Discuss and give clear examples of two health-related problems that the aging population faces. You should write approximately 3-5 paragraphs.

A Healthy Aging Program for Older Adults: Effects on Self- Efficacy and Morale

Matthew Scult, BS, Graduate Student, Center for Cognitive Neuroscience, Duke University, Durham, NC, USA

Vivian Haime, BS, Clinical Research Coordinator, Benson-Henry Institute for Mind Body Medicine

Jolene Jacquart, BS, Clinical Research Coordinator, Benson-Henry Institute for Mind Body Medicine

Jonathan Takahashi, MD, MPH, Resident Physician, Department of Family Medicine, University of Wisconsin-Madison, Madison, WI, USA

Barbara Moscowitz, MSW, LICSW, Program Director of Senior HealthWise, Geriatric Medicine Unit, Massachusetts General Hospital, Boston, MA, USA

Ann Webster, PhD, Director of Mind Body Program for Successful Aging, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, and Associate in Psychiatry, Department of Psychiatry, Massachusetts General Hospital and, Instructor in Medicine, Harvard Medical School, Boston, MA, USA

John W. Denninger, MD, PhD, and Director of Research, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital and Instructor in Psychiatry, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

Darshan H. Mehta, MD, MPH Medical Director, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital and Instructor in Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

Abstract

Correspondence: Darshan Mehta, MD, Benson-Henry Institute at Massachusetts General Hospital, 151 Merrimac Street, 4th Floor, Boston, MA 02114Tel: 617-643-6046, Fax: 617-643-6077, [email protected].

Financial Disclosure: This work was supported by the Harvard Catalyst at the Harvard Clinical and Translational Science Center, the National Center for Research Resources, and the National Center for Advancing Translational Sciences at the National Institutes of Health (Award #UL1 RR 025758 and financial contributions from Harvard University and its affiliated academic healthcare centers). The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.

HHS Public Access Author manuscript Adv Mind Body Med. Author manuscript; available in PMC 2015 May 19.

Published in final edited form as: Adv Mind Body Med. 2015 ; 29(1): 26–33.

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Context—As of 2012, 810 million people were over the age of 60 worldwide, accounting for 11 percent of the population. That number is expected to rise to 2 billion by 2050 or to 22 percent of

the overall population. As a result, a growing need exists to understand the factors that promote

mental and physical health in older populations.

Objectives—The purpose of this study was to develop a healthy aging program for older adults and to measure the changes from baseline to the end of the program in participants’ relevant

psychosocial outcomes; ie, self-efficacy and morale.

Design—The study’s Healthy Aging Mind Body Intervention (MBI) was adapted from the Relaxation Response Resiliency Program (3RP) at the Benson-Henry Institute for Mind Body

Medicine (BHI), which incorporates elements from the fields of stress management, cognitive-

behavioral therapy, and positive psychology. That program was modified with examples and

exercises targeted to an older population, and evaluated in the current, single-arm, pilot study.

Setting—The program took place at the Massachusetts General Hospital (MGH).

Participants—The 9-week Healthy Aging MBI was developed for participants aged 65 and over. Fifty-one older adults from the surrounding community participated in the study’s groups.

Intervention—A new intervention group began the program every 3 months, with a maximum of 12 individuals per group. For each group, the MBI consisted of weekly, 90-minute sessions for 9

consecutive weeks, directed by a psychologist. The program included sessions that taught

participants: (1) a variety of methods to elicit the relaxation response (RR), (2) the practice of

adaptive coping and cognitions, (3) behaviors necessary to create a healthy lifestyle, and (4)

methods of building social support.

Outcome Measures—The research team chose to focus on 2 psychological variables of interest for aging populations: morale and self-efficacy. The study used 2 questionnaires to measure those

outcomes, the Philadelphia Geriatric Center Morale Scale (PGCMS), a multidimensional measure

of the psychological state of older people, and the Coping Self-Efficacy Scale (CSES), a measure

that addresses the multiple dimensions of self-efficacy.

Results—Data from 5 intervention groups were combined for the current analysis. Forty-six participants enrolled and completed questionnaires. Of those participants, 41 attended at least 7

out of the 9 sessions. Significant increases in self-efficacy and morale were observed for program

completers. After a highly conservative sensitivity analysis, the change for the measure of self-

efficacy remained significant, and the change for the measure of morale trended toward

significance.

Conclusions—The study’s healthy aging program appears to be a feasible intervention for older adults, with the potential to increase levels of self-efficacy and morale in participants. Further

research is warranted to determine its effects on other psychosocial outcomes and healthcare

utilization in aging populations.

