evidence-based community support programs for early stage ... · early stage memory loss seminar...

Evidence-Based Community Support Programs for Early Stage Dementia

Rebecca G. Logsdon, PhD

Early Stage DiagnosisIndividuals who are diagnosed in the early stages will live with the

disease for many years.

Positive:• initiation of medical treatment

• legal and financial planning

• early mobilization of support services

Negative:• anxiety about the future

• negative stereotyping

• relationship changes

Early Stage services may alter the experience of the disease & quality of life for both the diagnosed person and for those who care for him or her.

Early Stage AD (Logsdon), NWGEC Winter 2015 1

Dementia as Chronic Illness Individuals who are diagnosed in the

early stages will live with the disease for many years.

Focused health promotion activities may alter the experience of the disease & quality of life for both the diagnosed person and for those who care for him or her.

Quality of Life

Quality of life for older adults with chronic illness: a sense of well-being, satisfaction with life, and self-esteem, accomplished through the care received, the accomplishment of desired goals, and the ability to exercise a satisfactory degree of control over one’s life.


Quality of Life for Individuals with Dementia

Sense of well-being Absence of clinical depression and excessive anxiety

Freedom from physical pain

Safety and security

Satisfaction with life Preferred living arrangements

Engagement in meaningful and pleasant activities

Participation in family and social activities

Self-esteem Recognition of contributions

Respect from others

Quality of Life for Individuals with Dementia

Care received Appropriate level of assistance

Provided in ways acceptable to the care recipient

Achievement of desired goals Recognition of personal preferences

Individualized care to accomplish individualized needs

Control over one’s life Participation in decision-making

Freedom to choose from acceptable alternatives


1. How can we measure QOL in individuals with early stage dementia?

2. What factors influence QOL in dementia?

3. What can we do to improve QOL for people with early stage dementia and their caregivers?

Research Questions

1. How can we measure QOL in individuals with early stage dementia?• Health Care provider ratings• Direct Observation • Caregiver/Family member ratings• Self Report by the individual

Research Questions


Assessment Tools for QOL in DementiaMeasure Population Administration

Affect Rating Scale (Lawton, 1996) Nursing Home: Mod to Severe Observation

QOL-D (Albert, 1996) Community: Mild to Severe Family Proxy

DQOL (Brod, 1999) Community: Mild to Mod Self-Report

QOL-AD (Logsdon, 1999) Community: Mild to Mod Self & Proxy

AD-QOL (Black, 2000) Residential Care: Mild to Severe Professional Proxy

QOL-NH (Kane, 2001) Nursing Home Residents Self-Report

Cornell-Brown QOLD (Ready, Ott, 2002)

Community: Mild to Mod Clinician Rating

Dementia Care Mapping (Brooker, 2006)

Residential/Day: Mild to Severe Observation

DEMQOL (Smith, 2005) Community: Mild to Mod Self & Proxy

Observing QOL in Dementia (Fulton, 2006)

Residential/Day: Mild to Severe Observation

Quality Of Life-AD

Structured interview with diagnosed individual

Caregiver questionnaire

13 items assessing 4 domains of QOL: physical, psychological, environmental, behavioral/functional

Good internal reliability (alpha = .86)

Good test-retest reliability (.76 for patient; .92 for caregiver)

Logsdon RG, Gibbons LE, McCurry SM, & Teri L.(1999). Quality of life in Alzheimer’s disease: Patientand caregiver reports. Journal of Mental Health andAging, 5 (1), 21-32.

Funded by: Alzheimer’s Association FSA 95009


2. What factors influence QOL in dementia?

Research Questions

ADL’s

Multivariate Associations

MMSE

Caregiver Burden

CaregiverDepression

PWDQOL-AD

(Self)

CGQOL-AD

(Proxy)

Participant Depression

PleasantEvents

ParticipantPhysical Function

1 1 2

4

3

6

5

2

3

(Logsdon, et al) Baseline multivariate analysis of QOL-AD data; N=176


Longitudinal Study (N=155)Logsdon R.G., Gibbons L.E., McCurry S.M., and Teri L. (2002) Assessing

Quality of life in older adults with cognitive impairment. Psychosomatic Medicine 64:510-519.

