FEATURE — Winter 2007

Photo: Staff-Giuliano/Superstock, Collage: Donna Boyd

Managing Successful Aging

Occupational therapists and geriatricians work together to help older adults maintain meaningful and highly functioning lives. Helping them stay in their own homes is at the top of the list.

By Kristin Tennant

Hearing loss, joint pain, memory issues, and a quest for meaning. The first three quickly come to mind when most people imagine the day-to-day lives of older adults. But the fourth—finding meaning—is at the heart of the matter for several Washington University researchers. Not only is living a meaningful life important in its own right, it is critically linked to physical well-being and mental health across the life span. Carolyn Baum, the Elias Michael Executive Director of the Program in Occupational Therapy, and a professor of occupational therapy and of neurology, is one of the researchers focusing on this overarching goal. “I want to make it possible for older adults to have meaningful lives,” Baum says. “We do that by helping people manage their health conditions and making sure they aren’t isolated from the things that are important to them.”

Carolyn Baum (standing), director of the Program in Occupational Therapy, conducts an “Activity Card Sort,” a measure to determine Jean Angeles’ and Tony Angeles’ engagement in activities. With this instrument, Baum can determine the impact of a health condition on participation in activities. Baum’s research focuses on enabling older adults with disabilities and chronic health conditions to maintain their home, family, and community activities.

For many older adults, maintaining or generating significant connections in their daily lives hinges on what is called “aging in place”—being able to stay in their homes and communities as long as possible. While aging in place might seem like a greater burden on caregivers, Baum and her colleagues say that, when managed properly, everyone benefits. Older adults are happier, more alert, and more independent, which in turn takes some of the responsibility and stress off their caregivers.

In-Home Services, an innovative clinical program at the University’s Program in Occupational Therapy (OT), helps make aging in place a reality for more people. First, In-Home Services sends an occupational therapist into an older adult’s home to observe him or her in that environment, with the caregivers. A holistic assessment of capabilities is made, with the focus being on abilities, not disabilities. By assessing a person in his or her primary care environment—looking at intrinsic and extrinsic factors—the clinician is able to create a matrix to help caregivers accurately estimate an older loved one’s abilities. Once those abilities are recognized, education, training, and management strategies come into play.

Baum, whose work focuses primarily on older adults who are dealing with the effects of a stroke, low vision, and Parkinson’s disease, has found that even those with chronic health conditions—even so-called “disabilities”—can lead meaningful lives in their homes and communities.

“The question we’re always asking is: ‘How can we help older adults manage their own health and function, so they can do the things they want to do?’” Baum says.

The focus is on self-care and management, but Baum says caregivers play an important role, too.

“In my dissertation research I found that if people can keep their loved ones active, they need less help with self-care,” Baum, Ph.D. ’93, says. “My research shows that staying active also reduces some of the behaviors that can go along with neurological problems, and caregivers are usually more upset by those behaviors than they are by having to care for someone.”

The Key to Remaining Active
Encouraging activity in older adults does not always mean sending them to an exercise class or making them walk around the block each day, Baum says. The activity should be cognitive as well as physical and something that easily fits into a daily routine.

(Top) Geriatrician David Carr researches older adults and driving (see sidebar in Transforming Later Life feature in this issue); here, he interviews Eva Adele. At the Memory Diagnostic Center, Carr also works closely with occupational therapists and other health professionals helping older adults “successfully age.” (Below) Occupational therapist Susan Stark (right) conducts studies of how environmental modifications affect the lives of older adults and people with disabilities. Ronald Fenster (center) and his wife, Marjorie, received modifications to enable Ronald to stay home.

“It’s often just about finding out what the individual has done over and over again for years, then figuring out how they can continue to do some of these activities that are meaningful and driven by procedural memory,” she says.

Baum tells the story of a man who was a plumber his whole life. Every morning he got out his plumber’s belt, put it over the back of the kitchen chair, ate his breakfast, then picked up his tools and went to work. When Alzheimer’s began to set in, the quality of the man’s plumbing work remained high, but he had trouble keeping track of appointments and billing, so they hired an apprentice to work with him. When the man eventually could no longer do the work at a professional level, his wife decided it was time to put away the plumber’s belt for good.