Keywords

Mind-body; successful aging; psychosocial; self-efficacy; morale

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As of 2012, 810 million people were over the age of 60 worldwide, accounting for 11

percent of the population. That number is expected to rise to 2 billion by 2050 and to

represent 22 percent of the overall population, with older adults surpassing the number of

children.1 As the world population ages, demand will increase for the management of

chronic conditions and of needs for long-term care.2 Given a forecasted shortage of

healthcare providers, the increase in demand for these services represents a growing public-

health concern.2 Many chronic conditions, such as diabetes and hypertension, can be

managed with the help of behavioral interventions.3–5 In the context of efforts to meet

patients’ care needs while slowing growth of healthcare spending, an imminent interest

exists in exploring interventions that promote self-care in older populations so that they can

better prevent, manage, and cope with mental and physical ailments.6–7

INNOVATION: THE HEALTHY AGING PROGRAM

Benefits

Healthy aging programs combine insights from programs for chronic-disease management

and mind-body interventions (MBIs), with the goal of improving self-care for older adults.

Some studies have demonstrated the value of interventions for improving self-care through

mind-body techniques in older adults,8 but most have tended to focus on the use of MBI for

participants with a single medical condition, such as chronic back pain or hypertension.9,10

For example, an intervention in 1577 Medicare patients found that individuals who had

myocardial infarctions or who had received cardiac procedures demonstrated significantly

lower hospitalization rates after completing a multicomponent MBI. The findings for the

intervention group also showed trends for yearly savings in the cost of care and lower

overall rates of mortality when compared to those of control participants.11

Initial studies with heterogeneous populations have also been encouraging. One such

multicomponent intervention found decreases in self-reported sleep difficulties, pain,

anxiety, and depressive symptoms compared to a control group as well as changes in the

health locus of control beliefs, which describe a patient’s beliefs about their ability to control

their health.12 It was found that stronger beliefs of ability to control health outcomes, for

example beliefs about ability to control stress levels and coping, were related to greater

positive health behaviors. At a one-year follow-up, the study’s intervention group

maintained its benefits related to sleep and locus of control and also showed an increase in

health behaviors; such as engaging in exercise, maintaining good nutrition, having

interpersonal support and utilizing stress management techniques.12

Another study enrolled patients with chronic diseases in a community-based, self-

management program that taught exercise, relaxation techniques, nutrition, sleep

management, strategies for emotional regulation, and methods for health-related

communication and decision making. The program resulted in improved health behaviors

and status as well as fewer hospitalizations and fewer days of hospitalization compared to

waitlisted controls.13 Results were maintained at a 2-year, follow-up evaluation, including

evidence that the program reduced healthcare costs.14

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The studies discussed above have demonstrated that programs for chronic-disease

management have the potential to reduce both use of the healthcare system and healthcare

costs, while they improve patients’ health; however, further research is needed to test the

effectiveness of healthy aging interventions more broadly applicable to the promotion of

self-care in older adults.

Conceptual Basis

Healthy aging programs have been inspired by group MBIs that focus on elicitation of the

relaxation response (RR). The RR is a physiological state that is characterized by decreased

heart rate, blood pressure, rate of breathing, and muscle tension. Regular elicitation of the

RR has been shown to be an effective therapeutic strategy for a wide range of stress-related

and chronic diseases, including immunological, cardiovascular, and neurodegenerative

diseases,15 and has also been shown to aid in improving attention in older adults.16 RR-

based MBIs also appear to be effective in decreasing symptoms in patients suffering from

depression and anxiety.17,18 Furthermore, elicitation of the RR has been shown to have

profound effects on physiology, including altering the genetic expression of gene families

involved in oxidative stress, energy metabolism, and inflammation,19 which can impact

processes related to chronic diseases.

In addition to elicitation of the RR, healthy aging programs are based on promoting other

aspects of resiliency.20 One aspect is physical activity. Regular physical activity is

particularly important for the physical and mental health of older adults.21 Previous studies

have shown that regular physical activity can produce long-term health benefits, such as

improved cognitive function, better sleep quality, lower risk of falls and broken bones,

increased positive well-being, and improved quality of life.22,23 Regular physical activity

has also been shown to reduce the risk of some age-related diseases and disabilities; eg,

balance problems or difficulties walking, as well as to manage many chronic conditions,

such as arthritis, heart disease, and chronic pain.24,25

Another component of resiliency that is important for aging populations is having a sense of

purpose in life and a strong social network. Several studies among aging populations have

suggested high levels of social activity and support are related to greater physical health,26

life satisfaction, and happiness27 as well as to better physical and cognitive functioning,

greater overall well-being, and reduced mortality.28,29 One study found that friendship

identity, the meaning attributed to oneself in the role as friend (i.e. “As a friend I am…”

“social”, “confident”, “happy”, “open”, “warm”, “successful”, “interested”), predicted well-

being more than income or marital status.30 A sense of purpose has also emerged as an

important factor for aging populations. Another study found that adults aged 50 and older

who were highly engaged in work or volunteer activities, reported greater psychological

well-being than those who were not involved.31

A Program for Older Adults

The new Healthy Aging MBI was developed for participants aged 65 and over. It was

designed to be accessible to a broad population, and for that reason, was implemented at a

low cost and through a community-care setting. It was implemented in collaboration with

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MGH Senior HealthWISE, a free hospital-based community benefit program designed to

enhance the health and well-being of older adults in the neighborhoods surrounding MGH.