Community-residing participant/caregiver dyads evaluated at home every 6 months for up to 5 years

Mean Age 77.2 (6.8)Education 13.5 (3.5)MMSE 16.4 (7.3)Dementia Duration 4.5 (3.0)Sex 57% maleCaregiver Relationship 83% spouse

Funded by: National Institute on Aging AG1084504

Predictors of 12 Month Change

PWD Self-Rating Decline Higher Depression

(GDS)

Less Productive Activity (SF-36)

CG Rating Decline Higher Depression

(GDS and RMBPC)

More Memory Problems (RMBPC)

Less Physical Mobility(SF-36)

PT=206 ObservationsCG=253 Observations


Confirmatory Studies

QOL in Persons with DementiaThorgrimsen, et al, 2003

Hoe, et al, 2005

Logsdon, et al, 2005

Selwood, et al, 2005

Snow, et al, 2005

Banerjee, et al, 2006

MoodMobility

Memory/ Function

Burden

Caregiver

3. What can we do to improve QOL for people with dementia and their caregivers?

Research Questions


Psychosocial Treatment Implications

Maximize social and ADL function

Treat depressive symptoms and encourage

pleasant activities

Improve or maintain physical mobility

Support caregivers to reduce burden

and depression

QOL & Psychosocial Intervention: RCT Evidence Base Maximize social and ADL function

Gitlin, 2001, 03, 05; Dooley, 2004; Graff, 2006

Lowenstein, 2004; Tarraga, 2006; Spector, 2003

Treat depressive symptoms and encourage pleasant activities

Teri, 1997, 2005; Gerdner, 1996, 2002; Huang, 2003; Lichtenberg, 2006


Lazowski, 1999; Littbrand, 2006; Rolland, 2007 (NH)

Teri, 2003; Logsdon, 2005 (Community)

Reduce caregiver burden and depression

Gallagher-Thompson, 1994, 2000, 07; Schulz, 2003, 05; Mittelman, 1995,

2004; Teri, 2005



Maximize social and ADL function


pleasant activities



and depression

Early Stage Support Groups• Logsdon RG, McCurry SM, & Teri L (2005). Time limited support groups for

individuals with early stage dementia and their care partners. Clinical Gerontologist, 30(2), 5-19.

• Logsdon, R.G., Pike, K.C., McCurry, S.M., Hunter, P., Maher, J., Snyder, L., & Teri, L. (2010) Early stage memory loss support groups: Outcomes from a randomized controlled clinical trial. Journal of Gerontology: Psychological Sciences.

National Alzheimer’s Association (IIRG # 0306319) & National Institute on Aging (R01AG23091-2)

Active treatment:● Early Stage Memory Loss seminar program

Control:● Delayed treatment

Support Group Facilitators: Master’s level social workers9 weekly sessions, participant and care partner attend togetherMMSE 18-30; Mean = 24Assessments at baseline and post treatment (2 months)


Early Stage Memory Loss SeminarsAnnual Facilitator Training and UpdateStructured Manual with Outline, Discussion Topics, & Handouts

Session 1 — Introduction and Overview

Session 2 — Coping with Memory Problems

Session 3 — Medical Update–Diagnosis, Treatment and Research

Session 4 — Social and Family Relationships

Session 5 — Considerations in Daily Living

Session 6 — Legal and Financial Considerations (speaker)

Session 7 — Planning for the Future

Session 8 — Health considerations & Review

Alzheimer’s Association Western & Central Washington State Chapter

Outcomes AssessmentConstruct Measure & Reference

Quality of Life QOL-AD; Logsdon et al, 2002SF-36; Stewart et al, 1988

Mood GDS; Yesavage et al, 1983

Perceived Stress PSS; Cohen et al, 1983

Self Efficacy McArthur Scale; Seeman et al, 1996

Family Communication Family Assessment Measure; Skinner et al, 1983

Participant Behaviors RMBPC; Teri et al, 1992

Caregiver Distress RMBPC; Teri et al, 1992


Demographics (N=142)Participant

Age 74 (51-93)

Education High School Grad=98%College Grad=51%

Gender 54% male; 46% female

Ethnicity 8% Hispanic; 2% Black2% American Indian; 1% Asian/Pacific Is

Relationship of Care Partner 82% Spouse14% Adult Child4% Other Relative

MMSE 23.5 (4.6)

General Health 11% Excellent65% Very Good / Good23% Fair / Poor

Quality of Life Outcome

-1.2-1

-0.8-0.6-0.4-0.2

00.20.40.60.8

ESSG (n=96)

WL (n=46)


Better

Participant Quality of Life (QOL-AD: = 1.74, p < .001)


