. Factor 1 measures agitation, which is characterized by anxiety experienced in older persons. Factor 2 addresses attitude toward one’s own aging process. Factor 3 looks at lonely dissatisfaction which represents the older person’s acceptance or dissatisfaction with the amount of social interaction they are presently experiencing. The results show a significant difference between the three populations when comparing each Factor subscale and overall Morale total. The higher the mean score, the higher the morale within each factor and overall score. With exception of the Attitude toward aging scale, all scores from this study fall below the published mean scores of the PGCMS. Within the Attitude subscale, the young-old and old-old populations scored slightly above the published means. Looking at the subscales in more detail, the young-old seem to have a higher level of agitation and a more pronounced lonely dissatisfaction. Within the subscale for attitude toward aging, the oldest-old population has a somewhat lower score. Overall, the old-old population presents a higher level of morale than the other groups. HEALTHY GENERATION BALANCED CALENDAR PROGRAMMING Assisted living developed as an option in the geriatric housing market in the continuum of care between community and nursing
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home in the continuum of care. Through the Healthy Generation model, LifeTrust has created an assisted living environment that goes beyond the provision of shelter and security. With the help of a consistent data collection system, the needs of new residents can be readily identified and addressed promptly. Drawing on this information and the holistic knowledge of the most important health and wellness needs of older adults, a unique approach to activity programming has been implemented to support and stimulate resident’s abilities to enhance and maintain their quality of life. The greatest challenge for a dispersed, multi-community organization such as LifeTrust America is to disseminate the core philosophy of wellness down to the individual resident’s daily experience. The vehicle for accomplishing this in Morningside communities is the Healthy Generation Balanced Calendar created at each community location monthly. To begin, LifeTrust’s centralized Program Development office initiates a package of programs and event ‘‘guides’’ that goes to each Program Coordinator. This package is made up of core, required programs. Each program or event is coded to indicate the domains of health engaged by the residents’ participation. Figure 2 illustrates an example of how programs are developed. ‘‘Core’’ programs have been developed to meet the most important health and wellcare needs of residents identified through LifeTrust’s knowledge of the health concerns and problems of older adults and results from the Healthy Generation survey. Examples of these core programs are a falls prevention education program and physical activity programs geared to recent research recommendations regarding the importance of strength building for even the oldest-old individuals. ‘‘Required’’ programs are special programs designed by the centralized Program Development office around a theme for each month; these programs are required offerings in each Morningside location. The program event, a ‘‘Sense-ual Thanksgiving,’’ a step-bystep plan for each community’s Program Coordinator to provide an experience where residents reminiscence about the smells, tastes, feelings, sounds, and sights of Thanksgiving, is one example of a required program. In addition, each local Program Coordinator selects ‘‘elective’’ programs to round out the calendar for their community and assure that all domains are addressed throughout the month. By combining core, required and elective programs, a calendar is tailored to meet the
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FIGURE 2. Balanced Calendar for November: Selected Programming Examples Program
Description
Domains
Core Programs: S *Fit for Life
S Hydration Break
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S Fall Recovery Class
S Exercise/fitness program designed to promote movement and enhance function S Two scheduled water breaks daily & education on the importance of hydration S Video, discussion & practice for residents at high risk for falling
S Physical, Emotional, Social
S Reminiscence experience through the use of seasonal items to stimulate memories to share S Brief history of the Mayflower and Pilgrims followed by sharing of individual family heritage S Creation of a bulletin board of the community’s thankful list with resident photos and their statements collected by visiting each individual
S Emotional, Spiritual, Intellectual, Social, Physical
S Based on needs and interests of residents S Customized at the community level
S Assure engagement of all domains
S Physical, Emotional, Intellectual, Social S Physical, Emotional, Intellectual, Social
Required Programs: S Sense-ual Thanksgiving
S Thanksgiving Awareness
S I am Thankful for
S Intellectual, Spiritual, Social, Emotional
S Emotional, Spiritual, Intellectual, Social
Elective Programs: S Selected to round out the balanced calendar
specific needs and interests at each individual community. The ‘‘balanced’’ calendar carries the holistic philosophy of Healthy Generation through to individual residents. Descriptions of ‘‘successes’’ associated with that month’s programming are shared with the central Program Development office and serve as an anecdotal evaluation of the benefits of various programs. This method of providing centralized planning as well as supporting local facility program planning best meets the needs of the residents. Further, by providing assistance in preparation planning for the activities reduces the pressure on the facilities personnel to ensure
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success in the programming efforts. Finally, such a method of program planning is consistent with what criteria Edwards (1994) reports must exist in order to offer successful activity programs that will positively affect health behaviors. These include: Stressing that one is not too old to change.