The goal of HealthWISE is to improve health management through education and support,

as well as provide opportunities for socialization, exercise and connection to community

resources for individuals over the age of 60.

The new program was adapted from the Relaxation Response Resiliency Program (3RP) at

the Benson-Henry Institute for Mind Body Medicine (BHI),20 which incorporates elements

from the fields of stress management, cognitive-behavioral therapy, and positive

psychology. The current research team modified that program by creating examples and

exercises targeted to an older population. Overall, the new program was developed to

promote skills that could enhance the psychosocial variables that are important for the health

of older populations: self-efficacy and morale.

Self-efficacy—Self-efficacy, a person’s belief in his or her ability to influence life events,32 has been associated with increased self-care among older persons,33 as well as

with improvements in older persons’ ratings of their healthy aging.6 Self-efficacy has also

been found to act as a mediator of changes in health behaviors and in use of the healthcare

system.14,34 For older adults, self-efficacy has also been related to increased energy, better

sleep, and decreased pain and discomfort as well as with overall satisfaction with life.33

Improving self-efficacy in aging populations is an important goal because self-efficacy has

been associated with increased resilience against development of depression35 and with

better overall health.36

Morale—Another important psychosocial factor, morale has also been positively associated with healthy aging. Morale is a multidimensional construct that includes the amount of

anxiety experienced, an individual’s attitude toward his or her own aging, and the level of

acceptance or dissatisfaction with social interactions.37,38 A better state of morale has been

shown to be negatively associated with functional disability and positively associated with

strength of social network and level of activity.39 Furthermore, it has been shown to be an

independent predictor of physical-health outcomes, such as decreased incidence of stroke40

and overall mortality.41

In its current, single-arm, pilot study, the research team evaluated the feasibility of the new

Healthy Aging MBI and recorded self-reported levels of self-efficacy and morale. The team

hypothesized that participants would demonstrate increases in self-efficacy and morale

relative to their baseline assessments after completing the groups.

METHODS

Participants

To obtain participants, the current study’s MBI program was advertised via the

Massachusetts General Hospital’s (MGH’s) newsletter. The group facilitator also gave a

public lecture previewing the program at MGH. Subjects were recruited from individuals

participating in the MGH Senior HealthWISE program. Patients were screened for their

ability to participate in the program (attend session, follow instructions, do home practice).

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Also, it was ensured that patients had an established primary care provider, in case of any

acute medical issues to be addressed.

An initial intake assessment was conducted by an internal-medicine physician and a

psychologist. Participants were required to be 65 or over, have no acute psychiatric or

medical condition that would substantially interfere with group participation, and be able to

speak and understand English. Approval for the use of human participants was obtained

from the Partners Human Research Committee. Participants were informed in the written

consent about the nature of the study. Fifty-one older adults participated in the groups.

Intervention

A new intervention group began the new MBI program every 3 months, with a maximum of

12 individuals per group. Five groups of 8–12 individuals participated in the intervention.

For each group, the program consisted of weekly, 90-minute sessions for 9 consecutive

weeks, directed by a psychologist. Each session had one or two central themes and multiple

sub-themes. The program included sessions that taught participants: (1) a variety of methods

to elicit the RR, including breath focus, single-pointed focus, imagery, contemplation, chair

yoga, and mindful awareness, which all involve repeatedly bringing the attention gently

back to either the breath, an imagined scene, movement or one of the senses; (2) the practice

of adaptive cognitive coping and cognitions; eg, optimism and acceptance, (3) behaviors

necessary to create a healthy lifestyle; eg, recommendations for nutrition, exercise, and

restorative sleep; and (4) methods of building social support. Details of the program are

provided in Table 1.

Throughout the course of treatment, participants were asked to elicit the RR at home each

day, through development of a consistent mind-body practice. They were instructed to use

the provided CD, recorded by the psychologist, to practice a meditation for 20 minutes daily.

Self-monitoring diary sheets were provided to participants to help them keep a record of

their daily meditation practice. Participants also completed brief homework activities that

reinforced the concepts learned during group sessions. The group’s facilitator collected the

diary sheets and written homework each week and handed them back the following week

with written comments.

In addition to focusing on elicitation of the RR and increasing resiliency, the new program

also focused on increasing self-efficacy and morale as well as promoting healthy lifestyles.

Two practices for achieving healthy lifestyles, (1) mindful eating, which involves slowly

eating and being aware of the sensations associated with each bite, (2) and physical activity

was promoted through chair-yoga sessions. Chair yoga involves a sequence of stretches that

participants perform while seated that brings attention to physical activity in a non-

judgmental and accessible manner. Participants were also encouraged to incorporate regular

physical activity into their days. In addition, participants engaged in experiential exercises

related to mindful eating during group sessions and explored food choices that promote

resilience.