Depression Outcome

-0.1

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

ESSG (n=96)

WL (n=46)


Worse

Participant Depression (GDS: = -1.34, p < .01)

SF‐36 Mental Health

Self Efficacy

Family Communication

Perceived Stress

Geriatric Depression Scale

RMBPC‐Depression

RMBPC‐Total

p < .01

p < .05

ESML participants whose QOL improved also had significant improvement on:


Benefits of Early Stage Groups0% 5% 10% 15% 20% 25% 30% 35%

Social Support

Information AboutAD

Decreased Isolation

Emotional Support

Legal Information

CommunityResources

Caregiving Advice

Participant Care Partner

Logsdon, et al, 2006 (Clinical Gerontologist)


Maximize social and ADL functioning


pleasant activities



and depression


Depression & Pleasant EventsTeri L, Logsdon RG, Uomoto J & McCurry SM. (1997). Behavioral treatment of depression in dementia: A controlled clinical trial. Journals of Gerontology: Psychological Sciences, 52(4), 150-166.

National Institute of Mental Health (MH43266) & National Institute of Aging (AG10845); L Teri, PI

Active treatment:

● Behavior Therapy–Pleasant Events/Problem Solving

Control:

● Typical Care or Wait List Control

Therapists: PhD clinical psychologists

9-week treatment duration

MMSE 0-29; Mean = 16

Assessments at baseline, post treatment, 6 months

Promoting Pleasant Events

Individuals with dementia retain many skills despite cognitive impairments.

Interpersonal relationships are very important, and are fostered by shared pleasant activities.

Caregiver depression and burden may be lessened by focusing on positive, rather than negative interactions.


PES-AD Items Social

Non-social

Solitary

Active

Passive

More/less complex

More/less supervision

Identify and Re-introduce Pleasant Activities

What did the person enjoy in the past?

What does he/she enjoy now?

How can tasks be modified to accommodate current abilities?

Who is available to help with these activities?


Depression in Dementia

0

10

20

30

40

50

60

70

80

Combined Treatment Combined Control

Better

Same

Worse

% Clinical Change

N=42 N=30

aX2 (6, N = 72) = 18.48; p < .005

16

1414.5

11

14

15

10

11

12

13

14

15

16

17

18

BT-PE* TAU WL

Pre

Post

Change in Patient DepressionHDRS

*p<.0001

Community-Residing AD Patients75% Major Depression25% Minor DepressionMMSE mean=16.5


87

667 7

0123456789

10

BT-PE* TAU WL

Pre

Post

Change in Caregiver DepressionHDRS

*p<.0001

Family Caregivers (79% spouses)14% Major Depression62% Minor Depression24% Non-depressed




pleasant activities



and depression


Benefits of Physical Activityfor Individuals with Dementia

Improve Strength and Mobility

Lazowski, et al, 1999Arkin, et al, 2003Hageman, et al, 2002Rolland, et al, 2000

Reduce DepressionTeri, et al, 2004

Decrease Behavioral Disturbances

Rolland, et al, 2000Teri, et al, 2004

Mitigate Cognitive Decline

Rolland, et al, 2000Emery, et al, 1998, 2003

Challenges of Exercise for Individuals with Dementia

• Reluctance to try new activities

• Difficulty learning & remembering to do exercises

• Inability to exercise independently due to safety concerns

• Family caregivers lack knowledge about exercise, already burdened by daily tasks, may be physically frail


Physical FunctionTeri L, Gibbons LE, McCurry SM, Logsdon RG, Buchner D, Barlow W, Kukull W,LaCroix A, McCormick W, Larson E. (2003) Exercise plus behavior management inpatients with Alzheimer’s disease: A controlled clinical trial. JAMA, 290(15); 2015-2022.

Funded by the National Institute on Aging AG10845 and AG14777

Active treatment:● Home-based exercise – strength, balance, endurance ● Behavior therapy – communication, problem-solving

Control:● Routine Medical Care

Therapists: Master’s level home health providers (SW & PT)12-week treatment duration, monthly follow-up 4 monthsMMSE 0 to 29; Mean = 17Assessments at baseline, 3, 6, 12, and 24 months

RDAD Treatment Protocol• 12-week program• Delivered by community home health

providers (physical therapist or social worker)

• Exercise Aerobic/endurance activities (walking) Strength Balance Flexibility

• Problem-solving Education about AD Intervening with behavioral problems Enhance caregiver resources and skills


