CBT EXPRESS TO IMPROVE PATIENT

HEALTH AND WELLNESS:

5-MINUTE EFFECTIVE BEHAVIOURACTIVATION TOOLS FOR USE IN ROUTINE CARE

By Dr. Keri-Leigh Cassidy

Dal Spring Refresher March 7 2019

Disclaimer

• Faculty: Keri-Leigh Cassidy

• Coinvestigator of the Brain Health and Wellness Project

• Founder of the Fountain of Health Initiative

• Relationships with financial sponsors:

• Grants/Research Support: Canadian Centre for Brain Health

Innovation, Baycrest

• Speakers Bureau/Honoraria: None

• Consulting Fees: None

• Patents: None

• Other: None

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Objectives

• To appreciate 5 key modifiable lifestyle areas of the

Fountain of Health Initiative to improve patients’ health

and wellness

• To know how to use effective 5-minute behavioural

activation Cognitive Behavioural Therapy tools in your

practice

• To be aware of the opportunity to try out these Fountain of

Health tools with support in the Brain Health and

Wellness Project

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What is the Fountain of Health?

• Canadian non-profit to share key modifiable lifestyle factors to promote health and wellness, reduce risk of illness and disability

• Translates science to: • Public

• Healthcare providers

• Promote brain health by modifying key health behaviours:• Based in Cognitive Behaviour Therapy (CBT)

• Clinical practice tools to promote health & prevent illness

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How Did FoH Develop?

Founded in 2011 in Nova Scotia, funded by gov’t / non-profits

Developed in phases: 1. Summary of science on key modifiable factors in brain health (2011-12)

2. Key messages, clinical tool & website development, speakers’ bureau(2013-15)

3. Public & healthcare provider dissemination efforts (2016-17)

4. Brain Health and Wellness Project (2018-19)

Who is Involved?

• NS & National teams.

• Stakeholders from provincial and national academic, healthcare, government

& non-profit organizations.

• Experts in Psychiatry, Cognitive Behaviour Therapy and Behaviour Change

The Evidence: Lifestyle & Health Behaviours

• Only 25% of longevity is accounted by inherited genes

• Lifestyle has a much greater impact!

• Key to primary/secondary prevention and delay of many conditions, including dementia!

Inherited Genes Epigenetic Factors

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Five Key Areas

Key Areas: Known modifiable/ lifestyle risk factors of dementia & effective promotors of brain health & wellness

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Which of the following is false?

• Light physical activity for only 15 mins a day can increaselife expectancy by 3 years

• Being socially active improves health and well-being;Secure relationships are the single most predictivevariable of well-being in late life

• Combined lifestyle factors, including challenging yourbrain with new learning, can reduce dementia risk by upto 35%

• Positive thinking about aging can prolong lifeexpectancy by up to 7.5 years

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Consider this…

What non-pharmacological treatment improves outcomes in heart disease, hypertension, diabetes, arthritis, depression, anxiety disorders, obesity, addictions & insomnia?

What is the #1 powerful promoter of brain neuroplasticity? (Also reduces risk of dementia)

What is the single best thing we can do for our overall health?

Consider This:

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Answer: Physical Activity!

• Best promoter of brain neuroplasticity across lifespan

• 150 min/wk moderate exercise ideal

• All forms of activity help:

• Simply not sitting is helpful!

• Light physical activity (15 mins) comparable benefit to giving up smoking

• For every daily flight of stairs climbed, increased brain grey matter - to equivalency of 0.58 years younger Just Move!

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• Cochrane review of 38 randomized double blind

studies (n=2326) on depression treatment:

exercise shows significant benefit for mood

regulation, especially for mild and moderate

depressive symptom

• Revised CANMAT Guidelines: physical activity

now 1st line treatment for mild and moderate

treatment of depression (Level 1 evidence, Sept 2016)

Physical Activity and Mood

What About Social Activity?

• Health risks associated with loneliness are of similar risk magnitude to smoking and obesity

• Isolation is an independent risk factor for developing dementia

• Secure relationships singlemost predictive variable in well-being in late life

Socialize!

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Harvard Study of Adult Development

• 724 subjects followed over 75 years

• 60 of original subjects still alive and participating in their

90’s

• 2 groups: Harvard sophomores and young adults from

poorest Boston neighborhoods

• At age 50, secure relationships were the single most

predictive variable related to well-being over 25 years

regardless of background

Robert Waldinger et al, 2015 J Psych of Aging

What About Brain Challenge?

• Cognitive activity promotes brain neuroplasticity across lifespan

• Higher education reduces risk of dementia and delays onset• For every year of additional education, brain

appears 0.95 years younger

• Complex, novel activities help most; changing routine can help

Try new things!