“He began acting out and being combative, and his behaviors suddenly became much worse,” Baum says.

Soon after the plumbing tools were packed away, the man and his wife came into the Memory and Aging Project for a scheduled visit. After hearing their story, Baum and her colleagues suggested building a plumbing workshop in the man’s garage, so he could continue a daily routine revolving around the tasks that had defined him for so many years.

“It’s a great example of how we can build routines that help older people maintain dignity and stay connected to what’s important to them,” Baum says. “They need these opportunities to define themselves, so we need to help caregivers problem-solve.”

Not only are activities like these good for restoring and maintaining physical health, they are good for an older adult’s mind and will, too, which can delay a move to a nursing home.

“That’s a huge cost benefit and a quality-of-life issue,” Baum says.

Geriatricians work closely with occupational therapists and other health professionals to help older adults age “successfully.” Ideally, Baum says, geriatricians are “the captains steering the ship” of an older adult’s care plan. David Carr, associate professor of medicine and neurology and a clinician in the University’s Memory Diagnostic Center, coordinates such interdisciplinary care teams. Carr says “successful aging” has three important pieces: avoiding disease and disability, maintaining high physical and cognitive function, and engaging in life.

Associate Professor David Carr says “successful aging” has three important pieces: avoiding disease and disability, maintaining high physical and cognitive function, and engaging in life.

As doctors, we’re not just focusing on the medical model,” Carr says. “Often there are social interventions, the patients may need cognitive stimulation, or the psychological aspect, such as the presence of a depression, may require attention. The caregivers may have needs that should be addressed, too. You can’t just prescribe medicine to solve these complex issues.”

Carr focuses on providing a diagnosis whenever possible, followed by education about the diagnosis, and a plan for managing the symptoms and behavior. Often this management plan involves Carr steering his patients and their caregivers toward available resources and programs—activities, support groups, transportation, and other services in the community. Referrals to other professionals, such as occupational therapists, social workers, and case managers, also are critical in managing successful aging or dealing with a disability.

Staying in the House
Susan Stark and Peggy Neufeld, both assistant professors of occupational therapy, are exactly the type of professionals to whom Carr likes to refer. Stark focuses on the home environments of older adults who do not want to move but who may need some modifications to make that possible; Neufeld picks up where Stark leaves off, making sure those who are “aging in place” get out of their homes periodically, where they can be socially and civically engaged.

Peggy Neufeld (right), Ph.D. ’02, assistant professor of occupational therapy, and Karen Berry-Elbert, M.S.W. ’77, are among the team members who meet regularly to assess and plan for a Naturally Occurring Retirement Community (NORC) in West St. Louis County. Neufeld is the Center for Aging’s research and community liaison to the NORC, conducting resident evaluations, and Berry-Elbert is NORC manager. Research shows that older adults stay socially and civically engaged when living in a NORC with opportunities for meaningful community involvement.

Not surprisingly, an overwhelming majority of older adults want to stay in their homes as long as possible, according to an AARP survey. But many older people, along with their adult children and caregivers, worry that the home is not the safest place. As a result, many people move into assisted living before it is necessary.

Making home modifications is the first step toward helping someone age in place, Stark says. Stark is the principal investigator in the Program in Occupational Therapy’s Environment and Occupational Performance Laboratory at the School of Medicine, where she conducts studies of how environmental modifications affect the lives of older adults and people with disabilities.

We can modify homes, so they will be safe and usable for older adults,” says Stark, M.S.O.T. ’89. “Research suggests that people who get modifications so they can stay in their homes might live longer, and be happier.”

It makes good economic sense, too. The average cost of a home modification is $660, Stark says, which is small compared to the cost of in-home caretakers or a move to assisted living. Most modifications are simple: a grab bar in the bathtub, new sink faucets that are easy to turn on and off, or laundry facilities on the main floor.

“You can’t always reverse the symptoms and syndromes older adults are facing, but you can alter their environment,” Stark says. “If you can’t fix the knees, fix the bathtub. Once people are able to get up and get cleaned, dressed, and out of the house, they’re automatically going to be more engaged in their community.”

‘Frailty’ Poses Difficulties
In the minds of most people, “frailty” is a decline of muscle strength that is simply a natural part of aging.