Through the group-based approach, participants also explored ways in which to develop the

healthy aspects of social support. Participants were asked to keep daily appreciation

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journals, in which they wrote about people and events in their lives that they were thankful

for. They would also begin sessions by sharing “news and goods,” recent positive events,

with the group. Participants were asked to explore and challenge patterns of distorted or

irrational automatic thoughts that were prevalent in their lives through the use of diary

entries and worksheets. Participants also were encouraged to set goals and to discover

meaning and purpose in their lives by taking up new hobbies, by volunteering, or by

learning something new. Finally, group exercises promoted humor, empathy, and social

support.

Sessions followed a regular structure and included time for didactic, experiential, and

discussion portions. During the first portion, the psychologist handed back diary sheets and

then used the sheets to encourage group members to share their entries and reflections. The

second portion consisted of eliciting the RR with a 15-minute guided meditation led by the

psychologist.

Outcome Measures

The current study focused on 2 psychological variables of interest for aging populations that

are related to concepts of resiliency and self-care: morale and self-efficacy.

The Philadelphia Geriatric Center Morale Scale (PGCMS).38—This scale has 17 items and was designed as a multidimensional measure of the psychological state of older

people. The 3 dimensions of morale measured by the PGCMS are agitation, attitude toward

own aging, and lonely dissatisfaction, the last of which describes depressive mood in

relation to social interactions.38 Each item is binary, with one response indicating high

morale and the other low morale. For each item, the high-morale responses receive a score

of 1, and the low-morale responses receive a score of 0. Scores range from 0–17, with scores

below 9 suggesting low morale. The mean PGCMS score in the original validation study of

928 men and women aged 70 to 90 years was 11.35 ± 3.76.37

The Coping Self-Efficacy Scale (CSES).42—This 26-item scale addresses the multiple dimensions of self-efficacy, including problem-focused coping, a focus on changing

problematic aspects of stressful events, emotion-focused coping, responses focused on

changing emotional responses to stressful events, and social support. It is also intended to

measure changes in coping self-efficacy following an intervention. Participants respond to

the question, “When things aren’t going well for you, how confident are you that you

can…?” by assigning a rating from 0–10 to specific stress-coping activities, with 0

indicating no confidence and 10 the highest confidence. Scores range from 0–260, with

higher scores indicating greater self-efficacy. The mean CSES score in a community-based

validation study of 182, mostly Caucasian, college-educated British men and women, aged

18 to 66 years, was 159.6 ± 41.0.43

Statistical Analyses

The data from the 5 intervention groups were combined for the purpose of analysis.

Analyses were run using SPSS Statistics 17 (SPSS Inc., Chicago, IL, USA). Descriptive

statistics were used to examine groups at baseline. Changes in morale and self-efficacy were

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tested using paired t-tests on pre- and postintervention data. Mean imputation was used to

complete instruments with missing data for the CSES, and missing items were coded as a 0

for PGCMS, in alignment with the methods used in previous studies.38,42 If questionnaires

were missing >20% they were marked as not-completed.

After completing a primary analysis, a highly conservative sensitivity analysis was

conducted to account for those participants who dropped out, in line with recommendations

for clinical trials by the National Research Council.44 As a sensitivity analysis, the research

team conservatively assumed that participants who were missing postintervention data

accrued no benefit from the intervention. Participants who dropped out of the study or did

not fill out pre- or postintervention instruments were given a pre-post change score equal to

the largest observed decrease of all participants, which would indicate a worsening score. A

Wilcoxon signed rank test was used for the sensitivity analysis.

Of note, the sensitivity analysis includes the pre-test data from one participant who dropped

the group and enrolled at a later date, at which time both pre- and post-test data were

collected. Since pre-test data was collected twice from this participant, and this was a

feasibility study, the original pre-test data was included in the sensitivity analysis with a

post-test score that was conservatively computed using the largest observed decrease

(worsening) in the group. This was so as to mirror the analyses of data from participants

who dropped the group entirely.

RESULTS

Participants

Of the 51 older adults who participated in the groups, 46 elected to fill out questionnaires.

Of those 46 participants, 41 (89.1%) attended at least 7 out of 9 (78%) sessions.

Participants’ ages ranged from 66 to 91 years, with an average age of 75.5 ± 6.7. As shown

in Table 2, the majority of participants were female (76.1%) white (89.1%), and retired

(74%). Sixteen of the participants were widowed (34.8%); 10 were divorced or separated

(21.7%); 9 were single (19.6%); 7 were married (15.2%); and 4 did not report statuses

(8.7%).

Psychosocial Outcomes

At baseline, participants reported a mean ± standard deviation of 10.73 ± 4.15 on the

PGCMS and 163.33 ± 43.73 on the CSES. The scores on both the PGCMS and the CSES

increased significantly among completers of the intervention; ie, the pre- to postintervention

change was: (1) PGCMS, 1.68 ± 2.94, p = 0.001; (2) CSES, 33.90 ± 36. 30, p < 0.001 (Table

3).