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Increased Longevity:

Positive Self-Perceptions of Aging

Positive self-perceptions of aging (PVA) linked to health behaviors & increased longevity

Levy (2002): 660 50+ y (OLSAR) Ohio Longitudinal Study of Ageing & Retirement

Longevity associated with positive self-perceptions of aging, measured up to 23 years earlier

Increased longevity by 7.5 years

• Controlled for other health factors

• Greater impact than low systolic blood pressure, cholesterol, BMI (1-3 years); no history of smoking, tendency to exercise (1-4 years)

Levy B et al Longevity increased by positive self-perceptions of aging J Pers Soc Psych 2002

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Views on Aging Serve A Self-

Fulfilling ProphesyI am over the hill now – it is all downhill from here, so why bother?

Sedentary

I have many plans for the next phase of my life

Get out for walks

Impact health behaviours, physical/ mental health & longevity

Key Ingredients of Resilient

Thinking

• Cognitive Flexibility : the ability to focus on what is

changeable in challenging situations. It’s about the

ability to shift focus away from ruminations about what

we can’t change and stay present.

• Optimism: not of a rose-coloured glasses variety, but a

willingness to see beyond problems and look for what

is good in ourselves and others for what is meaningful,

even in very difficult situations.

What is: Cognitive Behaviour Therapy?

CBT as a Treatment Intervention

Effective treatment for: Depressive, anxiety, bipolar and psychotic disorders; obesity and eating disorders treatment smoking, alcohol cessation

• Shifts outlook and behaviours

• Improves self care- in our minds, and behaviours

Treatment: 16-20 sessions, individually or in groups

• Cassidy et al.: Enhanced group CBT for late life depression and anxiety–therapist and patient manuals (email: keri-leigh.cassidy@nshealth.ca)

CBT techniques used for behaviour activation for exercise, stress reduction, nutrition, lifestyle modification:

• Fountain of Health: CBT Express -- Health behaviour change for general population with or without health risks or disease

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Health Behaviour Change is Difficult

• Healthcare providers have a powerful role to play!

• 5-minute CBT offers an efficient, effective approach

What are the Fountain of Health 5-Minute CBT Express Tools?

Tools developed for clinicians by clinicians with expertise in cognitive behavioural therapy and health behaviour change

Paper-based tools- For use in the office (electronic versions also available)

The Wellness App (wellnessapp.ca)- For use by the patient between contacts. Offers support to increase goal attainment; usable on any device.

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Does FoH’s CBT Express work?

Field-tested in >500 patients to date

Effective:• 80% success rate in goal attainment:

• Patients partially attained (35%)

• Fully met (40%)

• Exceeded (15%) health goal in 3 months

• 86% betaApp-users found it helped achieve goal

• 73% significantly improved self-rated wellbeing measures

Efficient: Simple & quick• 80% of clinicians found it easy, time-efficient to use

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CBT Express: Here is How it Works

Watch the Clinician Education video :

https://vimeo.com/309962460

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Invitational Approach

Invitational, NOT a prescriptive approach

(i.e. Telling a patient what to do does not work well for behaviour change…)

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Here’s How It Works

Visit 1

Assess - Invite 5+ patients/caregivers over 40 years old to self-complete a baseline on the Health and Resilience Pre-Questionnaire (paper form and/or The Wellness App)

Invite one small step - Offer support and guidance.

Help them to set one small S.M.A.R.T. health goal in 1domain (Complete Goal Doc Sheet).

Visit 2

Track Progress - Check in 1 month later in person or by phone.

Send completed forms to Regional Project Coordinator by email, fax or mail.

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What are S.M.A.R.T. Goals?

Specific - What concrete step will you take?

Measurable - How can success be measured?

Action-Oriented - What action or behaviour is needed?

Realistic - How realistic is it to accomplish?

Time-Limited - When will it be done? (what time, day, how often)

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S.M.A.R.T. Goals

Let’s make a S.M.A.R.T goal even “S.M.A.R.T”-er:

“I will walk my dog for 10 minutes a day”

Could become: “I will walk my dog for 10 minutes in the morning at least three times a week for the next 4

weeks” ( more specific, realistic, time-limited)

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Examples of small S.M.A.R.T. Goals

PHYSICAL ACTIVITYWalk to the mailbox 3 times a week for one week Get up during the ads in the 6 o’clock news 4 times a week

SOCIAL ACTIVITYCall a friend or family member once a weekSet up a coffee date once in the next 4 weeks

BRAIN CHALLENGE Read the paper 3 mornings a weekListen to a radio program twice a week

Other – Mental Health and Positive Thinking Attend yoga class once a week for 4 weeksWrite in a gratitude journal twice a week for 4 weeks

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Questions to Ask to Help Set a Goal

• How realistic is this goal for you in the next few weeks?

