Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
A Detailed Analysis of the Process and Content Components of the Lifestyle Redesign® Intervention
Dr. Florence Clark, PhD, OTR/L, FAOTA
OverviewHealthy Aging
Development of the Lifestyle Redesign® Intervention
Implementation of the Lifestyle Redesign® Intervention
Healthy Aging
Advice Through the Ages
44 B.C.E.• Cicero
1214-1294• Roger
Bacon
1484-1566• Luigi
Cornaro
1558-1609• Andre du
Laurens
1903• Sir Herman
Weber
Longevity – 44 B.C.
“We ought to take due care of our Health, and to eat and drink sparingly, and use moderate exercise, that we may be enlivened, and have fresher spirits, not be oppressed, and overloaded.”
Powers of the mind “become more refreshed and invigorated the more they are used.”
- Cicero, A Dialogue On Old Age, 44 B.C.
Longevity – 1500’s
“Nothing hastens old age more than idleness.”- Andre du Laurens (1558-1609)
“A temperate life would enable the body’s finite supply of vital spirits to last until life ebbed peacefully away between the ages of five and six score.”
- Luigi Cornaro (1464-1566)
Longevity – 1903 A.D.
“By moderation and abundant exercise of body and mind, including walking, climbing and breathing exercises, I have escaped death from these causes, have greatly prolonged my life, and am now in good health in my 91st year.”
– Case Study from Sir Hermann Weber, On Means for the Prolongation of Life, 1903
Longevity - 2000
“Heath risks such as smoking, physical inactivity, being overweight or obese, consumption of high fat diets, and inadequate fruit and vegetable intake are major determinants of morbidity and mortality.”
Robert Butler, M.D., founder, International Longevity Institute, founding director of the U.S. National Institute on Aging, Pulitzer Prize winner, gerontologist
The White Queen/Tudor Period (Mortality)
Name Age at Death • Elizabeth Woodville (White Queen) 55• Edward IV (White Queen’s husband) 41• Elizabeth of York (White Queen’s daughter) 37 • Margaret Beaufort (Red Queen) 66• Richard Neville (The Kingmaker) 42• Anne Neville (Kingmaker’s Daughter) 28• The Tudors
– Henry VII (Red Queen’s son) 52– Henry VIII (Henry VII’s son) 55– Elizabeth I (Henry VIII’s daughter) 69
Life Span of the Tudor Queens
Birth Age Married Age of Death Cause
Catherine of Aragon 1485 24 51 Executed
Anne Boleyn 1504 29 32 Executed
Jane Seymour 1508 28 29 Died
Anne of Cleves 1515 25 42 Died
Kathryn Howard 1521 19 21 Executed
Catherine Parr 1512 31 36 Died
Life Expectancy Today
US: 78.74 yearsIsrael: 81.7 yearsJapan: 83.1 years
Source: World Bank, 2015
Composing a Further Life:The Age of Active Wisdom
• Traditional Age - Groups– Childhood– Parenthood– Grandparenthood
• Adulthood I– Very busy, productive time, building careers, raising
children
• Adulthood II– Stage of active wisdom preceding old age
From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.
Composing a Further Life:The Age of Active Wisdom
Adulthood II
Long lives, Better health
Freedom from work
and raising a family
Rich Experiences
Wisdom combined
with activity
Adulthood II is an “improvisational art
form calling for imagination and the willingness to learn”
From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.
What do older adults believe contribute to their health and well-being?
• Reichstadt et al. (2007) found that older adults attribute successful aging to these factors:– Positive Attitude and Adaptability to Change– Sense of Security and Stability– Overall Health and Wellness– Engagement and Stimulation
From: Reichstadt, J., Depp, C. A., Palinkas, L. A., Folsom, D. P., & Jeste, D. V. (2007). Building blocks of successful aging: A focus group study of older adults' perceived contributors to successful aging. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 15(3), 194-201.
What factors have economists identified that influence
happiness over the life span?
Easterlin, R.A. (2006). Life Cycle Happiness and Its Sources: Intersection of Psychology, Economics, and Demography. Journal of Economic Psychology/ Elsevier, pp. 463-482.
How are gerontologists conceptualizing the
complexity of factors that contribute to healthy aging?