Now multifaceted research projects focus on frailty—what causes it, how to prevent and treat it, and what the link is between physical frailty and cognitive health.

Geriatricians at the University, led by Danforth Professor Samuel Klein, chief of the geriatrics and nutritional science division, are teaming up on research focusing on preventing, slowing, and even reversing frailty in older adults. They address frailty through research initiatives, including the effects of calorie restriction, obesity, bone and muscle strength, diabetes, and cognitive function on aging.

“Our research efforts overlap, so there is good interaction between faculty,” Klein says.

The Community Outreach Program at the medical school ties the research together, and works on preventing and treating physical dysfunction among underserved populations in the St. Louis community. The program (funded in part by the Barnes-Jewish Hospital Foundation and the David A. and Linda S. Yawitz Community Outreach Fund) also ties the work of University geriatricians to schools of nursing, social work, occupational therapy, and pharmacy.

Frailty results in a loss of independence and often leads to nursing home placement, Klein says. Geriatricians think of frailty as an impairment of function and decrease of physiological reserve that limits a person’s ability to perform daily tasks (such as bathing or climbing stairs). Much of the division’s research looks at frailty through the lens of nutrition and diet. While most think of frail older adults as underweight, he says a growing problem is frailty caused by obesity in older adults.

“An important question that we are studying is why obesity causes so many chronic diseases that further contribute to physical dysfunction and frailty in older adults,” Klein says. “The importance of nutrition in health is underappreciated. Unfortunately, obesity is a major health problem that will likely increase, unless lifestyle changes are made.”

Ellen Binder, associate professor in geriatrics and nutritional science, addresses frailty by looking for better ways to prevent and treat injuries such as hip fractures in older adults. Her research has shown that increasing the intensity of exercise in older adults, and the intensity of therapy after an injury like a hip fracture, increases the benefits.

“Getting people up and walking is one thing, but it’s only going to help so much,” Binder, M.D. ’81, says. “Weight training proves very effective for older, frail adults, as does more intense, acute rehabilitation.”

Binder also studies the effects of testosterone in enhancing the rehabilitation process, particularly after a hip fracture. Twenty-five percent of hip fracture patients die within a year, she says, usually because the fracture is just the tip of a whole iceberg of health issues.

“But on the other hand, 75 percent of these patients live, and I want to help them be as independent as possible,” Binder says.

Stanley Birge and Consuelo Wilkins, associate and assistant professors, respectively, in geriatrics and nutritional science, have learned that many physically frail older adults also have a cognitive impairment. Through their research, Birge and Wilkins hope to find out why, then to pinpoint preventative strategies and treatments.

“We think frailty, to a large extent, is due to brain aging, or cerebral vascular disease,” Birge, M.D. ’63, says. “The brain can’t process sensory information fast enough, which affects physical functioning.”

When processing is slowed, explains Wilkins, so are the movements that are required in walking, balance, and preventing falls. The good news in this connection, she says, is that much is known about treating vascular disease, which could in turn, slow or even reverse frailty in older adults.

Vitamin D is one treatment about which Birge and Wilkins are hopeful. They are at the forefront of studies concerning vitamin D, and the findings are very new. More than 1,000 older adults have been screened through the Community Outreach Program.

“Our preliminary data has shown we’ve been able to reverse some of the effects of aging through vitamin D. We’ve seen improvements in balance, cognitive function, and muscle strength,” Birge says.

Getting Out of the House
Once older adults are safe getting around in their homes, they often need encouragement or assistance in getting out. From her work in the community, Peggy Neufeld has seen much evidence that “social health” is closely related to physical and emotional health. Sufficient research and evaluation to back up these theories, however, is lacking, she says.

“It’s becoming clear that social and cognitive stimulation are key to being a healthy older adult,” Neufeld says. “People don’t get out of their homes and exercise because their doctor told them to; they move around because there are other things they want to do out of the house.”

Linking older adults to organizations, activities, and transportation services is a large part of Neufeld’s goal. In most communities this may happen through individual home visits and with coordination assistance from geriatricians.