Five participants who completed the PGCMS pre-test did not complete the post-test. Of

those participants who completed both pre- and post-test the largest observed decrease was a

worsening of 4 points. Therefore, for the sensitivity analysis, this value of −4 was

conservatively used as the change score for these 5 participants. Similarly, 7 participants

who completed the PGCMS pre-test did not complete the post-test. Of those participants

who completed both pre- and post-test the largest decrease was a worsening of 17 points.

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Therefore, for the sensitivity analysis, this value of −17 was conservatively used as the

change score for these 7 participants.

After the sensitivity analysis, the CSES pre-post change was still significant (p<0.001), and

the PGCMS trended toward statistical significance (p=0.064). Excluding the extra pre-test

data from the subject who enrolled at a later date, however, would lead to an overall change

in PGCMS from pre- to post-intervention would also remain significant (p=0.036).

DISCUSSION

As the percentage of older adults increases, demand grows for effective, accessible,

preventive-care options as does the need to understand factors that promote mental and

physical health in older populations. The present study provides the theory and outline of a

new Healthy Aging MBI program that was developed specifically to meet the needs of older

adults. The high retention and response rates in the study suggest that the program can be a

feasible intervention for use among aging populations.

The study also has shed light on important psychosocial factors related to self-care.

Statistically significant improvements in self-efficacy and morale were observed after the

program, with self-efficacy maintaining significance after a highly conservative sensitivity

analysis. The results represent meaningful improvements, with the overall group showing an

mean increase from 10.73 ± 4.15 to 12.41 ± 4.15 (15.7%) and from 163.33 ± 43.73 to

197.23 ± 39.80 (20.8%) in PGCMS and CSES scores, respectively.

Numerous studies have noted the importance of psychological variables in improving both

quality of life and objective health outcomes.45,46 In particular, self-efficacy has been used

as a theoretical framework to explain the utility of other interventions,47 and interventions

that have been shown to improve self-efficacy are related to subsequent change in health

behaviors.48 Additionally, an interaction has been shown between self-efficacy and change

in physical performance, suggesting a buffering effect for self-efficacy against functional

decline when older adults are faced with diminished physical capacity.49

While self-efficacy remained significant after the sensitivity analysis, morale did not. That

finding may be interpreted in the strictest sense as an indication that participants might not

have experienced improvements in morale; however, other possible explanations exist for

the results. Given that the PGCMS change in the sensitivity analysis was significant when

the participant who had 2 sets of data included in the sensitivity analysis—one as a

noncompleter due to scheduling conflicts and one as a completer—was only included once

as a completer, perhaps the more likely interpretation is that the results observed are due to a

lack of power. Further studies with larger sample sizes could determine if lack of power is

the case. Overall, the present results provide evidence that psychological variables can be

improved through the new, multicomponent, group intervention adapted for older adults.

Barriers to Implementation and Future Directions

Limitations of the study included a lack of a control group and the fact that the sample was

predominantly female and white. Participants consisted mostly of high-functioning

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individuals without any severe medical or psychological conditions that would preclude

their participation in the program. As a result, participants at baseline were only slightly

below or even scored above established norms on the PGCMS and CSES respectively.

Future studies could investigate the efficacy of this intervention for more diverse

populations, including individuals with lower baseline levels of functioning. In addition,

subsequent investigations could explore whether the intervention generalizes to other

settings, such as nursing homes or non-hospital community health centers. As designed, the

study was intended to collect preliminary data on a new healthy aging program, and the

findings suggest that larger randomized controlled studies are warranted.

A final important consideration is that the present intervention was designed to impact

multiple individuals working with a single provider rather than the traditional one-on-one

encounter. Given that healthcare costs have expanded at exponential rates, national and

international imperatives exist to contain costs and still deliver high-quality healthcare. The

current study’s type of intervention was designed to use an adequate appropriation of

resources, and also allowed patients to be participatory in their health and well-being. For

future studies, it will be valuable to examine the financial impact of such interventions.

CONCLUSION

In the current study, the research team was able to demonstrate a feasible model of a group-

based Healthy Aging MBI, with potential for adaptation to diverse aging populations. The

goal of the program was to teach self-care strategies that allowed patients to thrive well into

their later years. This intervention is innovative in its application to a broad aging

population, with a range of chronic health conditions, rather than a population with a

specific disease. While the current pilot study was intended to demonstrate feasibility,

participation in the Healthy Aging MBI was shown to be associated with increases in self-

efficacy and morale, which have been established as important mediators of changes in

health behavior. Through larger randomized controlled studies, future researchers should

examine the relative contributions of the various components of the intervention. In

addition, it will important to understand how such group-based MBIs might be helpful in

promoting efficient use of health care within diverse populations.