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Promoting the immediate benefits of the activity. Establishing a link between the healthy behaviors and specific health problems. Providing specific information about the actions required. Providing group support and an opportunity to rehearse or practice the behavior. Including the older adults in the planning process. (page 279) CONCLUSION The Healthy Generation model is made up of three parts: (1) a holistic philosophy identified as five domains of health and wellness important to older adults, (2) a survey instrument that provides information about these five domains on Morningside residents, and (3) a balanced program of events and activities that flows from the model. Results of the Healthy Generation Survey offer a snapshot of the residents in each individual community, as well as in the entire network of Morningside communities operated by LifeTrust America, Inc. With this data, LifeTrust can address the needs of residents individually and as an entire population. From this picture of their residents and a belief that quality of life and a sense of wellbeing result from attention to the needs of the whole person, a monthly calendar for each Morningside community is developed that engages each domain. Repeated use of the Healthy Generation Survey over time will provide a means of evaluating outcomes of various programming elements and interventions. In keeping with the social model, it is acknowledged that each resident has a choice about which program
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elements and activities she/he will participate in. The assisted living community is the resident’s home. This concept is presented as part of the culture in the training of each staff member. In conclusion, this paper has described one assisted living model, Morningside, and its holistic wellcare approach, Healthy Generation. In addition, an initial description of the residential population has been provided from compilation of results from the Healthy Generation survey administered to all entrants to Morningside communities. While not yet proven, continued refinement and use of the survey instrument will provide a useful data base to guide programming, to address resident needs, and to follow, over time, the population of older adults who seek to make their homes in Morningside assisted living communities. This is an instrument and a conceptual model that can support the occupational therapist’s efforts to provide activity programming for assisted living residents that can support their efforts to remain in an assisted living environment as well as help to attain and maintain a healthy lifestyle. REFERENCES Ardelt, M. (1997). Wisdom and life satisfaction in old age. Journal of Gerontology, 52B(1): 15-27. Brill, P. A., Jensen, R. L., Koltyn, K.F., Morgan, L. A., Morrow, J. R., Keller, M.J., & Jackson, A.W. (1998). The feasibility of conducting a group-based progressive strength training program in residents of a multi-level care facility. Activities, Adaptation & Aging, 22(4): 53-63. Buchanan, D. M. (1993). Meaning-in-Life, Depression and Suicide in Older Adults: A Comparative Survey Study. Rush University: College of Nursing. Campbell, A. J., Borrie, M. J., & Spears, G. F. (1989). Risk factors for falls in a community-based prospective study of people 70 years and older. Journal of Gerontology, 44: M112-M117. Chandler, J. M., Duncan, P. W., Kochersberger, G., & Studenski, S. (1998). Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community dwelling elders? Archives of Physical Medicine and Rehabilitation, 79(1):24-30. Edwards D. F. (1994). Prevention of performance deficits. In Bonder, B. R. & Wagner, M. B. (eds): Functional Performance in Older Adults, F. A. Davis Company, Philadelphia, PA. Fiatarone, M. A., O’Neill, E. F., Ryan, N. D., Clements, K.M., Solares, G. R., Nelson, M. E., Roberts, S. S., Kehayias, J. J., Lipsitz, L. A., & Evans, W. J. (1994). Exercise training and nutritional supplementation for physical frailty in very elderly people. The New England Journal of Medicine, 330(25): 1769-1775.
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George, L. K. & Fillenbaum, G. G. (1985). OARS methodology: A decade of experience in geriatric assessment. Journal of American Geriatrics Society 33(9): 607-615. Gryfe, C. I., Amies, A., & Ashley, M. J. (1977). A longitudinal study of falls in an elderly population: Incidence and morbidity. Age Aging 6:210. Hamdorf, P. A., Withers, R. T., Penhall, R. K., & Haslam, M. V. (1992). Physical training effects on the fitness and habitual activity patterns of elderly women. Archives of Physical Medicine Rehabilitation, 73(7): 603-608. Horowitz, B. P., Tollin, R., & Cassidy, G. (1997). Grip strength: Collection of normative data with community dwelling elders. Physical & Occupational Therapy in Geriatrics, 15(1): 53-64. Koenig, H. G. (1994). Aging and God: Spiritual pathways to mental health in midlife and later years, New York: Haworth Press. Krach, P., Devaney, S., DeTurk, C., & Zink, M.H. (1996). Functional status of the oldest-old in a home setting. Journal of Advanced Nursing, 24(3): 456-64. Lawton, M.P. (1975). The Philadelphia center morale scale: A revision. Journal of Gerontology, 30: 85-89. Liang, J. & Bollen, K. A. (1983). The structure of the Philadelphia Geriatric Center Morale Scale: A reinterpretation. Journal of Gerontology, 38(2): 181-189. Maxson, P. J., Berg, S., & McClearn G. (1997). Multidimensional patterns of aging: A cluster-analytic approach. Experimental Aging Research, 23: 13-31. McWhorter, R. C. (1997). LifeTrust America, Inc., meeting at Belmont University, Nashville, TN. Nelson, P. B. (1990). Intrinsic/extrinsic religious orientation of the elderly: Relationship to depression and self esteem. Journal of Gerontological Nursing, 16(2): 29-35. Neugarten, B. (1978). The rise of the young-old. In Gross, R., Goss, & Seidman, S. (Eds). The New Age: Struggling for Decent Aging, Garden City, N. J.: Doubleday. Pfeifer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23: 433-441. Russell, D. W. (1996). UCLA loneliness scale (version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66(1): 20-40. Russell, D. W., Cutona, C. E., and Hessling, R. (1998). Social Contact and Morality Among Rural Older Adults: A Structural Equation Modeling Analysis. Paper presented to the American Psychological Association (publication pending). Thapa, T. P., Brockman, K. G., Gideon, P., Fought, R. L., & Ray, W. A. (1996). Injurious falls in non-ambulatory nursing home residents. Journal of the American Geriatric Society, 44: 273-278. Thorson, J.A. & Cook, T. C. (1980). Spiritual well being of the elderly. Springfield, IL: Charles C. Thomas. Unger, J. B., Johnson, C. A., & Marks, G. (1997). Functional decline in the elderly: Evidence for direct and stress-buffering protective effects of social interactions and physical activity. Annals of Behavioral Medicine 19(2):152-60. US Department of Health and Human Services (Public Health Service) (1992). Healthy People 2000. Full Report.
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Willis, S. H. (1996). Everyday competence in elderly persons: Conceptual issues and empirical findings. The Gerontologist, 36(5): 595-601. Zorn, C. R. & Johnson, M. T. (1997). Religious well-being in non-institutionalized elderly women. Health Care for Women International, 18(3): 209-219.
