Original Research

Healthy Aging Project-Brain: A Psychoeducational and Motivational Group for Older Veterans

Fed Pract. 2020 July;37(7):309-315

Author(s):

Introduction: Positive health behaviors can promote brain health with age. Although healthy lifestyle factors are often encouraged by health care providers, many older adults experience difficulty incorporating these into their daily life.

Methods: To address this gap, we developed a novel health education and implementation group for older veterans (aged > 50 years). The primary objectives of this group were to provide psychoeducation about the link between behaviors and brain health, increase personal awareness of specific health behaviors, and promote behavior change through individualized goal setting, monitoring, and support. Based on input from medical providers, group content targeted behaviors known to support cognitive functioning: physical activity, sleep, cognitive stimulation, and social engagement.

Results: Thirty-one veterans participated in six 90-minute weekly classes and attended 5 of the 6 groups on average. The average age for the predominantly male (90%) and white (70%) group was 71 years. Qualitative feedback indicated high satisfaction and increased awareness of health behaviors. Results of paired samples t tests comparing baseline to posttreatment self-report measures revealed a significant decline in depressive symptoms ( P = .01) and increases in satisfaction with life ( P = .003) and self-efficacy ( P = .008).

Conclusions: This development project showed evidence of increased awareness of health behaviors and improved mood. Expanded data collection will strengthen power and generalizability of results (increase sample diversity). It will also allow us to examine moderating factors, such as perceived self-efficacy, on outcomes.

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References

1. Jacobsen LA, Kent M, Lee M, Mather M. America’s aging population. Popul Bull. 2011;66(1):1-20.

2. Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: A systematic review and meta-analysis of prospective studies. Sleep. 2010;33(5):85-592. doi:10.1093/sleep/33.5.585

3. Kelly ME, Loughrey D, Lawlor BA, Robertson IH, Walsh C, Brennan S. The impact of exercise on the cognitive functioning of healthy older adults: a systematic review and meta-analysis. Ageing Res Rev. 2014;16:12-31. doi:10.1016/j.arr.2014.05.002

4. Middleton LE, Manini TM, Simonsick EM, et al. Activity energy expenditure and incident cognitive impairment in older adults. Arch Intern Med. 2011;171(14):1251-1257. doi:10.1001/archinternmed.2011.277

5. World Health Organization. Interventions on diet and physical activity: what works. https://www.who.int/dietphysicalactivity/whatworks/en/. Published 2009. Accessed June 19, 2020.

6. Seeman TE, Lusignolo TM, Albert M, Berkman L. Social relationships, social support, and patterns of cognitive aging in healthy, high-functioning older adults: MacArthur studies of successful aging. Health Psychol. 2001;20(4):243-255. doi:10.1037//0278-6133.20.4.243

7. La Rue A. Healthy brain aging: role of cognitive reserve, cognitive stimulation and cognitive exercises. Clin Geriatr Med. 2010;26(1):99-111. doi:10.1016/j.cger.2009.11.003

8. Salthouse TA, Berish DE, Miles JD. The role of cognitive stimulation on the relations between age and cognitive functioning. Psychol Aging. 2002;17(4):548-557. doi:10.1037//0882-7974.17.4.548

9. Wrosch C, Schulz R, Heckhausen J. Health stresses and depressive symptomatology in the elderly: the importance of health engagement control strategies. Health Psychol. 2002;21(4):340-348. doi:10.1037//0278-6133.21.4.340

10. Pronk NP, Anderson LH, Crain AL, et al. Meeting recommendations for multiple healthy lifestyle factors: prevalence, clustering, and predictors among adolescent, adult, and senior health plan members. Am J Prev Med. 2004;27(suppl 2):25-33. doi:10.1016/j.amepre.2004.04.022

11. Gross AL, Parisi JM, Spira AP, et al. Memory training interventions for older adults: a meta-analysis. Aging Ment Health. 2012;16(6):722-734. doi:10.1080/13607863.2012.667783

12. Miller KJ, Siddarth P, Gaines JM, et al. The memory fitness program: cognitive effects of a healthy aging intervention. Am J Geriat Psychiatry. 2012;20(6):514-523. doi:10.1097/JGP.0b013e318227f821

13. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: mild cognitive impairment: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018;90(3):126-135. doi:10.1212/WNL.0000000000004826

14. Gauthier S, Reisberg B, Zaudig M, et al. Mild cognitive impairment. Lancet. 2006;367(9518):1262-1270. doi:10.1016/S0140-6736(06)68542-5

15. US Department of Veteran Affairs, National Center for Veteran Analysis and Statistics.Veteran population. 2020. https://www.va.gov/vetdata/Veteran_Population.asp. Updated May 21, 2020 . Accessed June 17, 2020.