Change in Percent of Subjects Exercising 60+ Minutes a Week

26

86

3

0

5

10

15

20

25

30

3-Month 12-Month

RDAD

RMC

ITT: Pre-Post <.01

Community-residing AD patientsMean Age = 78Mean MMSE = 1756% exercising 60+ minutes at baseline

108

-17

-6

-20

-15

-10

-5

0

5

10

15

3-month 12-month

RDAD

RMC

Change in Daily Activities

SF-36 Role Functioning

ITT: Pre-Post p<.01


-2

-3.2

0.6

-1.6

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

0.5

1

3-Month 24-Month

RDAD

RMC

Change in Depression

ITT: Pre-Post

p< .05

Longitudinal

p=.05

HDRS, Pts >6 on Cornell at baseline

Change in Behavior

19%24%

19%18%

27%

50%

-10%

0%

10%

20%

30%

40%

50%

60%

Illness or CognitiveDecline

Increased ADLImpairment

Behavioral Problems

RDAD

RMC

Reasons for residential placement over 24-month follow-up


Promoting Exercise for Individuals with Dementia

• What “exercise” did the person enjoy in the past?

• Provide support, assistance, lots of repetition for group programs

• Monitor for safety; simplify, avoid or closely supervise use of unfamiliar equipment

• Encourage family caregivers to incorporate a daily walk to the routine, and gradually increase the time, distance, and speed of walking

• Make physical activity a pleasant event




pleasant activities



and depression


Time Spent Caregiving

0

20

40

60

80

100

120

Not Employed Employed

Primary FamilyCaregiverPaid Help

Other family & Friends

Hours Per

Week

Caregiver Depression & Burden Helplessness Grief Self-Doubt Anger Guilt Anxiety Sleep

Disturbance Alcohol Abuse


Caregiver SupportTeri L, McCurry SM, Logsdon RG, & Gibbons LE. (2005). Training community consultants to help family members improve dementia care: A randomized controlled trial. The Gerontologist, 45(6), 802-811.

Funding: Alzheimer’s Association Pioneer Grant P10-1800

Active treatment:

● Seattle Protocols – communication, problem solving, pleasant events

Control:

● Routine medical care

Caregiving consultants: Master’s-level mental health counselors

8 weekly sessions, monthly phone calls 4 months

MMSE 0-28; Mean = 14

Assessments at baseline, 3, 6, and 12 months

STAR Caregivers

• 8 weekly in-home caregiver counseling sessions

• Communication, problem-solving, pleasant events

• Target behaviors

• agitation, anxiety, depression

• Provided by master’s level caregiving consultants

• Companion for person with dementia if needed

• Training, ongoing supervision, and weekly monitoring of adherence to protocol by geropsychologists


ABCs and Problem-Solving

Problem behaviors can interfere with your ability to care for a person with dementia and their ability to enjoy life

Understanding dementia-related behaviors requires observation of the ABCs: Activators, Behaviors, and Consequences

You can change a problem behavior by preventing it, or stopping it once it occurs

gram.

The ABC Problem Solving Plan

Where can you break the chain of

events???


Caregiver Depression: CESD

14.8

13.2

12.4

13.6

12.5

15.8

10

11

12

13

14

15

16

17

STAR RMC

Baseline

Post

Follow-up

Pre-Post p<.05

Longitudinal p<.02

Caregiver Burden: SCB

25

23

20

23

21

26

15

17

19

21

23

25

27

STAR RMC

Baseline

Post

Follow-up

Pre-Post p<.01

Longitudinal p<.03


Caregiver Reaction to Behavioral Disturbances

28.1

25

22.3

23.3

20

21

22

23

24

25

26

27

28

29

30

STAR RMC

Baseline

Post

Follow-up

Pre-Post p<.03

Longitudinal p<.04

Care Recipient QOL-AD

27.8

28.3

29.4

28.428.428.2

25

25.5

26

26.5

27

27.5

28

28.5

29

29.5

30

STAR RMC

Baseline

Post

Follow-up

Pre-Post p<.05

Longitudinal p<.03


Caregivers Hold the Keys to Success Energy, desire, ability to do

things differently

Willingness to ask for and

accept help from others

Flexibility in thinking and

problem solving

Sense of humor

Patient, but able to be firm

Belief that things can change

Good prior relationship with

care recipient

Future Directions in Early Stage Memory Loss Programming

• Counseling & Support Groups: Best Research Support• Family/couples Counseling (C. Whitlatch, M. Mittelman)

• Social/Emotional Support Groups (L. Snyder; R. Yale; R. Logsdon)

• Cognitive Behavior Therapy (M. Stanley)

• Physical Activity: Mixed Results • Reducing Disability in Alzheimer’s Disease (L. Teri, R. Logsdon,

S. McCurry)

• Improving sleep in dementia patients (S. McCurry)



• Cognitive Rehabilitation Programs: Mixed Results• Cognitive Rehabilitation & Stimulation (L. Clare; A. Spector; M.

