Ageing well - a complex topic for research and for practice.

1. Ageing well: a complex topic for
research and for practice
Gail Mountain
Professor of Health Services Research
(assisted living)

2. What makes it complex?

3. Incorporates our own perceptions
and experiences

4. What we know
The following are key to wellbeing in later life:-
•Participation
•Health
These factors erode wellbeing:-
•Poor physical health
•Loss such as unplanned retirement, widowhood
•Loneliness/ poor psychological health
How to limit the negative factors and promote those that are positive?
No simple solutions
Forthcoming NICE guidance will promote the importance of multi
component interventions that can be personalised (in addition to PH
guidance 16)

5. University of Southern California
Centre for Lifestyle Redesign

6. Starting with the Concept
of Lifestyle Redesign.....
The process of developing and enacting a
customised routine of health promoting
and meaningful daily activities (Clark
1998 in Mandel 1999)

7. The Well Elderly study of Lifestyle Redesign
Clark, et al (1997) Occupational Therapy for
independent older living adults: a randomised
controlled trial. Journal of the American Medical
Association, 278, 1321-1326
•Participants experienced benefit; health, function
and quality of life
•Benefit was sustained six months later
•The interventions were cost effective

8. The Lifestyle Matters ethos
• A preventive health approach which focuses on
the benefits of activity
• Underpinned by the belief that what we do on a
day to day basis is central to our health and
wellbeing
• And that positive changes can only be sustained if
they are embedded within what a person does on
a day to day basis

9. UK Medical Research Council
Complex Interventions framework (2008)
Development
Feasibility and Pilot
Evaluation
Implementation
http://www.bmj.com/content/337/bmj.a1655

10. Complexity: need for research and
clinical skills/ knowledge
Develop intervention
Test it in practice
Undertake research to
examine effectiveness

11. Lifestyle Matters programme
• Developed in partnership
with older people for
older people in the UK
• Inspired by Lifestyle
Redesign®; a programme
developed and tested in
the US

12. A model of preventive health:
group and individual interventions

13. The UK programme: selecting from
a menu of activities
Beginnings: celebration
Activity and health
• The ageing process and activity
• Personal energy, time and activity
• Goals; realising hopes and wishes
• Pulling things together – how is activity related to
health

14. Ideas continued…
Maintaining mental wellbeing
• Sleep as an activity
• Keeping mentally active
• Memory
Maintaining physical wellbeing
• Nutrition
• Pain
• Keeping physically active

15. And more…
Occupation in the home and community
• Transportation
• Opportunities for new learning
• Experiencing new technologies
Safety in and around the home
• Keeping safe in the community
• Keeping safe in the home

16. Yet more….
Personal circumstances
• Dealing with finance
• Social relationships and maintaining friendships
• Dining as an activity
• Interests and pastimes
• Caring for others, caring for self
• Spirituality
Endings

17. Feasibility Study (2004-2005)
What we had to consider
 Recruitment of older people: community living
 Who will deliver the programme and how will they be
trained and supported: different to US model
 Outcome measures necessary for a future
randomised controlled trial

18. Results of feasibility study
• Twenty eight people aged 60 and over
commenced the eight month programme and
26 completed it
• They still meet together independently
(several years later)
• Post intervention interviews illustrated the
benefits participants experienced with greater
self efficacy being a significant theme
(Mountain & Craig, Occupational Therapy International, 2011)

19. Results cont.
• Comparison of pre and post scores on
quantitative measures showed upward trends
on all dimensions of quality of life (Mountain et al,
British Journal of Occ Therapy, 2008)
• Measurement of cognition and dependency
proved useful for screening purposes and for
identifying individuals at risk, but not as
outcome measures

20. Outputs from the feasibility study
Results used to inform national guidance alongside well
elderly study http://guidance.nice.org.uk/PH16
Intervention published

21. Funded by the UK Medical Research
Council 2011-2015
1.3M over 4 years
http://www.sheffield.ac.uk/lifestylematters

22. Lifestyle Matters programme of
research
 Population based study of effectiveness: RCT
 Evaluation of cost effectiveness: HE evaluation
embedded
 Research into implementation: process evaluation
and fidelity assessment
 Translation of findings into practice: open source –
video, audio and web based material

23. Trial design
• Two arm cluster randomised controlled trial (Lifestyle Matters and
‘standard care’)
• Two recruitment sites – Sheffield (urban) and Bangor, North Wales (rural)
• Outcome measures applied at baseline (consent), six months and two
years
• Primary outcome: SF36 (mental health)
• Secondary outcomes: SF36 (physical health), General Self Efficacy scale,
EQ5D, PHQ9, de Jong loneliness scale, health and social care utilisation

24. Intervention delivery
• Intervention delivered for 4 months in a community venue
• All participants offered monthly 1:1 sessions
• Intervention facilitated by grade 4 NHS equivalent staff (lower
pay than for occupational therapists)
• Training provided for intervention delivery and weekly
supervision

25. Recruitment
Target: 268 randomised participants
Actual: 270 randomised
18 couples randomised
Total: 288 participants

26. Review of recruitment strategies
•Most successful method
was GP mail-outs
•9379 letters, sixteen surgeries
in Sheffield and North Wales
•414 enquires. 389 result of the
GP mail-outs representing a
4% response rate
•25 enquiries from direct referrers from NHS and community
services and general advertising