• When is the last time you did… (this activity at this intensity)?

• How confident are you that you’ll accomplish this goal?

• What times of day/ week are most feasible for this goal?

• What are some of the barriers you expect you’ll face in doing this goal? What might increase your odds of success?

• How likely is it that you will actually do this?

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Shift from Prescriptive & Disease Paradigm

• To feel good and enjoy life - Rather than to address negative thinking and prevent depression/anxiety relapse

• To have fun hiking/walking/time in nature - Rather than to reduce sedentary behavior and depression/dementia risks

• To enjoy time with family/friends - Rather than to avoid social isolation as a depression/dementia risk factor

• To get satisfaction from learning new things - Rather than to increase hippocampal volume and promote “cognitive reserve” to mitigate subsequent risk of dementia

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Barriers to “Health Promotion”

Common Concerns reported by Clinicians:

• I don’t have the time

• I don’t have the training

• This is not my area-- I’m an expert in disease, not “health

promotion” – that’s someone else’s job

• My patients are too sick for this

• I council people all the time, but they don’t follow through

• I find I just can’t get my patients to ”do” things for their

health

Which do you think is the #1 concern?

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Barriers to Health Promotion or Self-Care

Concerns reported by Patients/ Clients:

• I am too …. (busy, stressed, old, sick) to do anything

• This isn’t relevant for me or my medical situation

• It’s too late for this to make a difference for me

• If I try this, I will fail/ let people down

• This goal is too small to matter

Which do you think is the #1 concern?

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CBT Express: Do you want to try it out?

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The Good News

The reality is most healthcare clinicians already invite behavior change every day. We DO:

- Discuss patient’s lifestyle, physical activity, social supports

- Review community activities & resources, assign reading

- Encourage self-care, stress management, good nutrition

- But... Most of us do this work without a systematic approach or outcome measures

The Brain Health and Wellness Project

is here to support you to do this… in 5 minutes!

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Let’s Take a Look at the Toolkit

Clinician paper-based tools include:

• Office Laminate (guide for clinicians’ use)

• Health and Resilience Questionnaires (Pre/ Post)

• Goal Doc Sheet (1 completed per patient)

Patient paper-based tool includes:

• Take Home Goal Sheet (1 per patient for their use)

The Wellness App (for patient and clinician) includes:

• Pre/Post Questionnaires

• Goal-tracking and a 4 week report to share with you (printable summary of scores/ goal attainment)

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The Office Laminate

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Step 1 – Assess: Get a Health and Resilience Baseline

PAPER APP

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STEP 2 – Invite: Small Health Behaviour ChangeInvite your patient to make a small health behaviourchange in ONE area:

Physical Activity Social Activity Brain Challenge

(Or another of their choosing: nutrition, yoga, mindfulness)

Give a rationale, make it relevant for this patient!

E.g:” Based on your answers to the Health and Resilience Questionnaire,

it looks like you feel there is room to improve your _____ (physical

activity, or other area)”

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Write Down a GoalPaper

The Wellness App

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Patient Goal-Tracking on App

App users receive support,reminders & encouragement.They can track progress & print / share a 4 week summary with you

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Step 3 –Track Progress: Goal Follow Up at 4 weeks• Check in - In person or by phone

• Complete 2nd visit information on Goal Doc Sheet• Rate patients’ goal attainment and repeat the Health and Resilience

Questionnaire as post-measures

• If The Wellness App was used, review the 4 week Checkout or feedback, with pre-post graphs

• Appreciate any progress

with goal set and discuss

barriers to change

Repeat!

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Clinician’s Goal Doc Sheet

Paper (or e-form)

Complete one per patient

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Role Play

Working with the person next to you, role play a clinican and

patient (or family member) over 40 years:

Choose a common problem area for this patient to have and

be seen in follow up:

heart disease, hypertension, diabetes, arthritis, depression, anxiety, pain, obesity, addictions & insomnia

• Draw a connection between the problem area as you invite

the patient to complete the Health and Resilience

Questionnaire

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Behavior Change Invitation #2:

You’re Ideal

Use the presenting concern as the relevant

springboard to invite a behavior change

Sample Invitation:

“The pain/mobility/med side effects/blood

pressure/work stress that you are dealing with

make you ideal for a health and resilience project

we have in the province that could help - would

you like to hear about it?”

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Behavior Change Invite #3:

The 4 Seasons

Use seasonality to invite or renew a relevant

health goal

Sample Invitation:

“Now that it’s Spring/Summer/Winter/Fall, lets

looks at your baseline to see how you feel you are

doing in some key health areas.