HAWORTH JOURNALS ARE AVAILABLE ON MICROFORM All Haworth journals are now available in either microfiche or microfilm from The Haworth Microform/Microfiche Division at the lowest possible prices. Microfiche and microfilms are available at 25% above the ‘‘library’’ subscription rate. For journal subscription rates, please look within the journal on the copyright pages. For all microform subscriptions, these charges apply: outside US and Canada: 40% to total; in Canada, 30% to total as well as 7% GST. Microfilm specifications: 35mm; diazo or silver. Microfiche specifications: 105mm x 184mm (4” x 6”); reduction ratio: 24X; nonsilver (diazo) positive polarity. Microform are mailed upon completion of each volume. For further information, contact Janette Kemmerer, Microform Contact, The Haworth Press, Inc., 10 Alice Street, Binghamton, NY 13904-1580; Tel: (607) 722-5857, ext. 311; Fax: (607) 722-1424; E-Mail: [email protected] Microform and microfiche are also available from Bell & Howell Information and Learning (formerly University Microfilms International), 300 North Zeeb Road, Ann Arbor, MI 48106-1346; Tel: (800) 521-0600.
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Scott D. McPhee, MS, DrPH, OTR, FAOTA Timothy Johnson, DA ABSTRACT. Occupational therapy has long had a vested interest in activity programming for the elderly. During the past, this interest has been largely confined to adult day care centers for community dwelling elderly, and to nursing homes for long term care of the elderly. In light of the interest generated by the recent entry of assisted living into the housing continuum, program models and understanding of the population of people who choose this option are of interest. This article introduces one model of wellcare for assisted living residents and describes a population of 626 residents in approximately 30 Morningside assisted living communities dispersed over the Southeast. The Healthy Generation model outlined in this article emphasizes five separate but inter-related domains that have been shown to impact the quality of life of aging individuals. Through the use of a multidimensional instrument, these domains (intellectual, social, physical, spiritual and emotional) are surveyed at the time each resident moves into a Morningside community. The resulting picture of the population is utilized by the assisted living program planners to create a monthly balanced calendar that intentionally engages each domain to support and enhance resident function and well being. This model has a direct bearing on practice of geriatric occupational therapy and this emerging area of practice. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: [email protected] ]
Scott D. McPhee is Associate Dean and Chair, School of Occupational Therapy, Belmont University. Timothy Johnson is Assistant Professor, Department of Physical Education, Health and Wellness, Belmont University. The authors wish to acknowledge the following for their early contributions to the writing of this article: Susan Cheatham, MBA, Director of Programming, LifeTrust America, Inc.; Elaine Blake, MSN, RN, Assistant Professor, Sharon Dowdy, PhD, RN, Assistant Professor, Lynne S. Shores, PhD, RN, Associate Professor, School of Nursing, Belmont University; and Debra B. Wollaber, PhD, RN, Dean, College of Health Sciences, Belmont University. Occupational Therapy in Health Care, Vol. 12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
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KEYWORDS. Gerontology, assisted living, wellcare, activity programming, occupational therapy
‘‘Meeting the wellcare, fitness, nutrition and spiritual needs of our residents will enhance their quality of life and help produce a healthier generation.’’
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R. Clayton McWhorter, 1997 INTRODUCTION The US Census reports that by the year 2000, there will be 35 million people who are older than 65 years, 4.6 million people over 85 years of age, and 61,000 who are over 100 years old (US DHHS, 1992). Independence as one ages has long been a guiding standard for families, healthcare providers and older adults themselves. However, as the number of adults over the age of 65 years increases, providing some assistance in daily living becomes necessary for many. To encourage the independence of these older adults, the concept of an assisted living environment has emerged. Assisted living represents a substantial expansion in the housing market for the older adult. In this environment, older adults can receive a range of assistance with daily living needs without giving up the independence and autonomy as often occurs in nursing homes. The demand for assisted living units is expected to increase from the current 7500 new units annually to over 9000 units per year. Assisted living differs dramatically from a nursing home environment. Whereas the nursing home concept endorses the medical model (dependency, regulations, invasive/clinical, institutionalized), assisted living embraces a social model (independence, flexibility, privacy/dignity, individual choice, homelike, reasonable risk). In this paper, one model for assisted living developed by LifeTrust America, Inc. will be outlined and the population of residents living in this environment will be described. Morningside, the name given to all LifeTrust America assisted living communities, brings a unique blend of hospitality and wellcare to the partnership they offer to older adults and their families. Values central to LifeTrust’s mission include promoting quality of life, staff