27. Cycles of intervention delivery
(9-16 participants per group)
Sheffield Six groups
Two locations used
Bangor, North Wales Five groups
Four locations used

28. From feasibility to population
based study
• Less ‘hands on’ - larger project team and
range of involvement
• Broader range of participants, locations
and venues and facilitators
• Devolved supervision arrangements

29. Attendance: groups
•n=97 (74%) received therapeutic dose (8 weeks)
•n=34 attended 7 weekly sessions or less
•Average weeks attended 10.19
Sheffield Bangor Total
Group 1 – 18/09/2012 n=13 Group 1 – 11/10/2012 n=10
11 Groups
n=131
Group 2 – 17/10/2012 n=9 Group 2 – 13/11/2012 n=10
Group 3 – 22/11/2012 n=10 Group 3 – 19/12/2012 n=12
Group 4 – 24/01/2013 n=15 Group 4 – 21/02/2013 n=16
Group 5 – 01/03/2013 n=14 Group 5 – 24/04/2013 n= 11
Group 6 – 05/04/2013 n= 11

30. Outcomes of attendance: 1-1s
• 113 participants approached
• n=404 meetings offered
• n=143 meetings accepted
(35% of those offered)
• n=124 meetings attended
(87% of those accepted)
Number of 1-1
sessions attended
Number of
participants
0 36
1 41
2 22
3 10
4 4

31. Final summary stats
Entered the programme 92 men
196 women
Completed 6 month follow
up
262
Completed 24 month
follow up
240
Provided qualitative
feedback
13 at 6 month follow up
26 at 2 year follow up

32. Process evaluation
• Interviewed all 4 facilitators, 2 time points
• Interviewed all 3 OT supervisors post intervention
• Interviewed 13 participants (10% purposive sample)
post intervention
– Participants from 6 groups across all 3 cycles
– Both sites (Sheffield n=7, Bangor n=6)
– Selection criteria included age, sex, geographical area,
attendance as individual or part of a couple, education,
previous occupation, level of current activity, number of
sessions attended

33. Emergent results from process
evaluation (facilitators)
• The facilitators did not change attitudes and understanding but
did develop and improve their skills
• They enabled people to contribute and encouraged the group to
make decisions rather than instructing and leading
• Group dynamics were important
• Older people shared and developed coping strategies for
managing the challenges of ageing
• The programme provided opportunities to try out new activities
and community facilities, which led to changes in routines and
behaviour
• There was less evidence of the older people taking over the
organisation of the group over the 4 months of delivery

34. Emergent results from process
evaluation at 6 months (participants)
• Main reasons for not attending were illness or being ‘too
busy’ but non attendance was also viewed negatively
• Concerns over male/ female mix
"I remember when I went in there that first day and, oh
god, I was the only bloke there and I thought, what the
hell have I let myself in for here? And when I was going,
the last one [group meeting], I was quite, I was quite
sad that it was over with, you know, because the group
had joined in…as a gel, yeah, you know.

35. Emergent results from process
evaluation (participants)
Challenges were posed by transport and the climate;
Shall we go, shan’t we go because of the snow and one
thing and another, which again was unfortunate...when
er, you know, we had two out of the, three out of the
sixteen weeks...where I couldn’t go, er, and I mean I only
live a couple of hundred yards away”.

36. Emergent results from process
evaluation (participants)
Most of those interviewed indicated that with the support of
the group and the facilitators they had found the impetus to
pursue one or more activities or interests since taking part in
the programme
I think what we’re going to do now, [wife] and I have decided
that on Thursdays it should be an activity day for us…Erm but
we’ve said, ‘OK, Thursday, we’ve enjoyed it so much, why
don’t we go out and make Thursday an activity day’. We’ve
nothing else to worry about, we’ve no dependents as such, we
can go, go out any day, but Thursday ‘cause we’ve got into a
routine, ‘yeah, let’s go and try so-and-so.

37. What might be the
outcome?
• Results of feasibility study could be ‘diluted’
due to wider application
• Problems with implementing 1:1 sessions may
have also diluted the effect
• Were the outcome measures most
appropriate – no measure of participation

38. Some of the learning points
so far
• Methodological contribution - evaluation of complex, group
based interventions
• Recruitment challenges – how to reach those in most need?
• Service readiness – existing implementation has largely
involved use of the programme within existing secondary
care services; no infrastructure for preventive services
• Training and supervision requirements for best delivery

39. Trying the Lifestyle Matters intervention
with other user groups
People with early stage dementia in Sheffield
 ‘Journeying through Dementia’ programme content
 Recruitment methods
 Sample size for an RCT
 Outcome measures – tolerance and suitability
 Length and modes of delivery
Older people with diagnosed mild to moderate depression
in Wales
 Recruitment strategies
 Explore research methods and study design
 Outcome measures – tolerance and suitability
 Develop and modify selected topics from intervention

40. Two preparatory studies in dementia
to produce a draft manual
Mountain GA and Craig C
(2012) what should be in a
self management
programme for people with
early stage dementia?
Aging and Mental Health,
2012, 16(5)

41. Thank you
g.a.mountain@sheffield.ac.uk