Acknowledgments

The research team would like to thank Eric Macklin at Massachusetts General Hospital, who advised on the analysis, with support from Harvard Catalyst; Sue Clough at the Benson-Henry Institute; and the staff of Senior HealthWISE for coordinating the Successful Aging groups.

References

1. Population ageing and development: ten years after Madrid. Population Facts 2012/4. New York, NY: UN Dept of Economic and Social Affairs, Population Division; 2012. UN Dept of Economic and Social Affairs.

2. Wiener JM, Tilly J. Population ageing in the United States of America: implications for public programmes. Int J Epidemiol. 2002; 31(4):776–781. [PubMed: 12177018]

3. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint

Scult et al. Page 10

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A u th

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a n u scrip

t A

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t

National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42(6):1206–1252. [PubMed: 14656957]

4. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key Indicators of Well-Being. Washington, DC: Federal Interagency Forum on Aging-Related Statistics; 2012.

5. Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002; 25(12):2165–2171. [PubMed: 12453955]

6. Cha NH, Seo EJ, Sok SR. Factors influencing the successful aging of older Korean adults. Contemp Nurse. 2012; 41(1):78–87. [PubMed: 22724909]

7. Depp CA, Jeste DV. Definitions and predictors of successful aging: a comprehensive review of larger quantitative studies. Am J Geriatr Psychiatry. 2006; 14(1):6–20. [PubMed: 16407577]

8. Rejeski WJ. Mindfulness: reconnecting the body and mind in geriatric medicine and gerontology. Gerontologist. 2008; 48(2):135–141. [PubMed: 18483425]

9. Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Med. 2007; 8(4):359–375. [PubMed: 17610459]

10. Palta P, Page G, Piferi RL, et al. Evaluation of a mindfulness-based intervention program to decrease blood pressure in low-income African-American older adults. J Urban Health. 2012; 89(2):308–316. [PubMed: 22302233]

11. Zeng W, Stason WB, Fournier S, et al. Benefits and costs of intensive lifestyle modification programs for symptomatic coronary disease in Medicare beneficiaries. Am Heart J. 2013; 165(5): 785–792. [PubMed: 23622916]

12. Rybarczyk B, DeMarco G, DeLaCruz M, Lapidos S, Fortner B. A classroom mind/body wellness intervention for older adults with chronic illness: comparing immediate and 1-year benefits. Behav Med. 2001; 27(1):15–27. [PubMed: 11575169]

13. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self- management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999; 37(1):5–14. [PubMed: 10413387]

14. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001; 39(11):1217–1223. [PubMed: 11606875]

15. Esch T, Fricchione GL, Stefano GB. The therapeutic use of the relaxation response in stress-related diseases. Med Sci Monit. 2003; 9(2):RA23–RA34. [PubMed: 12601303]

16. Galvin JA, Benson H, Deckro GR, Fricchione GL, Dusek JA. The relaxation response: reducing stress and improving cognition in healthy aging adults. Complement Ther Clin Pract. 2006; 12(3): 186–191. [PubMed: 16835029]

17. Jacquart J, Miller KM, Radossi A, et al. The effectiveness of a community-based mind-body group intervention for symptoms of depression and anxiety. Adv Mind Body Med. In press.

18. Taylor AG, Goehler LE, Galper DI, Innes KE, Bourguignon C. Top-down and bottom-up mechanisms in mind-body medicine: development of an integrative framework for psychophysiological research. Explore (NY). 2010; 6(1):29–41. [PubMed: 20129310]

19. Bhasin MK, Dusek JA, Chang BH, et al. Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways. PLoS One. 2013; 8(5):e62817. [PubMed: 23650531]

20. Park ER, Traeger L, Vranceanu AM, et al. The development of a patient-centered program based on the relaxation response: the Relaxation Response Resiliency Program (3RP). Psychosomatics. 2013; 54(2):165–174. [PubMed: 23352048]

21. King AC, King DK. Physical activity for an aging population. Public Health Rev. 2010; 32(2): 401–426.

22. Geda YE, Roberts RO, Knopman DS, et al. Physical exercise, aging, and mild cognitive impairment: a population-based study. Arch Neurol. 2010; 67(1):80–86. [PubMed: 20065133]

23. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: US Dept of Health and Human Services; 2008.

24. National Institute on Aging. Exercise and Physical Activity: Your Everyday Guide. Bethesda, MD: National Institute on Aging, National Institutes of Health, US Dept of Health and Human Services; 2011.

Scult et al. Page 11

Adv Mind Body Med. Author manuscript; available in PMC 2015 May 19.