One of the most effective ways for older adults to stay socially and civically engaged, Neufeld says, is to live in a NORC (Naturally Occurring Retirement Community). A NORC, which is a fairly new concept, is generally defined as a geographic area with a high density of older adults who have lived for decades in their own homes, yet the area was not designed for seniors. Much of Neufeld’s work is observed and facilitated in a NORC Demonstration Project in a 3-square-mile area of West St. Louis County, where there are about 3,050 residents over the age of 65. Following an initial needs assessment by researchers at Washington University’s Harvey A. Friedman Center for Aging, a staff team from partner agencies translated the study recommendations to programs and services, thanks to a grant from the U.S. Administration on Aging to the Jewish Federation of St. Louis.

Neufeld’s job, as research and community liaison for the NORC, is to facilitate residents’ engagement with the community, empower involvement and leadership, and evaluate the results.

“When I’m evaluating the NORC, I am looking for indicators of a healthy community,” Neufeld says. “In a healthy community, people are aware of resources available to them, and they know their neighbors, and they participate in activities and assume some leadership.”

When the community is healthy, older adults can age in place rather than move to an assisted-living facility. People in the neighborhood check in on each other and help elderly residents with tasks they cannot do on their own. In the St. Louis NORC, activities like “chair yoga,” a storytelling group, a computer club, and resident councils motivate people to get out of their homes, as do bus trips to museums or the garden. A NORC newsletter keeps everyone in touch with each other and notifies residents of planned events and available services—it even serves as a tool for keeping adult children and other family members informed, regardless of where they live.

Changing Mindsets and the System
If the benefits of aging in place and being socially active are so clear—not only for the well-being of older adults themselves, but also for their caregivers, and from an economic standpoint—why are so many people still going into institutionalized care facilities? University researchers point to several issues that may hinder successful aging.

One of the problems is a lack of funding, which is embedded in the insurance system. Medicare, for instance, will pay for an assistant to go into the home to help someone bathe and get out of the tub, but it will not pay for a bath bench and a grab bar, which allows many older people to bathe independently. Susan Stark says these insurance policies do not currently reimburse for home modifications because there is not hard evidence to support the health benefits—a problem Stark and her colleagues are working to change through their research.

A lack of awareness and education is another issue, Stark says—one that plays directly into why so many people simply accept their limitations as they age. Stark is working to educate clinicians and build clinical models to assure that more people will be better informed about available home modifications.

“So many older adults feel as if their limitations are inevitable, so they give up on their activities, whether they’re social or tasks around the house,” Stark says. “They can’t imagine a way to solve their problem, whatever it is, and they often don’t report it because they’re afraid they’ll be told that they have to leave their home.”

Mindsets about aging can be negatively impacted by even the best-intentioned people and concepts. Neufeld says even common terminologies, like the word “caregiving” itself, can do damage.

“The word ‘caregiving’ can be unfortunate, because it may set up a dependency model,” Neufeld says. “There’s this sense that all old people are frail and needy, and a burden on their families and communities. But these people really value their independence. When they’re a part of a healthy community, like a NORC, they aren’t just the ones who ‘take’ and ‘need.’ They give back, too.”

Carolyn Baum and her OT colleagues Stark, Neufeld, Kathy Kniepmann, Shirley Behr, Monica Perlmutter, and others are working to change mindsets and approaches by teaching their ability-focused, aging-in-place methods to the University’s OT students. They also have built a measurement model that demonstrates the capacity of a person to engage in activities, tasks, and roles.

Collaboration at the Core
Collaboration is a critical component of successful aging. Baum says if more people were teaming up and using the approaches being promoted through In-Home Services and the St. Louis NORC, it would significantly reduce the number of people going into nursing homes.

“I’m a firm believer in interdisciplinary efforts,” Baum says. “They’re at the heart of what Washington University is about, but you have to work harder to make them happen in the community.”

The NORC project team, for example, consists of occupational therapists like Neufeld, along with social workers and geriatricians. From a geriatrician’s perspective, as Carr points out, having a strong team that works together is absolutely necessary, seeing as how the four tenets of geriatric assessment—medical, psychological, functional, and social well-being—are so diverse.

“Being holistic and interdisciplinary is critical if we want to improve the quality of older people’s lives,” Baum says.

Kristin Tennant is a freelance writer based in Urbana, Illinois.