Orrell)

• Computer-based Training and Practice (no support from RCTs with dementia; for older adults, mixed results)

• Results often short-lived, clinical significance unclear


• Arts Programs: Qualitative research support & high interest• Art Museum Programs (e.g. Meet Me at MOMA-Mittelman;

“here:now” programs at Frye Art Museum in Seattle)

• Photography (e.g. PhotoVoice-Ataie)

• Choirs (e.g. The Unforgettables-Mittelman)

• Drama (e.g. The Penelope Project-Bastings)

• Storytelling (e.g. TimeSlips-Bastings)

• Intergenerational Programs: Beginning to accumulate qualitative support• Partnering dementia patients and medical students (Morhardt)

• Day care associated with assisted living (Whitehouse)


Recommendations for Early Stage Memory Loss Programming

• Provide a variety of programs

• Provide memory support by using visual aids, handouts, recordings

• Individualize programs as much as possible

• Make existing programs for older adults accessible to individuals despite increasing memory loss

• Create new social networks and opportunities

• Develop or modify volunteer programs for individuals with memory loss or other age-related changes

Take Home Messages

Quality of life as perceived by the person with dementia does not necessarily decline due to memory loss or cognitive decline.

Quality of life is strongly influenced by mood.

Mood is influenced by pleasant activities, exercise, and social support.

Family members, friends, and other caregivers can significantly impact QOL for individuals with dementia.

What’s good for the person with dementia is good for the caregiver.


Evidence-Based Community Support Programs for Early Stage Dementia

(NWGEC Lecture Series Winter 2015)

Acronyms

BT-PE – Behavior Therapy-Pleasant Events

ESSG – Early Stage Support Group

GDS – Geriatric Depression Scale

RDAD – Reducing Disability in Alzheimer’s Disease

RMBPC – Revised Memory and Behavior Problems Checklist

RMC – Routine Medical Care

STAR - Staff Training in Assisted-living Residences

STAR-C - STAR-Caregivers

TAU – Treatment As Usual

WL – Wait List

© L. Teri, Ph.D. & R.G. Logsdon, Ph.D. – Page 1

Brief Descriptive Information about the Pleasant Events Schedule-AD Citations: Logsdon, R.G. & Teri,L. (1997). The Pleasant Events Schedule-AD: Psychometric

properties of long and short forms and an investigation of its association to depression and cognition in Alzheimer's disease patients. The Gerontologist, 37(1), 40-45.

Teri, L. and Logsdon, R.G. (1991) Identifying pleasant activities for Alzheimer's

patients: The PES-AD. The Gerontologist, 31(1), 124-127. Teri, L., Logsdon, R.G., Uomoto, J.,& McCurry, S.M. (1997). Treatment of depression

in dementia patients: A controlled clinical trial. The Journals of Gerontology: Psychological Sciences, 52(4), 150-166.

Description & Psychometrics: The Pleasant Events Schedule-AD is a caregiver-report questionnaire designed to identify pleasant events for Alzheimer’s disease patients. It consists of a list of potential pleasant events in which AD patients may engage, and asks caregivers to rate whether their patient now enjoys each activity, whether the patient enjoyed it in the past, and how frequently their patient engaged in each activity during the prior month. It can be administered to caregivers as a questionnaire, and takes caregivers about 15 minutes to complete. Scoring is objective, and takes about 15 minutes. Scores include an overall activity frequency rating, an overall enjoyment rating, and a cross product between the two to determine frequency of enjoyable activity. The PES-AD was demonstrated to have good internal consistency (alpha=.90) and to correlate with severity of depression in AD patients, assessed by the Hamilton Depression Rating Scale (r=.41), and with depression diagnosis (r=.59). A long (53 item) and short (20 item) version are available. Correlation between the two versions is .95. The PES-AD has been used in a published depression treatment study with these individuals (Teri, Logsdon, Uomoto, & McCurry, 1997).