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training and fostering teamwork. Core to their philosophy is a holistic approach to the care of their residents. Provided at all Morningside assisted living communities, Healthy Generation is the wellcare program designed to sustain independence and promote a balanced lifestyle for residents. The purpose is to create a culture and environment that enhances the quality of daily living at Morningside. This holistic program is built around five domains of health: social, physical, intellectual, emotional, and spiritual. The philosophy is carried out through a balanced calendar of activities that is developed monthly for each community. Research literature documents that functional capacity and quality of life in old age are associated with multiple dimensions rather than any single descriptive factor. Through systematic application of this approach in an assisted living environment, the Healthy Generation model offers a distinctive advantage toward meeting residents’ needs. Review of the Literature Using descriptive categories to characterize the aging process is not new. George and Fillenbaum (1985) developed the Older Americans Resource and Services (OARS) questionnaire to measure functional capacity in five dimensions: social resources, economic resources, mental health, physical health, and activities of daily living. They emphasized that functioning is associated with multiple, interacting dimensions and not reliant on single factors alone. Krach et al. (1996) examined six domains of functioning with a population of older persons, over the age of 85. They concluded that the domains of physical, mental, social, spiritual, economic, and activities of daily living are important areas of study with this older population. They further found that a multidimensional assessment of these domains is necessary to provide intervention strategies to regain, maintain or enhance functioning in the oldest-old people. Maxson, Berg and McClearn (1997), reporting on their patterned approach to study of the aging process, found that the domains of well being, physical health, functional capacity, cognitive abilities, and social contacts enhance the descriptive efficiency for reporting functional status relative to the aging process. Since functional status spans all domains, the outcome of maintaining activity in all domains contributes to the maintenance of overall functional independence. The Healthy Generation model is aimed at incorporating such a multidi-
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mensional approach to interactions and activities that may maintain function and promote quality of life (see Figure 1). The social domain encompasses the ability to communicate, establish relationships and live in harmony with others within the community and the environment. Maintaining interaction with one’s peers has been clearly shown to have a positive effect on quality of life (Russell et al., 1998; Maxson, 1997). Koenig (1994) reports that there is an inter-relatedness among the social, physical, intellectual and spiritual factors associated with the aging process. If one factor is affected, this will affect the performance within and between other factors as well. The physical domain relates to the physiological and functional condition of the body and how it responds to physical activity, nutrition and disease. The physical health of community-dwelling elderly has been studied extensively. Overall, studies have shown that, for the older population, regular physical activity and exercise is associated with positive functional outcomes (Chandler et al., 1998; Brill et al., 1998; Horowitz et al., 1997; Fiatarone et al., 1994; Hamdorf et al., 1992). Further, research shows that there is a positive association between physical activity, social interaction and functional independence (Unger et al., 1997).
FIGURE 1. Elements that Comprise the Healthy Generation Model
Spiritual: Physical: Fitness Functional Capacity Disability Nutrition Safety Self-Care
Meaning and Purpose Values Ethics
Emotional: Relationships Personal Satisfaction Self-esteem Decrease Anxiety & Stress Feelings of well-being Sexuality
Social:
Intellectual:
Social Interactions Interpersonal Relationships Family Community Environment
Mental Health Creative Thinking Informational Skills Decision Making
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The emotional domain emphasizes the exploration of feelings that each individual has toward self, situations, and other people, the awareness of one’s own emotions and how to cope with everyday life and stress. Maxson et al. (1997) found that older adults who have high social scores also did well in the area of cognition, regardless of their level of health status. Looking at patterns associated with the aging process, their data concludes that the greater the number of social contacts maintained, the better older adults perform cognitively, the stronger their feeling of well being, and the greater their level of life satisfaction. The intellectual domain encourages creative thinking and promotes lifelong learning to stimulate an individual’s ability to make sound decisions (Ardelt, 1997; Willis, 1996). Research findings show a modest cognitive decline in performing complex everyday tasks during the ages of 60-69 and a more significant decline in the late 70s and 80s. Ardelt (1997) states that ‘‘. . . successful aging in the later years has to do with both one’s developmental and social pathways. The impact of objective conditions on life satisfaction in old age depends on the specific circumstances of the individual, their vulnerabilities, anxieties, and strengths, whereas a lifelong accumulation of wisdom tends to increase life satisfaction for all people’’ (p. 24). Her research clearly demonstrates the inter-relatedness of the intellectual, social and emotional domains. As defined by the National Interfaith Council on Aging (Thorson, 1980), spiritual well being is the affirmation of life in a relationship with God, self, community, and environment that nurtures and celebrates wholeness. Spiritual elements include the ability to seek purpose and meaning in life, to love, to forgive, to pray, and to worship. Several authors have concluded that involvement with religion has a significant impact upon an older population’s quality of life (Russell et al., 1998; Zorn and Johnson, 1997; Koenig, 1994; Buchanan, 1993; Nelson, 1990). Further, Koenig (1994) reports a positive relationship between cognitive function and spirituality; as cognitive function increases, spirituality increases as well, and as cognitive function decreases, so does spirituality. He further demonstrates that social support, physical activity, and mental alertness impact spirituality. This brief review provides support from the research literature for the inter-relatedness of the social, intellectual, physical, spiritual and emotional domains. Carrying this philosophy into the daily lives of
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residents of assisted living communities is the challenge. Healthy Generation has been designed as the vehicle to accomplish this in the Morningside population described in this paper.