Agency(Life Choices)
Structure(Life Chances)
Lifestyle
Hendricks, J. & Hatch, L.R. (2006). Lifestyle and aging. In R. Binstock & L.K. George (Eds.) Handbook of aging and the social sciences (5th ed., pp. 301-319). San Diego, CA: Academic Press.
The Model on Agency and Structure
• Genetics• Staying active• Lifelong learning• Optimism / Love of Life
Helen “Happy” Reichert with her caretaker
• Kahn Family – All four siblings lived to be centenarians!
• Helen “Happy” Reichert, 108• Irving Kahn, 104• Peter Kahn, 100• Lee Kahn passed away in 2005 at the age of 102
Helen Reichert & Irving Kahn in Time Magazine
Aging Around the World
Okinawan Secrets
Hippocratic Medicine
Traditional Chinese
Medicine
Seventh-Day Adventists
Sardinia
Okinawan Secrets: Japan• Traditional Okinawan diet
– Low in fat and calories– High in carbohydrates (e.g. vegetables, grains)
and nutrients– Lots of vegetables, tofu, seaweed, tea
• Modern fast food invasion…– Increased caloric consumption– Lost #1 life expectancy ranking in Japan
• Low stress and rigorous physical activity
• Moai - a support network providing financial, social, and emotional help throughout life
• Ikigai – a reason to wake up in the morning
Average life expectancy• Female: 87 years• Male: 79 years (among longest in the world)US Average Life Expectancy = 78.8 years
So how can we optimize the chances of staying healthy
during Adulthood II?
Identified a need for in-depth qualitative research to gain critical insights about the needs of the participants and inform protocol refinements
The Qualitative Domain Study• Documented the life
domains and adaptive strategies used by older people living in the setting from which the RCT sample would be drawn
• Provided a rich database to guide tailoring of the intervention protocol
Task Analysis - Mapping the Well Elderly Intervention
• Czaja, Schulz, Lee, C. C., & Belle (2003)• Jackson, Carlson, Mandel, Zemke, & Clark (1998)
Theories:Occupation as Emergent, Dynamic Systems, Meaning through Occupation, Humans as
Occupational Beings
Objective #1:Enhance the selection of
occupations
Key Activities:- Increased occupational balance- Heightened flexibility- More overt strategizing
Objective #2:Enhance the experienced meaning of occupations
Key Activities:- Enactment of flow- Improved connections to life course- Enhanced meaning in daily routine
Treatment Outcomes:Primary Outcomes: Enhanced physical health, Improved mental health, Superior
occupational functioning, and Increased life satisfaction
Adopting a Healthy Lifestyle Later in Life
After only 4 years, adopting a healthy lifestyle in middle age can:
• Reduce mortality risk by 40% • Reduce cardiovascular disease risk by 35%
Theme:
We become what we have done
Break
Development of the Lifestyle Redesign® Intervention
Research Base
Hoffman, T., Bennett, S. & Del Mar, C. (2010). Introduction to evidence-based practice. In T. Hoffman, S. Bennett & C. DelMar (Eds.). Evidence-based practice across the health professions, pp. 1-15. Elsevier Australia: Chastswood, NSW.
EVIDENCE-BASED PRACTICE IS…
…the integration of:
• the best research evidence• clinical expertise• the client’s values and circumstances• the practice context
Why is Evidence-Based Practice Important?
• Evidence-based practice promotes:– The most effective care– Improved outcomes– An attitude of inquiry– Professional accountability – Appropriate use of resources
Hoffman, T., Bennett, S. & Del Mar, C. (2010). Introduction to evidence-based practice. In T. Hoffman, S. Bennett & C. Del Mar(Eds.). Evidence-based practice across the health professions, pp. 1-15. Elsevier Australia: Chatswood, NSW.