Pleasant Events Schedule: AD (Short Version)

© 1995 R. G. Logsdon, Ph.D. & L. Teri, Ph.D.

Instructions: This schedule contains a list of events or activities that people sometimes enjoy. It is designed to find out about things your relative has enjoyed during the past month. Please rate each item twice. The first time, rate each item on how many times it happened in the past month (frequency); the second time, rate each event on how much your relative enjoys the activity. Frequency Enjoy Activity Not

At All 1 to 6 Times

7 or more Times

Not At All

Some-what

A Great Deal

1. Being outside

2. Shopping, buying things

3. Reading or listening to stories, magazines, newspapers

4. Listening to music

5. Watching T.V.

6. Laughing

7. Having meals with friends or family

8. Making or eating snacks

9. Helping around the house

10. Being with family

11. Wearing favorite clothes

12. Listening to the sounds of nature (birdsong, wind, surf)

13. Getting/sending letters, cards

14. Going on outings (to the park, a picnic, etc.)

15. Having coffee, tea, etc. with friends

16. Being complimented

17. Exercising (walking, dancing, etc.)

18. Going for a ride in the car

19. Grooming (wearing make up, shaving, having hair cut)

20. Recalling and discussing past events


Pleasant Events Schedule (Long Version)

©1991 Linda Teri, PhD & Rebecca Logsdon, PhD; University of Washington

Instructions: This schedule contains a list of events or activities that people sometimes enjoy. It is designed to find out about things that your relative has enjoyed during the past month. Please rate each item twice. The first time, rate each item on how many times it happened in the past month (frequency); the second time, rate each event on how much your relative enjoys the activity. Frequency Enjoy Activity Not

At All 1 to 6 Times

7 or more Times

Not At All

Some-what

A Lot

1. Being outside (sitting outside, being in the country

2. Meeting someone new or making new friends

3. Planning trips or vacations

4. Shopping, buying things (for self or others)

5. Being at the beach

6. Reading or listening to stories, novels, plays or poems

7. Listening to music (radio, stereo)

8. Watching TV

9. Camping

10. Thinking about something good in the future

11. Completing a difficult task

12. Laughing

13. Doing jigsaw puzzles, crosswords, and word games

14. Having meals with friends or family (at home or out, special occasions)

15. Taking a shower or bath

16. Being with animals or pets

17. Listening to non-music radio programs (talk shows)

18. Making or eating snacks

19. Helping others, helping around the house, dusting, cleaning, setting the table, cooking


Frequency Enjoy Activity Not

At All 1 to 6 Times

7 or more Times

Not At All

Some-what

A Lot

20. Combing or brushing my hair

21. Taking a nap

22. Being with my family (children, grandchildren, siblings, others)

23. Watching animals or birds (in a zoo or in the yard)

24. Wearing certain clothes (such as new, informal, formal, or favorite clothes)

25. Listening to the sounds of nature (birdsong, wind, surf)

26. Having friends come to visit

27. Getting or sending letters, cards, notes

28. Watching the clouds, sky, or a storm

29. Going on outings (to the park, a picnic, or barbecue, etc.)

30. Reading, watching or listening to the news

31. Watching people 32. Having coffee, tea, a soda, etc. with

friends

33. Being complimented or told I have done something well

34. Being told I am loved 35. Having family members or friends tell

me something that makes me proud of them

36. Seeing or speaking with old friends (in person or on the telephone)

37. Looking at the stars or moon 38. Playing cards or games 39. Doing handwork (crocheting,

woodworking, crafts, knitting, painting, drawing, ceramics clay work, other)

40. Exercising (walking, aerobics, swimming, dancing, other)

41. Indoor gardening or related activities (tending plants)


Frequency Enjoy Activity Not

At All 1 to 6 Times

7 or more Times

Not At All

Some-what

A Lot

42. Outdoor gardening or related activities (mowing lawn, raking leaves, watering plants, yard work)

43. Going to museums, art exhibits or related cultural activities

44. Looking at photo albums and photos

45. Stamp collecting, or other collections

46. Sorting out drawers or closets

47. Going for a ride in the car

48. Going to church, attending religious services

49. Singing

50. Grooming self (wearing make-up, having hair cut, shaving)

51. Going to the movies

52. Recalling and discussing past events

53. Participating in or watching sports (golf, baseball, football, etc.)

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