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SURVEY RESULTS The Healthy Generation Assessment Tool is a self-reported, health status survey that contains questions related to each of the five target domains as well as items concerned with clinical and medical data. Each assessment was completed with the help of a Morningside Program Coordinator specifically trained to administer the tool and was assessed by the School of Occupational Therapy at Belmont University. The survey is designed to (1) provide information about each resident’s needs and interests for program planning in each individual community and (2) to provide LifeTrust with a summative picture of its resident population. Statistical Analysis was completed using a SPSS package for descriptive and inferential statistics. The KruskalWallis H test was used to determine whether the independent samples were from the same population. The descriptive results presented here are based on survey reports from a total of 626 assisted living residents from Morningside communities in three southeastern states (Tennessee, Georgia, and Alabama) during 1998 and 1999. The survey was part of routine entry information gathering. Of the 626 residents surveyed to date, 117 were male and 509 were female. The overall average age was 83.3 years (males 81.7 years and females 83.6 years). For the purposes of this study, the ages of residents will be divided into three categories: young-old (60-75 years), old-old (76-84 years), and oldest-old (85 years and older) in keeping with categories commonly used in literature on aging (Neugarten, 1978). Table 1 displays information regarding the health status of Morningside residents. The table is divided into four sections: self-perception of overall state of health, medical problems (diagnosed problems), health-related problems (complaints not specific to established diagnoses), and preventive care. With regards to the self-perception of health status, the young-old differed significantly from the other groups in that they felt that their health was better than a year ago. This group, less than 75 years of age, was also least likely to report their
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TABLE 1. Health Care Status for Morningside Residents (N = 626)
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Condition
< 75 Years (n = 86)
76-84 Years (n = 255)
85+ Years (n = 285)
n (%)
n (%)
n (%)
pa
Self Perception of Health Status Health gets in way of doing things Health is better than 1 year ago Overall Health -- excellent to good
36 (.43) 23 (.27) 48 (.57)
82 (.32) 43 (.17) 169 (.68)
95 (.35) 34 (.13) 204 (.76)
.069 .138 .000
Medical Problems (currently diagnosed) Stomach Problems Circulatory Problems High Blood Pressure Breathing Problems Memory Problems Urinary Problems Heart Problems Parkinson’s Depression Diabetes Arthritis Cancer Stroke
21 (.25) 29 (.35) 36 (.43) 16 (.19) 25 (.30) 21 (.26) 13 (.16) 11 (.13) 25 (.31) 22 (.27) 35 (.44) 4 (.05) 25 (.30)
55 (.22) 54 (.22) 86 (.34) 47 (.19) 90 (.37) 50 (.20) 47 (.19) 12 (.05) 41 (.17) 22 (.09) 128 (.53) 2 (.08) 47 (.19)
63 (.23) 81 (.30) 72 (.27) 35 (.13) 112 (.42) 87 (.32) 74 (.27) 9 (.03) 52 (.19) 21 (.08) 121 (.45) 6 (.02) 46 (.17)
.216 .059 .019 .193 .132 .004 .050 .007 .008 .000 .194 .695 .037
Health Related Problems (non-diagnosed) Decreased appetite Foot/Toe problems Fatigue/Lack of energy Tooth/Denture problems Chronic pain Urinary problems Weight gain/loss
20 (.23) 34 (.40) 49 (.60) 21 (.25) 31 (.37) 25 (.30) 32 (.38)
45 (.18) 86 (.35) 123 (.49) 56 (.23) 71 (.29) 85 (.34) 65 (.26)
51 (.19) 102 (.38) 146 (.55) 48 (.18) 68 (.26) 105 (.40) 61 (.23)
.551 .629 .183 .250 .137 .210 .024
Preventive Care Activities Dental exam in last year Vision exam in last year Hearing exam in last year Flu shot within last year Colonoscopy in last year Pneumonia vaccination Blood pressure check last year
47 (.55) 58 (.69) 24 (.29) 58 (.69) 24 (.29) 40 (.49) 78 (.95)
154 (.62) 168 (.69) 79 (.32) 183 (.75) 72 (.29) 130 (.53) 226 (.94)
149 (.55) 183 (.68) 116 (.43) 206 (.77) 58 (.22) 119 (.46) 240 (.92)
.197 .969 .010 .294 .147 .207 .456
Women only: Pap smear in last year Mammogram in last year Bone density in last year
34 (.53) 36 (.56) 21 (.34)
87 (.44) 87 (.44) 42 (.21)
65 (.28) 80 (.36) 36 (.17)
.000 .012 .011
Men only: PSA/Prostate exam last year
11 (.58)
29 (.57)
30 (.73)
.243
aKruskal-Wallis
H One Way Analysis of Variance test; age divided into three grouping variables
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overall health as excellent to good. This seems to suggest that some illness event preceded their move to assisted living at this early age. There is no significant difference in 6 of the 20 medical and healthrelated problems in the three age groups. Of interest, the young-old category has a higher incidence of specific medical problems such as high blood pressure and diabetes while general complaints of heart and urinary problems were more often reported by the oldest age group. Not surprisingly, the most reported medical condition across all age groups was arthritis; about half the residents acknowledged this as a current complaint. The most frequently reported non-specific healthrelated problem was fatigue and lack of energy (60%, 49% and 55%, respectively, youngest to oldest). Depression was highest in the young-old (31% reported) and modestly lower in older groups (17% and 19%, respectively). Clearly, concern for healthcare issues and accessibility of healthcare resources must be a consideration in planning a successful assisted living model. Further, health related problems have a direct bearing on activity planning for this age population. With a few exceptions, all three age groups report approximately the same involvement in preventive care activities. However, women are less likely to have had regular pap smears, mammograms or bone density measures completed at older ages while men are more likely to have PSA and prostate exams as they age. Table 2 summarizes results of four of five domains studied in the survey (physical, social, cognitive and spiritual domains). The physical domain shows no significant difference in four of its five reported elements across ages. It is noteworthy that there is no reported difference in the percentages of respondents who participate in physical exercise or recreational activities. Yet, the number of residents stating that they walk unassisted drops significantly as they age. Interestingly, with each age category it was reported that approximately one third had fallen during the past year (36%, 33% and 31%, respectively, youngest to oldest). Compare this to annual fall incidence among community dwelling older adults reported to increase from 25% at 70 years to 40% after age 80 (Campbell et al., 1989). Annually, about 50% of nursing home residents are expected to fall (Gryfe et al., 1977; Thapa et al., 1996). The Social domain is revealing about the residents’ outlook on life. There is no significant difference between the three groups in the three elements of this domain. Although each age group reports that less than a third participate in group activities, a small percentage attribute