A u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t

25. Williamson J, Pahor M. Evidence regarding the benefits of physical exercise. Arch Intern Med. 2010; 170(2):124–125. [PubMed: 20101006]

26. Everard KM, Lach HW, Fisher EB, Baum MC. Relationship of activity and social support to the functional health of older adults. J Gerontol B Psychol Sci Soc Sci. 2000; 55(4):S208–S212. [PubMed: 11584883]

27. Newsom JT, Schulz R. Social support as a mediator in the relation between functional status and quality of life in older adults. Psychol Aging. 1996; 11(1):34–44. [PubMed: 8726368]

28. Menec VH. The relation between everyday activities and successful aging: a 6-year longitudinal study. J Gerontol B Psychol Sci Soc Sci. 2003; 58(2):S74–S82. [PubMed: 12646596]

29. Perkins MM, Ball MM, Kemp CL, Hollingsworth C. Social relations and resident health in assisted living: an application of the convoy model. Gerontologist. 2013; 53(3):495–507. [PubMed: 23042689]

30. Siebert DC, Mutran EJ, Reitzes DC. Friendship and social support: the importance of role identity to aging adults. Soc Work. 1999; 44(6):522–533. [PubMed: 10568025]

31. Matz-Costa C, Besen E, Boone James J, Pitt-Catsouphes M. Differential impact of multiple levels of productive activity engagement on psychological well-being in middle and later life. Gerontologist. 2014; 54(2):277–289. [PubMed: 23213083]

32. Bandura, A. Self-efficacy. In: Weiner, IB.; Craighead, WE., editors. Corsini Encyclopedia of Psychology. Hoboken, NJ: John Wiley & Sons; 2010.

33. Kostka T, Jachimowicz V. Relationship of quality of life to dispositional optimism, health locus of control and self-efficacy in older subjects living in different environments. Qual Life Res. 2010; 19(3):351–361. [PubMed: 20146007]

34. Anderson ES, Winett RA, Wojcik JR, Williams DM. Social cognitive mediators of change in a group randomized nutrition and physical activity intervention: social support, self-efficacy, outcome expectations and self-regulation in the guide-to-health trial. J Health Psychol. 2010; 15(1):21–32. [PubMed: 20064881]

35. Holahan CK, Holahan CJ. Self-efficacy, social support, and depression in aging: a longitudinal analysis. J Gerontol. 1987; 42(1):65–68. [PubMed: 3794199]

36. Grembowski D, Patrick D, Diehr P, et al. Self-efficacy and health behavior among older adults. J Health Soc Behav. 1993; 34(2):89–104. [PubMed: 8277130]

37. Lawton, MP. The dimensions of morale. In: Kent, DP.; Kastenbaum, R.; Sherwood, S., editors. Research, Planning, and Action for the Elderly: The Power and Potential of Social Science. New York, NY: Behavioral Publications; 1972.

38. Lawton MP. The Philadelphia Geriatric Center Morale Scale: a revision. J Gerontol. 1975; 30(1): 85–89. [PubMed: 1109399]

39. Litwin H. The path to well-being among elderly Arab Israelis. J Cross Cult Gerontol. 2006; 21(1– 2):25–40. [PubMed: 17103310]

40. Araki A, Murotani Y, Kamimiya F, Ito H. Low well-being is an independent predictor for stroke in elderly patients with diabetes mellitus. J Am Geriatr Soc. 2004; 52(2):205–210. [PubMed: 14728628]

41. Benito-León J, Louis ED, Rivera-Navarro J, Medrano MJ, Vega S, Bermejo-Pareja F. Low morale is associated with increased risk of mortality in the elderly: a population-based prospective study (NEDICES). Age Ageing. 2010; 39(3):366–373. [PubMed: 20299322]

42. Chesney MA, Neilands TB, Chambers DB, Taylor JM, Folkman S. A validity and reliability study of the coping-self-efficacy scale. Br J Health Psychol. 2006; 11:421–437. [PubMed: 16870053]

43. Colodro H, Godoy-Izquierdo D, Godoy J. Coping self-efficacy in a community-based sample of women and men from the United Kingdom: the impact of sex and health status. Behav Med. 2010; 36(1):12–23. [PubMed: 20185397]

44. Little RJ, D’Agostino R, Cohen ML, et al. The prevention and treatment of missing data in clinical trials. N Engl J Med. 2012; 367(14):1355–1360. [PubMed: 23034025]

45. Smith KW, Avis NE, Assmann SF. Distinguishing between quality of life and health status in quality of life research: a meta-analysis. Qual Life Res. 1999; 8(5):447–459. [PubMed: 10474286]

Scult et al. Page 12

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u th

o r M

a n u scrip

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o r M

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t

46. Cohen S, Herbert TB. Health psychology: psychological factors and physical disease from the perspective of human psychoneuroimmunology. Annu Rev Psychol. 1996; 47:113–142. [PubMed: 8624135]

47. Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy- enhancing interventions for reducing chronic disability: implications for health education practice (part I). Health Promot Pract. 2005; 6(1):37–43. [PubMed: 15574526]

48. Strecher VJ, DeVellis BM, Becker MH, Rosenstock IM. The role of self-efficacy in achieving health behavior change. Health Educ Q. 1986; 13(1):73–92. [PubMed: 3957687]