16. Eibner C, Krull H, Brown K, et al. Current and projected characteristics and unique healthcare needs of the patient population served by the Department of Veterans Affairs. RAND Health Q. 2016;5(4):13.

17. Orkaby AR, Nussbaum L, Ho Y, et al. The burden of frailty among U.S. Veterans and its association with mortality, 2002-2012. J Gerontol A Biol Med Sci. 2019;74(8):1257-1264. doi:10.1093/gerona/gly232

18. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manag Rev. 1981;70(11):35-36.

19. Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985;49(1):71-75. doi:10.1207/s15327752jpa4901-13

20. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5(1-2):165-173. doi:10.1300/J018v05n01_09

21. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705-714. doi:10.1016/0277-9536(91)90150-b

22. Buysse DJ, Reynolds CF III, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193-213. doi:10.1016/0165-1781(89)90047-4

23. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483.

24. Huckans M, Pavawalla S, Demadura T, et al. A pilot study examining effects of group-based cognitive strategy training treatment on self-reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury. J Rehabil Res Dev. 2010;47(1):43-60. doi:10.1682/jrrd.2009.02.0019

25. Pearson ES. Goal setting as a health behavior change strategy in overweight and obese adults: a systematic literature review examining intervention components. Patient Educ Couns. 2012;87(1):32-42. doi:10.1016/j.pec.2011.07.018

With a rapidly growing older adult population, increased attention has been given to cognitive changes that occur with age, with a focus on optimizing the cognitive health of aging individuals.¹ Given the absence of pharmaceutical treatments to prevent cognitive decline, there is an increased need for health care systems to offer alternative or behavioral interventions that can mitigate the effects of cognitive decline in aging.

Notably, many individuals are able to maintain or even improve cognitive functioning throughout their lifespan, with some research implicating health behaviors as an important factor for promoting brain health with age. Specifically, sleep, exercise, eating habits, social engagement, and cognitive stimulation have been linked to improved cognitive functioning.^2-8 In addition to the potential benefits for brain health, there is evidence that greater investment in attaining health goals is associated with subjective reports of higher well-being, fewer mental health symptoms, lower physical health stresses, decreased caregiver burden, and increased functional independence linked with longer independent living.⁹ The latter has a substantial financial impact, such that the positive consequence of increased independence is likely staving off the need for admission to assisted living and adult family homes, which can be costly.

Despite the role of health behaviors in brain aging and overall health and functioning, research indicates that only a small number of older adults (12.8%) follow recommended guidelines for healthy lifestyle factors.¹⁰ Education has been identified as one factor associated with the likelihood of engaging in positive health behaviors, prompting the delivery of health-education interventions. Most psychoeducational interventions have traditionally focused on one aspect of behavior change at a time (eg, sleep); however, Gross and colleaguesconducted a meta-analysis of cognitive interventions and in addition to the overall positive benefits (effect size 0.38), they also found suggestive evidence that interventions that combined multiple training strategies were associated with larger training gains (P = .04) after adjusting for multiple comparisons.¹¹ For example, Miller and colleagues found a significant improvement on both subjective and objective measures of memory following a multicomponent approach that combined training in memory skills, stress reduction, nutrition, and physical activity.¹²

In addition to the potential positive impacts of health behaviors on brain health, findings suggest that targeted emphasis on health behavior change may have the potential to stave off mild cognitiveimpairment (MCI) or dementia even if for a short time. Given the increasing prevalence rates of MCI with age (6.7% in adults aged 60-64 years, reaching 25.2% in adults aged 80-84 years¹³) and dementia (prevalence of MCI converting to dementia is 18-40%¹⁴), as well as the corresponding emotional, financial, and family-oriented consequences (eg, impact on the well-being of family caregivers), the need for behavioral interventions that seek to optimize brain health is becoming increasingly apparent.

More than 9 million veterans are now aged ≥ 65 years.¹⁵ In addition to representing nearly half of all veterans and a sizable portion of aging adults in the US, older veterans are at increased risk of frailty, mortality, and high rates of chronic medical/mental health conditions that can lead to accelerated cognitive aging.^6-17 Together, these conditions highlight the importance of developing comprehensive psychoeducational and behavioral interventions in this population. To address this need, we developed a novel psychoeducation and behavior change group called the Healthy Aging Project-Brain (HAP-B, pronounced “happy”). The HAP-B intervention was designed to promote healthy brain aging by using empirically supported health behavior change strategies, including education, personalized goal setting, and community support. The primary aim of this project was to develop and implement an intervention that was feasible and acceptable (eg, could be implemented in our setting, was appropriate for a veteran population) and to determine any positive outcomes/preliminary effects on overall health and well-being.