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TABLE 2. Descriptions of Domains for Morningside Residents; Percents Indicate Those Residents Who Responded Positively to the Category (N = 626) Condition
pa
< 75 Years (n = 86)
76-84 Years (n = 255)
85+ Years (n = 285)
n (%)
n (%)
n (%)
51 (.61) 47 (.57) 47 (.56) 31 (.36) 35 (.44)
158 (.63) 149 (.62) 166 (.67) 81 (.33) 112 (.49)
159 (.59) 156 (.59) 167 (.62) 85 (.31) 77 (.29)
.586 .774 .270 .592 .000
3 (.04) 29 (.34) 40 (.46) 10 (.12) 24 (.28) 29 (.35) 71 (.85) 63 (.77)
25 (.10) 59 (.23) 77 (.30) 28 (.11) 77 (.30) 83 (.33) 214 (.87) 206 (.83)
10 (.04) 66 (.23) 83 (.29) 29 (.10) 80 (.28) 90 (.33) 233 (.87) 199 (.75)
n/a n/a n/a n/a n/a .949 .965 .452
30 (.61) 17 (.35) 0 (.00) 2 (.04)
80 (.43) 54 (.29) 28 (.15) 24 (.13)
76 (.38) 42 (.21) 64 (.32) 18 (.09)
6 (.10) 15 (.25) 7 (.12) 31 (.52)
11 (.07) 40 (.24) 24 (.14) 90 (.54)
1 (.05) 27 (.14) 30 (.16) 131 (.69)
Physical Domain
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Physical exercise or recreation Enjoy exercise or recreation Participate greater than once/week Recent fall to ground or on stairs Unassisted walking Social Domain Social Contacts in the area: Spouse Son Daughter Sibling Other Relatives Participate in group activities Enjoy social interactions Have a best friend
.003
Cognitive Domain Intact mental functioning Mild mental impairment Moderate mental impairment Severe mental impairment Spiritual Domain Belief important to small extent Belief important to moderate extent Belief important to large extent Belief is most important aKruskal-Wallis
.011
H One Way Analysis of Variance test; age divided into three grouping variables
this to being unable for health reasons. This is true for both male and female respondents. Given this finding, each age group shows a high percentage of respondents who would like to be socially involved and report having a best friend. Dividing this factor by age and gender, the response was constant across all age groups for both genders. Table 2 lists the relatives that live near the Morningside residents. As expected, few report spouse as the relative close by. The percentage having a son or daughter in the community is near 50% in young old
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residents but dwindles considerably in the old-old (sons-- 24%; daughters-- 31%). Report of ‘‘other relatives’’ in the community remains relatively constant as residents age. The Cognitive domain was measured using the Short Portable Mental Status Questionnaire (Pfeifer, 1975). After adjusting for education, results indicated a significant difference between the three age categories (H = 16.13; p = .000), particularly between the youngest-old and the other two categories. Overall, the data shows that as the population ages, there is a decrease in mental capacity for both the male and female groups. When dividing the data by age and gender, results show that the female population maintained intact cognition during most of the aging process (63%, 43%, and 40% for the three age groups, respectively). However, for the male population, the decrease was more dramatic as they aged (54%, 45%, and 27%, respectively). The Spiritual Domain was measured by the Religious Coping Index (Koenig, 1994). This index was designed to generate an overall spirituality score for an elderly population. Koenig defines spirituality as belief in God and reliance on prayer as a way of coping with difficult times. The overall mean spirituality score was 21.44 (score of 30 possible). Separated by gender, the scores were 17.47 for males, and 22.53 for females. The mean spirituality score by category is as follows: youngest-old, 19.61; old-old, 20.33; oldest-old, 22.98 (H = 15.28; p < .000). The biggest difference in spirituality scores is between the youngest-old and the oldest-old categories. Russell et al. (1998) found, in their longitudinal study of individuals 65 and older, that physical health is significantly related to church involvement. In their study of rural older adults in Iowa, those who reported attending church regularly during their baseline interviews were less likely to die over the subsequent 12 to 13 years. Our findings show support for Russell’s study in that a strong association was found between age and spirituality (rho = .195; p = .000). This indicates that the older the population, spirituality is given more importance. Further, a significant positive correlation exists between spirituality and life satisfaction (rho = .119; p = .017), interest in life (rho = .156; p = .000). These findings indicate that the stronger the spiritual scores, the more satisfied they are with their lives. Table 3 displays information about the Emotional domain. The Philadelphia Geriatric Center Morale Scale (Lawton, 1975) is the tool used to measure the emotional domain in the Healthy Generation
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TABLE 3. Emotion Domain Results for Morningside Residents; Mean Response by Year Group (N = 626) < 75 Years (n = 86)
76-84 Years (n = 255)
85+ Years (n = 285)
mean (SD)
mean (SD)
mean (SD)
4.34 (1.52) 2.43 (1.34) 4.35 (1.40) 11.13 (3.27)
3.98 (1.78) 2.13 (1.36) 4.04 (1.48) 10.14 (3.67)
pa
PGCMSb Subscales
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Factor 1: Agitation scale Factor 2: Attitude toward aging scale Factor 3: Lonely dissatisfaction scale Overall Morale Score
3.65 (1.88) 2.34 (1.12) 3.87 (1.81) 10.00 (3.65)
.012 .037 .044 .012
aKruskal-Wallis
H One Way Analysis of Variance test; age divided into three grouping variables Geriatric Center Morale Scale The mean score (standard deviation) for the PGCMS for factor 1 is 4.28 (1.65), factor 2 is 2.17 (1.56), factor 3 is 4.81 (1.50), and total is 11.35 (3.76).