USC Division of Occupational Science and Occupational Therapy
Well Elderly Research Program
The USC Well Elderly Studies1994-1997: Well Elderly 1 Study
National Institute on Aging (R01 AG11810, R01 AG11810-03S1)NIH, AHCPR, NCMRR
American Occupational Therapy Foundation (NNPUBS-068-98)PI: Florence Clark, PhD, OTR/L, FAOTA
2004-2008: Well Elderly 2 StudyNational Institute on Aging (R01 AG 021108)
PI: Florence Clark, PhD, OTR/L, FAOTA
Florence Clark, PhD Occupational TherapyRuth Zemke, PhD Occupational TherapyJeanne Jackson, PhD Occupational TherapyMichael Carlson, PhD Social PsychologyLoren G. Lipson, MD Geriatric MedicineStanley P. Azen, PhD Preventive Medicine, BiostatisticsJoel W. Hay, PhD Pharmaceutical Policy & EconomicsBarbara J. Cherry, PhD Cognitive PsychologyDeborah Mandel, OTD Occupational TherapyKaren Josephson, MD Geriatric Medicine
USC Well Elderly 1 Study (WE1) Team
Florence Clark, PhD Occupational TherapyJeanne Jackson, PhD Occupational TherapyStanley P. Azen, PhD Preventive Medicine, BiostatisticsChih-Ping Chou, PhD Preventive MedicineBarbara J. Cherry, PhD Cognitive PsychologyMaryalice Jordan-Marsh, PhD NursingBrett White, MD Family MedicineDouglas Granger, PhD Biobehavioral Health, Penn State Robert Knight, PhD Psychology, GerontologyMichael Carlson, PhD Social PsychologyRand Wilcox, PhD Psychology, StatisticsDeborah Mandel, OTD Occupational TherapyJeanine Blanchard, PhD Occupational Therapy
USC Well Elderly 2 Study (WE2) Team
Well Elderly Study 2: Intent-to-Treat ResultsTreatment (n=187) vs. Control (n=173)
Health Related Quality of Life (SF36V2)
Mental Health 0.03
Social Function 0.04
Vitality 0.03
Bodily Pain 0.02
Composite: Mental 0.03
Composite: Physical 0.09
General Health 0.25
Physical Function 0.09
Role Physical 0.18
Role Emotional 0.16
Life Satisfaction (LSI-Z) 0.03
Depression (CES-D) 0.03
Cognition
Memory (CERAD)
• Immediate Recall 0.20
• Delayed Recall 0.38
• Recognition 0.26
Visual Search 0.49
Psychomotor Speed 0.49
Lifestyle Redesign® Intervention
Lifestyle Redesign®
Lifestyle Redesign® enables patients to design, practice,
and ultimately enact a personalized, sustainable
health-promoting daily routine that is tailored to address
chronic disease risk factors as well as promote health and well-being more generally.
• Can be delayed, even prevented, through lifestyle changes– Coronary heart disease– Certain cancers– Diabetes– Dementia– Arthritis
Age-related Diseases
Lifestyle Redesign
Awareness of Activity Patterns Analysis of Activity Patterns
Changing Habits and RoutinesDevelopment of a
Personalized Engagement Plan (PEP)
Lifestyle Redesign Process
Key Ideas of the Lifestyle Redesign Program
1. Experience in occupation produces radiating, not linear, change.
2. Occupational self-analysis is possible.
3. When people understand occupation, they can redesign their lives.
4. Occupation is the impetus that propels people forward.
5. Active coping is a learned skill that can positively affect well-being.
Occupation Produces Radiating, Not Linear, Change
New sense of social
connectedness
New transportati
on skills
New positive self-image
What changes occur when a participant tries public
transportation for the first time?
Occupational Self-Analysis Is Possible
Who are you as an occupational being?
What occupations do youlike best?
Are you experiencing occupational deprivation?
How do your occupations affect your health?
What is your plan for healthier living? How will you enact your plan?