References

1. Jacobsen LA, Kent M, Lee M, Mather M. America’s aging population. Popul Bull. 2011;66(1):1-20.

2. Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: A systematic review and meta-analysis of prospective studies. Sleep. 2010;33(5):85-592. doi:10.1093/sleep/33.5.585

3. Kelly ME, Loughrey D, Lawlor BA, Robertson IH, Walsh C, Brennan S. The impact of exercise on the cognitive functioning of healthy older adults: a systematic review and meta-analysis. Ageing Res Rev. 2014;16:12-31. doi:10.1016/j.arr.2014.05.002

4. Middleton LE, Manini TM, Simonsick EM, et al. Activity energy expenditure and incident cognitive impairment in older adults. Arch Intern Med. 2011;171(14):1251-1257. doi:10.1001/archinternmed.2011.277

5. World Health Organization. Interventions on diet and physical activity: what works. https://www.who.int/dietphysicalactivity/whatworks/en/. Published 2009. Accessed June 19, 2020.

6. Seeman TE, Lusignolo TM, Albert M, Berkman L. Social relationships, social support, and patterns of cognitive aging in healthy, high-functioning older adults: MacArthur studies of successful aging. Health Psychol. 2001;20(4):243-255. doi:10.1037//0278-6133.20.4.243

7. La Rue A. Healthy brain aging: role of cognitive reserve, cognitive stimulation and cognitive exercises. Clin Geriatr Med. 2010;26(1):99-111. doi:10.1016/j.cger.2009.11.003

8. Salthouse TA, Berish DE, Miles JD. The role of cognitive stimulation on the relations between age and cognitive functioning. Psychol Aging. 2002;17(4):548-557. doi:10.1037//0882-7974.17.4.548

9. Wrosch C, Schulz R, Heckhausen J. Health stresses and depressive symptomatology in the elderly: the importance of health engagement control strategies. Health Psychol. 2002;21(4):340-348. doi:10.1037//0278-6133.21.4.340

10. Pronk NP, Anderson LH, Crain AL, et al. Meeting recommendations for multiple healthy lifestyle factors: prevalence, clustering, and predictors among adolescent, adult, and senior health plan members. Am J Prev Med. 2004;27(suppl 2):25-33. doi:10.1016/j.amepre.2004.04.022

11. Gross AL, Parisi JM, Spira AP, et al. Memory training interventions for older adults: a meta-analysis. Aging Ment Health. 2012;16(6):722-734. doi:10.1080/13607863.2012.667783

12. Miller KJ, Siddarth P, Gaines JM, et al. The memory fitness program: cognitive effects of a healthy aging intervention. Am J Geriat Psychiatry. 2012;20(6):514-523. doi:10.1097/JGP.0b013e318227f821

13. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: mild cognitive impairment: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018;90(3):126-135. doi:10.1212/WNL.0000000000004826

14. Gauthier S, Reisberg B, Zaudig M, et al. Mild cognitive impairment. Lancet. 2006;367(9518):1262-1270. doi:10.1016/S0140-6736(06)68542-5

15. US Department of Veteran Affairs, National Center for Veteran Analysis and Statistics.Veteran population. 2020. https://www.va.gov/vetdata/Veteran_Population.asp. Updated May 21, 2020 . Accessed June 17, 2020.

16. Eibner C, Krull H, Brown K, et al. Current and projected characteristics and unique healthcare needs of the patient population served by the Department of Veterans Affairs. RAND Health Q. 2016;5(4):13.

17. Orkaby AR, Nussbaum L, Ho Y, et al. The burden of frailty among U.S. Veterans and its association with mortality, 2002-2012. J Gerontol A Biol Med Sci. 2019;74(8):1257-1264. doi:10.1093/gerona/gly232

18. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manag Rev. 1981;70(11):35-36.

19. Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985;49(1):71-75. doi:10.1207/s15327752jpa4901-13

20. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5(1-2):165-173. doi:10.1300/J018v05n01_09

21. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705-714. doi:10.1016/0277-9536(91)90150-b

22. Buysse DJ, Reynolds CF III, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193-213. doi:10.1016/0165-1781(89)90047-4

23. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483.

24. Huckans M, Pavawalla S, Demadura T, et al. A pilot study examining effects of group-based cognitive strategy training treatment on self-reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury. J Rehabil Res Dev. 2010;47(1):43-60. doi:10.1682/jrrd.2009.02.0019

25. Pearson ES. Goal setting as a health behavior change strategy in overweight and obese adults: a systematic literature review examining intervention components. Patient Educ Couns. 2012;87(1):32-42. doi:10.1016/j.pec.2011.07.018

Healthy Aging Project-Brain: A Psychoeducational and Motivational Group for Older Veterans

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