bPhiladelphia
survey. This scale has been found to be a good measure of global life satisfaction (Liang and Bollen, 1983). The scale divides into three factors. Factor 1 measures agitation, which is characterized by anxiety experienced in older persons. Factor 2 addresses attitude toward one’s own aging process. Factor 3 looks at lonely dissatisfaction which represents the older person’s acceptance or dissatisfaction with the amount of social interaction they are presently experiencing. The results show a significant difference between the three populations when comparing each Factor subscale and overall Morale total. The higher the mean score, the higher the morale within each factor and overall score. With exception of the Attitude toward aging scale, all scores from this study fall below the published mean scores of the PGCMS. Within the Attitude subscale, the young-old and old-old populations scored slightly above the published means. Looking at the subscales in more detail, the young-old seem to have a higher level of agitation and a more pronounced lonely dissatisfaction. Within the subscale for attitude toward aging, the oldest-old population has a somewhat lower score. Overall, the old-old population presents a higher level of morale than the other groups. HEALTHY GENERATION BALANCED CALENDAR PROGRAMMING Assisted living developed as an option in the geriatric housing market in the continuum of care between community and nursing
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home in the continuum of care. Through the Healthy Generation model, LifeTrust has created an assisted living environment that goes beyond the provision of shelter and security. With the help of a consistent data collection system, the needs of new residents can be readily identified and addressed promptly. Drawing on this information and the holistic knowledge of the most important health and wellness needs of older adults, a unique approach to activity programming has been implemented to support and stimulate resident’s abilities to enhance and maintain their quality of life. The greatest challenge for a dispersed, multi-community organization such as LifeTrust America is to disseminate the core philosophy of wellness down to the individual resident’s daily experience. The vehicle for accomplishing this in Morningside communities is the Healthy Generation Balanced Calendar created at each community location monthly. To begin, LifeTrust’s centralized Program Development office initiates a package of programs and event ‘‘guides’’ that goes to each Program Coordinator. This package is made up of core, required programs. Each program or event is coded to indicate the domains of health engaged by the residents’ participation. Figure 2 illustrates an example of how programs are developed. ‘‘Core’’ programs have been developed to meet the most important health and wellcare needs of residents identified through LifeTrust’s knowledge of the health concerns and problems of older adults and results from the Healthy Generation survey. Examples of these core programs are a falls prevention education program and physical activity programs geared to recent research recommendations regarding the importance of strength building for even the oldest-old individuals. ‘‘Required’’ programs are special programs designed by the centralized Program Development office around a theme for each month; these programs are required offerings in each Morningside location. The program event, a ‘‘Sense-ual Thanksgiving,’’ a step-bystep plan for each community’s Program Coordinator to provide an experience where residents reminiscence about the smells, tastes, feelings, sounds, and sights of Thanksgiving, is one example of a required program. In addition, each local Program Coordinator selects ‘‘elective’’ programs to round out the calendar for their community and assure that all domains are addressed throughout the month. By combining core, required and elective programs, a calendar is tailored to meet the
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FIGURE 2. Balanced Calendar for November: Selected Programming Examples Program
Description
Domains
Core Programs: S *Fit for Life
S Hydration Break
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S Fall Recovery Class
S Exercise/fitness program designed to promote movement and enhance function S Two scheduled water breaks daily & education on the importance of hydration S Video, discussion & practice for residents at high risk for falling
S Physical, Emotional, Social
S Reminiscence experience through the use of seasonal items to stimulate memories to share S Brief history of the Mayflower and Pilgrims followed by sharing of individual family heritage S Creation of a bulletin board of the community’s thankful list with resident photos and their statements collected by visiting each individual
S Emotional, Spiritual, Intellectual, Social, Physical
S Based on needs and interests of residents S Customized at the community level
S Assure engagement of all domains
S Physical, Emotional, Intellectual, Social S Physical, Emotional, Intellectual, Social
Required Programs: S Sense-ual Thanksgiving
S Thanksgiving Awareness
S I am Thankful for
S Intellectual, Spiritual, Social, Emotional
S Emotional, Spiritual, Intellectual, Social
Elective Programs: S Selected to round out the balanced calendar
specific needs and interests at each individual community. The ‘‘balanced’’ calendar carries the holistic philosophy of Healthy Generation through to individual residents. Descriptions of ‘‘successes’’ associated with that month’s programming are shared with the central Program Development office and serve as an anecdotal evaluation of the benefits of various programs. This method of providing centralized planning as well as supporting local facility program planning best meets the needs of the residents. Further, by providing assistance in preparation planning for the activities reduces the pressure on the facilities personnel to ensure
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success in the programming efforts. Finally, such a method of program planning is consistent with what criteria Edwards (1994) reports must exist in order to offer successful activity programs that will positively affect health behaviors. These include: Stressing that one is not too old to change.