Lifestyle Redesign Provides a Valuable “Toolkit”
“Toolkit” of Lifestyle Redesign
1) Purposeful selection of health-promoting
occupations
2) Experienced meaning
Occupation Propels People Forward
Technique Occupational Storytelling Occupational Storymaking
Collaboration Evoking stories of occupation Occupational coaching• Encouraging positive remake• Offering occupational
strategies• Reaffirming and marking
progress
Building Empathy Analysis and synthesis• Time• Value
Evoking insight (problems and solutions)
Inclusion of Ordinary • Joint task interaction with self-interest manifested
• Identify and meet group norms and goals
Broadened view of activities of daily living• Handling emotion• Friendship and intimacy• Symbolic dimension of
occupation
Listening Image reconstruction
Reflection Cultural place
Occupation Propels People Forward
Active Coping Is a Learned SkillThe Stress Response
The Transformative Process of Lifestyle Redesign
Conceptual Foundation
• Occupation is essential for human existence• Occupation is transformational• Occupations vary in their degree of
meaningfulness (and positive or negative impact on health)
• People can reorder their occupational patterns from disequilibrium to stability (dynamic systems theory)
Mechanisms of Change
Knowledge Acquisition
Internalization
Habit Formation
Goals of Lifestyle Redesign®
• Assist each participant to develop:– A personally feasible, healthy lifestyle
– Sustainable within the fabric of his or her everyday routines
• Increase or maintain:– Independence
– Health
– Well-Being
Awakening
“I wouldn’t have done itif it weren’t for you!”
• Becoming hyper-cognizant of activity patterns and their impact on health
• Activity Pattern Analysis
• Lifestyle Redesign®
Lifestyle Redesign® Intervention
Knowledge: Understanding the Impact of Activity on Health
• Notice and name activities
• Explore the dimensions of activities– Physical, cognitive, social, emotional & spiritual
• Learn the relationship of activities to health and well-being
• Experience the relationship of activities to health and well-being
Activity Pattern Analysis
• Self-reflect
• Identify barriers
• Identify options and alternatives
Potlucks
Writing
MeditatingRemembering the old
days
Dancing
Going to Church
Exercising
Praying
Reading the Newspaper
Doing Puzzles
Walking
Singing
Parties
El Grupo de Bienestar:Naming Occupations
WellnessMental
Social
Emotional
Spiritual
Physical
Dimensions of Wellness
Developed by El Grupo de Bienestar
Read the NewspaperWritePuzzles
Remember the old daysYogaReadingMusicMeditation
ChurchMassPray
WalkDanceSingExercise
PartiesPotluckDancing
Mental
Social
Spiritual
Physical
Emotional
Wellnessand
Occupation
Developed by El Grupo de Bienestar
Lifestyle Redesign®
• Select personalized healthy activity options
• Make changes in routines
• Practice habits and routines
Preliminary Individual Assessment Investigate: • Medical history• Current daily routines • Functional limitations• Occupational history• Barriers and support systems• Time use/energy management• Stress management• Leisure interests• Long term goals • Diet/exercise
The Personal Engagement Plan (PEP)
Customized to fit the participant’s• Attitudes• Needs• Preferences• Capacities• Environmental
facilitators and constraints
• Health profile
My Life
My Attitudes
Other Key Information
My NeedsMy Health Status
My Behaviors
Making Health Habits and Routines Permanent
Sustainable, healthy routines are a main objective of the Lifestyle Redesign program
Performed somewhat automatically
Provide daily structure
Can counteract the development of chronic disease and disability
Factors that Influence Habits and Routines
Habits and
Routines
Environment
Social support
Financial security
Sleep patterns
Influential people
Biological factors
Others
Adapting Habits and Routines
• Reexamine goals and routines periodically, and adjust when necessary• Include caregivers in habit formation and goal setting• Encourage flexibility and set expectation that plans will be modified over
time
Intervention Delivery
• Didactic Presentation
• Peer Exchange
• Direct Experience
• Personal Exploration
• Personal goals
• Build new habits
• Traditional occupational therapy
• Reinforce and individualize materials from group sessions
Group Meetings Individual Sessions
USC Well Elderly Program ModelContent Areas
Aging, Health, and OccupationTransportation
Safety
Dining
Physical and Mental Activity
Relationships
Cultural Awareness
Finances
Integrative Summary
Methods of Delivery
Group and Individual
Didactic Presentation
Peer Exchange
Direct Experience
Personal Exploration
Health Related Outcomes
Enhanced Physical Health
Superior Occupational Functioning
Increased Life Satisfaction
Modules Utilized in WE1• Occupation, Health, and Aging• Transportation and Occupation• Health Through Occupation: Physical and Mental
Activity• Dining as Occupation• Time and Occupation• Home and Community Safety• Relationships and Occupation• Outings, Exploration, and Special Events• Ending a Group
Program Adaptations (WE1 WE2)• Intervention shortened from 9 months to 6
months• More diverse participants• Research sites expanded to include senior
centers and 1 continuous care retirement community
• Modules were updated and modified
Lunch