Would you like to set a goal to activate your health

over Winter/Summer/now that it’s Spring/as the

colder weather approaches…?”

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Behavior Change Invite #4:

Transition Points

Use a life transition/developmental milestone or

even a birthday as a springboard

Sample Invitations:

”Now that you are retired/living alone/dealing with

a new medical issue/facing these financial

concerns/figuring out your life as a single

parent/caregiver - this would be a good time to

check in on how you are feeling about some key

health areas to help you stay as well as you can…”

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How did that go?

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Role Play

Invite one small health goal– Connect back to questionnaire

Help the patient set a S.M.A.R.T. goal

Record it on their Take Home Goal sheet; clinician uses Goal

Doc Sheet

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Invite a Health Behaviour Change:

The Classic

Use the Health and Resilience Questionnaire

results to invite a health change

Sample invitation:

“Based on your answers it looks like you feel

there’s be some room to improve your physical

activity/staying connected to friends/learning

something new - would you like to set a small goal

to work on that?”

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Questions to Ask to Help Set a Goal

• How realistic is this goal for you in the next few weeks?

• When is the last time you did… (this activity at this intensity)?

• How confident are you that you’ll accomplish this goal?

• What times of day/ week are most feasible for this goal?

• What are some of the barriers you expect you’ll face in doing this goal? What might increase your odds of success?

• How likely is it that you will actually do this?

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Write Down a GoalPaper

The Wellness App

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How did that go?

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Follow up!

• In about 4 weeks

• In person or by phone

• Vital to support patient’s efforts

• Shows importance, value of behaviour change to health

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Ways to Use The Wellness App

• Self-guided in waiting room

• Assisted during visit

• Self-guided after visit

Note: In all 3 cases, clinician helps with S.M.A.R.T. goal setting & documents patient results on Goal Doc Sheet

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Try out the Wellness App!

Log in at www.fountainofhealth.ca or

https://wellnessapp.ca

Take a Look at the Wellness App Features:

• Health and Resilience Questionnaire

• SMART goal-setting

• Readiness assessment using red, yellow and green

light responses

• Daily encouragement

• Daily check-in calendar

• Useful links for online resources for insomnia (CBTi),

anxiety and stress management, online beginner

meditation. yoga, nutrition, Exercise is Medicine, 23 ½

Hours, TED Talk and FoH video on Optimal Aging

Patient Goal-Tracking on App

App users receive support,reminders & encouragement.They can track progress & print / share a 4 week summary with you

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Encouragement Section with Audio

Supports

Track Progress: Goal Follow Up at 4 weeks• Check in - In person or by phone

• Complete 2nd visit information on Goal Doc Sheet• If The Wellness App was used, review the 4 week Checkout or feedback,

with pre-post graphs

• Appreciate any progress

with goal set and discuss

barriers to change

Repeat!

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The Brain Health & Wellness Project:What Supports are Offered?Registered clinicians receive:

• All materials including:• The Health and Behaviour Change Toolkit• The Wellness App

• Support from project team:• Site Leads, Educational coaches & Project Manager • Julie Mitchell, Ottawa Project Coordinator• Ariane Séguin, Toronto Project Coordinator• Laurie Low, Vancouver Project Coordinator• Jean Robinson-Dexter, Atlantic Project Coordinator• Support Via Email or toll-free number

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Examples of Participating Clinicians

• Family Physicians

• Nurses/Nurse Practitioners

• Psychologists

• Geriatric Psychiatrists

• Geriatricians/Gerontologists

• Occupational Therapists

• Social Workers

• Pharmacists

• Clinical Educators

• Health Promotion Workers

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Brain Health and Wellness:What you Need to Know• Patients participating are aged 40 and over.

• Patients’ family members or caregivers can be included in all settings.

• Only exclusion criteria is people with dementia.

• Process takes a few minutes in context of routine care.

• All data are anonymous and confidential.

• No written patient consent is required.

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You are Invited…

To join The Brain Health & Wellness Project

• Register (online or paper sign-up)

• Take Your Toolkit

• Select 5 clients or more by June 2019• Individuals or a group, family members/caregivers

• Clients you think are ready for health change

• Complete forms/app over 2 contacts and return all completed tools to us by mail, fax or email

• Provide your feedback on the tools

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Become part of a culture shift to help all Canadians improve brain health and

well-being.

The Brain Health and Wellness project offers an exciting opportunity for hundreds

of clinicians like you to receive the tools and support they need to be confident

promoting better health in their patients.

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Thank You

Register online at https://fountainofhealth.ca/wellness-

project and click on The Wellness Project

App: wellnessapp.ca

Email: info@wellnessapp.ca

Toll Free Phone: 1-833-722-2151

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