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Promoting the immediate benefits of the activity. Establishing a link between the healthy behaviors and specific health problems. Providing specific information about the actions required. Providing group support and an opportunity to rehearse or practice the behavior. Including the older adults in the planning process. (page 279) CONCLUSION The Healthy Generation model is made up of three parts: (1) a holistic philosophy identified as five domains of health and wellness important to older adults, (2) a survey instrument that provides information about these five domains on Morningside residents, and (3) a balanced program of events and activities that flows from the model. Results of the Healthy Generation Survey offer a snapshot of the residents in each individual community, as well as in the entire network of Morningside communities operated by LifeTrust America, Inc. With this data, LifeTrust can address the needs of residents individually and as an entire population. From this picture of their residents and a belief that quality of life and a sense of wellbeing result from attention to the needs of the whole person, a monthly calendar for each Morningside community is developed that engages each domain. Repeated use of the Healthy Generation Survey over time will provide a means of evaluating outcomes of various programming elements and interventions. In keeping with the social model, it is acknowledged that each resident has a choice about which program
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elements and activities she/he will participate in. The assisted living community is the resident’s home. This concept is presented as part of the culture in the training of each staff member. In conclusion, this paper has described one assisted living model, Morningside, and its holistic wellcare approach, Healthy Generation. In addition, an initial description of the residential population has been provided from compilation of results from the Healthy Generation survey administered to all entrants to Morningside communities. While not yet proven, continued refinement and use of the survey instrument will provide a useful data base to guide programming, to address resident needs, and to follow, over time, the population of older adults who seek to make their homes in Morningside assisted living communities. This is an instrument and a conceptual model that can support the occupational therapist’s efforts to provide activity programming for assisted living residents that can support their efforts to remain in an assisted living environment as well as help to attain and maintain a healthy lifestyle. REFERENCES Ardelt, M. (1997). Wisdom and life satisfaction in old age. Journal of Gerontology, 52B(1): 15-27. Brill, P. A., Jensen, R. L., Koltyn, K.F., Morgan, L. A., Morrow, J. R., Keller, M.J., & Jackson, A.W. (1998). The feasibility of conducting a group-based progressive strength training program in residents of a multi-level care facility. Activities, Adaptation & Aging, 22(4): 53-63. Buchanan, D. M. (1993). Meaning-in-Life, Depression and Suicide in Older Adults: A Comparative Survey Study. Rush University: College of Nursing. Campbell, A. J., Borrie, M. J., & Spears, G. F. (1989). Risk factors for falls in a community-based prospective study of people 70 years and older. Journal of Gerontology, 44: M112-M117. Chandler, J. M., Duncan, P. W., Kochersberger, G., & Studenski, S. (1998). Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community dwelling elders? Archives of Physical Medicine and Rehabilitation, 79(1):24-30. Edwards D. F. (1994). Prevention of performance deficits. In Bonder, B. R. & Wagner, M. B. (eds): Functional Performance in Older Adults, F. A. Davis Company, Philadelphia, PA. Fiatarone, M. A., O’Neill, E. F., Ryan, N. D., Clements, K.M., Solares, G. R., Nelson, M. E., Roberts, S. S., Kehayias, J. J., Lipsitz, L. A., & Evans, W. J. (1994). Exercise training and nutritional supplementation for physical frailty in very elderly people. The New England Journal of Medicine, 330(25): 1769-1775.
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George, L. K. & Fillenbaum, G. G. (1985). OARS methodology: A decade of experience in geriatric assessment. Journal of American Geriatrics Society 33(9): 607-615. Gryfe, C. I., Amies, A., & Ashley, M. J. (1977). A longitudinal study of falls in an elderly population: Incidence and morbidity. Age Aging 6:210. Hamdorf, P. A., Withers, R. T., Penhall, R. K., & Haslam, M. V. (1992). Physical training effects on the fitness and habitual activity patterns of elderly women. Archives of Physical Medicine Rehabilitation, 73(7): 603-608. Horowitz, B. P., Tollin, R., & Cassidy, G. (1997). Grip strength: Collection of normative data with community dwelling elders. Physical & Occupational Therapy in Geriatrics, 15(1): 53-64. Koenig, H. G. (1994). Aging and God: Spiritual pathways to mental health in midlife and later years, New York: Haworth Press. Krach, P., Devaney, S., DeTurk, C., & Zink, M.H. (1996). Functional status of the oldest-old in a home setting. Journal of Advanced Nursing, 24(3): 456-64. Lawton, M.P. (1975). The Philadelphia center morale scale: A revision. Journal of Gerontology, 30: 85-89. Liang, J. & Bollen, K. A. (1983). The structure of the Philadelphia Geriatric Center Morale Scale: A reinterpretation. Journal of Gerontology, 38(2): 181-189. Maxson, P. J., Berg, S., & McClearn G. (1997). Multidimensional patterns of aging: A cluster-analytic approach. Experimental Aging Research, 23: 13-31. McWhorter, R. C. (1997). LifeTrust America, Inc., meeting at Belmont University, Nashville, TN. Nelson, P. B. (1990). Intrinsic/extrinsic religious orientation of the elderly: Relationship to depression and self esteem. Journal of Gerontological Nursing, 16(2): 29-35. Neugarten, B. (1978). The rise of the young-old. In Gross, R., Goss, & Seidman, S. (Eds). The New Age: Struggling for Decent Aging, Garden City, N. J.: Doubleday. Pfeifer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23: 433-441. Russell, D. W. (1996). UCLA loneliness scale (version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66(1): 20-40. Russell, D. W., Cutona, C. E., and Hessling, R. (1998). Social Contact and Morality Among Rural Older Adults: A Structural Equation Modeling Analysis. Paper presented to the American Psychological Association (publication pending). Thapa, T. P., Brockman, K. G., Gideon, P., Fought, R. L., & Ray, W. A. (1996). Injurious falls in non-ambulatory nursing home residents. Journal of the American Geriatric Society, 44: 273-278. Thorson, J.A. & Cook, T. C. (1980). Spiritual well being of the elderly. Springfield, IL: Charles C. Thomas. Unger, J. B., Johnson, C. A., & Marks, G. (1997). Functional decline in the elderly: Evidence for direct and stress-buffering protective effects of social interactions and physical activity. Annals of Behavioral Medicine 19(2):152-60. US Department of Health and Human Services (Public Health Service) (1992). Healthy People 2000. Full Report.
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Willis, S. H. (1996). Everyday competence in elderly persons: Conceptual issues and empirical findings. The Gerontologist, 36(5): 595-601. Zorn, C. R. & Johnson, M. T. (1997). Religious well-being in non-institutionalized elderly women. Health Care for Women International, 18(3): 209-219.
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