Implementation of the Lifestyle Redesign® Intervention
How to Use the Modules
Occupation, health, and aging
Community mobility, transportation, and
occupation
The building blocks of longevity: physical,
mental, spiritual, social, and productive activity
Stress and inflammation management
Dining and nutrition Time and occupation Home and community safety
Relationships and occupation
Thriving Navigating health care Hormones, aging, and sexuality Ending a group
Module 1: Occupation, Health, and Aging
• Goals – Enable participants to:– Describe occupation (homeostasis, routine,
balance, circadian rhythms)– Understand the relationship of occupation to
health and apply concepts in their own lives– Develop their individual preliminary Personalized
Engagement Plans (PEP)
Module 2: Community Mobility, Transportation and Occupation
• Goals – Enable participants to:– Develop an understanding of mobility challenges– Plan and enact solutions to challenges in
preparation for community outings• Focus varies depending on population
– Driving– Public transportation– Having multiple options
Module 3: The Building Blocks of Longevity: Various Types of Activity
• Goals – Enable participants to:– Understand that health and wellbeing requires engagement in a
diverse range of meaningful and health-promoting activities (in addition to avoidance of illness)
– Employ practical approaches for incorporating healthy occupations into daily lives
– Recognize different types of activity:• Physical• Mental• Spiritual• Social• Productive
– Utilize strategies for dealing with factors that impede activity engagement (e.g., urinary incontinence)
What is Occupation?
30% engage in sexual activity at least once per month
Cognitive
Physical
Social
Productive
Spiritual
Module 4: Stress and Inflammation Management
• Goals – Enable participants to:– Understand the relationship of stress and sleep
deprivation on inflammation– Recognize the impact of stress on their minds and
bodies and explore healthy ways to decrease stress– Utilize active coping
• Problem-focused coping– Acting– Planning– Suppressing distracting activities
– Develop strategies for managing sleep
Heckhausen & Schulz (1995), Schulz & Heckhausen (1996)
Homeostasis and Occupation
Homeostasisis a state of balance within the body.
Sometimes we use occupation to help achieve homeostasis.
Circadian Rhythm and Occupation
Module 5: Dining and Nutrition• Goals – Enable participants to:
– Describe what constitutes “healthy eating”– Recognize the relationship of food intake to
activity engagement– Engage in a group cooking and dining activity
based on themes of nutrition and understanding food labels
– Explore the social dimension of eating– Enact methods for organizing medication intake
according to a schedule
Module 6: Time and Occupation• Goals – Enable participants to:
– Analyze their lives in terms of pace, past, present, anticipated future, and degree of forward progression
– Reflect upon the experience of time– Implement strategies for taking control of time
through activity orchestration/management– Chart circadian rhythms
Module 7: Home and Community Safety
• Goals – Enable participants to:– Explore small changes that could prevent an unwanted
attack or improve personal safety at home and in community
– Take appropriate risks, develop friendships, and use available resources to be more comfortable exploring community
– Modify their home environments to eliminate hazards and to promote safe activity engagement
– Employ strategies for fall prevention
Module 8: Relationships and Occupation
• Goals – Enable participants to:– Explore the topics of community and
communication and the impact of loneliness on health
– Discuss cultural and personal strategies for coping with loss or death and dying
– Recognize the importance of end-of-life planning
Module 9: Thriving
• Goals – Enable participants to:– Recognize and exercise their own potential by
• Exploring what they care about most• Engaging in life more profoundly• Discovering their deepest priorities and potentials• Pursuing new forms of meaning
Module 10: Navigating Healthcare
• Goals – Enable participants to:– Increase their health literacy by reviewing and
discussing pertinent content which has been tailored to the particular healthcare system concerns of their group
Module 11: Hormones, Aging, and Sexuality
• Goals – Enable participants to:– Understand the effects of aging on hormones and
sexuality for both men and women– Discuss lifestyle, social, and pharmacological
factors affecting sexuality in later life
Module 12: Ending a Group – Finalizing Personal Engagement Plans (PEPs)
• Goals – Enable participants to:– Finalize their PEPs
• Health promoting habits, routines, and strategies for sustaining enactment of plan over time
– Engage in a ritual/ceremony which marks their transition to a healthy lifestyle independent of group involvement
Personal Engagement Plan (PEP) Select Content Recommendations
for Participants
Plans must be customized to be sustainable
But they should include these components…
1. Learning to listen to your body
• Follow your circadian rhythms• Become mindful of when you are at
homeostasis• Use technology to track your biomarkers
and activity pattern
From: Agus, D. B. (2011). The end of illness. New York: Free Press.