49. Mendes de Leon CF, Seeman TE, Baker DI, Richardson ED, Tinetti ME. Self-efficacy, physical decline, and change in functioning in community-living elders: a prospective study. J Gerontol B Psychol Sci Soc Sci. 1996; 51(4):S183–S190. [PubMed: 8673647]

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Table 1

Sessions and Goals for the Healthy Aging Mind-body Intervention

Session Title Goals

Session 1: Start Where You Are, the Mind Body Connection

• Discussion of stress physiology and the mind-body connection

• Identification of stress warning signs

• Tips for successful aging

• Explanation of self-monitoring diary sheets

• Practice in eliciting the relaxation response (RR), CDs provided

• Receipt of course materials

Session 2: It All Starts with the Breath

• Review of self-monitoring diary sheets

• Practice in eliciting the RR

• Discussion of relaxation practice—what worked, what didn’t work

• Explanation of minis; ie, brief elicitations of the RR to use throughout the day

• Explanation of biodots: sensors placed on hand that measure skin temperature -- used for biofeedback during meditation sessions

• Discussion of the attitude of gratitude

Session 3: Hurry Up and Relax

• Review of diary sheets and minis

• Practice in eliciting the RR

• Discussion of biodots

• Introduction of the stress-hardiness characteristic and stress buffers

• Explanation of mindfulness

Session 4: Yoga • Review of diary sheets

• Discussion of the health benefits of physical activity

• Explanation of the elicitation of the RR through chair yoga and gentle stretching exercises

Session 5: Resiliency • Practice in eliciting the RR

• Discussion of the research on resiliency—rolling with life’s punches

• Discussion of the characteristics of resiliency: commitment, control, challenge, and community

• Practice of an experiential exercise on creating meaning and purpose in life

Session 6: Change Your Mind, Change Your Mood—Part 1

• Practice in eliciting the RR

• Discussion of cognitive restructuring—how thoughts affect the body

• Discussion of the fact that stress is often caused by distorted, illogical, irrational thinking

• Discussion of the replacement of irrational negative thoughts with more rational ones

Session 7: Change Your Mind, Change Your Mood—Part 2

• Introduction of a new method to elicit the RR

• Discussion of the use of cognitive reappraisal as a way to build adaptation

• Practice of the visual imagery exercise

• Small-group discussion of cognitive-restructuring diary sheets

• Discussion of positive beliefs as antidotes for negative thoughts and beliefs

• Discussion of styles of communication

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Session Title Goals

Session 8: Nutrition • Practice in eliciting the RR

• Discussion: What is a healthy diet?

• Discussion: What should your plate look like?

• Discussion of eating for strong bones, a healthy heart, and an efficient immune system

• Discussion on preparation of food

• Discussion on sharing meals with friends

• Discussion: It’s not just what you eat; it’s also how you eat

• Discussion of the use of vitamins and supplements

Session 9: Review and Relapse Prevention

• Practice in eliciting the RR

• Review of the entire program

• Letter writing, with commitment to the changes the individual has made

• Provision of a shared meal

• Completion of postprogram questions

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Table 2

Demographics of the Study’s Participants (n=46)

Characteristic N (%) Mean ± SD

Age, y 75.5 ± 6.7

Gender

Male 8 (17.4)

Female 35 (76.1)

Unreported 3 (6.5)

Race

White/Caucasian 41 (89.1)

African American 1 (2.2)

Unreported 4 (8.7)

Marital Status

Single 9 (19.6)

Married 7 (15.2)

Divorced or separated 10 (21.7)

Widowed 16 (34.8)

Unreported 4 (8.7)

Employment Status

Retired 34 (74)

Part-time 3 (6.5)

Full-time 3 (6.5)

Disabled 2 (4.3)

Unreported 4 (8.7)

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Table 3

Results.

Completer Analysis, n=41 for PGCMS and n=38 for CSES

Pre-intervention Mean (SD)

Postintervention Mean (SD)

Change Mean (SD) p-value

PGCMS 10.73 (4.15) 12.41 (4.15) 1.68 (2.94) 0.001

CSES 163.33 (43.73) 197.23 (39.80) 33.90 (36.30) <0.001

Sensitivity Analysis, n=46 for PGCMS and n=45 for CSES

Pre-intervention Mean (SD)

Postintervention Mean (SD)

Change Mean (SD) p-value

PGCMS 10.48 (4.15) 11.54 (4.80) 1.07 (3.30) 0.064

CSES 164.47 (43.47) 190.45 (43.14) 25.98 (38.16) <0.001

The table shows the results of a completer analysis with paired t-tests and a Wilcoxon signed rank test for a sensitivity analysis, which shows an n = 45 for the CSES because one participant complete neither a pre- or a posttest questionnaire.

Adv Mind Body Med. Author manuscript; available in PMC 2015 May 19.