• Through simple everyday practice– i.e., avoid wearing high heels, carrying heavy
purchases, wearing uncomfortable or binding clothes, using heavy suitcases, etc.
2. Trying to avoid chronic inflammation
From: Agus, D. B. (2011). The end of illness. New York: Free Press.
• As much as possible, try to eat…– On a regular schedule– Cold water fish (i.e. trout, tuna, halibut) 3x
per week– A multi-colored diet– Red wine (if you wish) 5 nights per week
• Unless you are at high risk for cancer
– A good-fat diet– Natural, non-processed food
3. Trying to eat a healthy aging diet
From: Agus, D. B. (2011). The end of illness. New York: Free Press.
• Some stress is normal and adaptive• Chronic stress is health-compromising
– Becoming aware of sources of chronic stress is important• Ways of managing stress:
– Finding ways to rest– Avoiding chronic stressors (as much as possible)– Spacing– Taking breaks– Just saying no– Escape– Personal therapeutic activities that are enjoyable, soothing
4. Minimizing your stress
From: Agus, D. B. (2011). The end of illness. New York: Free Press.
• Genetic risk factors – Predisposition to common conditions
• Lifestyle factors can counteract these risks– Physical exercise changes gene expression
5. Knowing your risk factors
From: Agus, D. B. (2011). The end of illness. New York: Free Press.
• Eat, sleep, and exercise at predictable times every day
• Engage in the social, productive, and spiritual activities you value
• Choose physical activities you enjoy (as much as possible)– Consistent physical activities such as walking or
dancing can be very health-promoting • Take time to rest• Avoid sedentary activity as much as feasible
6. Incorporating health-promoting practices
From: Agus, D. B. (2011). The end of illness. New York: Free Press.
• Explore what you care most about– Engage in life more profoundly– Explore your deepest priorities and potentials– Pursue new forms of meaning
7. Developing in new ways
From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.
• Taking action is self-perpetuating
8. Getting started
From: Agus, D. B. (2011). The end of illness. New York: Free Press.
What’s really happening in those
groups?
Safe Place
Someone was there to trust.
You will love us, accept us, who we are.
You can make mistakes.
There will be no judgment.
Affirmation that they were on a journey
together.
You did your best to get us where to be.
We could be ourselves.
Touched each other in different
ways.
Talked to each other.
There was nowhere they could talk at this level.
They grew and changed as a
person.
They experienced it and no one can take
that away.
So what did the intervention provide overall?
Lifestyle Redesign®
• Select personalized healthy activity options
• Make changes in routines
• Practice habits and routines
References• Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage
Books.• Easterlin, R.A. (2006). Life Cycle Happiness and Its Sources: Intersection of Psychology, Economies,
and Demography. Journal of Economic Psychology, 27, 463-482.• Heckhausen, J. & Schulz, R. (1995). A life-span theory of control. Psychological Review, 102, 284-
304. • Hendricks, J. & Hatch, L.R. (2006). Lifestyle and aging. In R. Binstock & L.K. George (Eds.) Handbook
of Aging and the Social Sciences (5th ed., pp. 301-319). San Diego, CA: Academic Press.• Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign:
The Well Elderly Study occupational therapy program. American Journal of Occupational Therapy, 52, 326-336.
• Reichstadt, J., Depp, C. A., Palinkas, L. A., Folsom, D. P., & Jeste, D. V. (2007). Building blocks of successful aging: A focus group study of older adults' perceived contributors to successful aging.The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 15(3), 194-201.
• Schulz, R., & Heckhausen, J. (1996). A life span model of successful aging. American Psychologist, 51, 702-714.
Thank you!