Running head: HEART DISEASE AND STOKE PREVENTION 1

Heart Disease and Stroke Prevention for Adults Over the Age of 55

Meghan Berry, Derek Jones

University of Utah
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Heart disease has consistently ranked as the leading cause of death for Americans for the past 80

years and is a major cause of disability (CDC, 2005). Stroke has followed closely behind and is currently

the 5th leading cause of death in America (American Heart Association, 2017). These two chronic

diseases account for more than 740,000 deaths in the U.S per year and leave and even larger number of

survivors with lasting deficits that affect their occupational performance and overall quality of life (AHA,

2017). The numbers alone are concerning, but perhaps what is even more alarming is that these two

leading causes of death and disability are among the most preventable (Aldana, 2005). The American

heart Association identifies hypertension, obesity, cholesterol, physical inactivity, smoking, healthy diet,

and diabetes as risk factors for heart disease and stroke (AHA, 2017). Each one of these risk factors is

something that can either be avoided or managed through the adoption of a healthy lifestyle. Many elderly

individuals may think that it is too late to make these important lifestyle changes. However, research has

shown that the risk of heart disease and stroke can be significantly reduced even when these changes are

implemented in old age (Aldana, 2005). Many times, these older individuals are not aware of their level

of risk for these chronic diseases and don’t know the necessary action that needs to be taken in order to

decrease these risks. Our intervention program will help these older individuals become more aware of

these risks for developing cardiovascular issues. It will also introduce effective methods and techniques

they can use to adopt these changes into their lives.

There have been significant amounts of research regarding the prevention of heart disease and

stroke among older adults. The U.S. Department of Health and Human Services has teamed up with the

Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS)

to form an initiative called Million Hearts. It aims to successfully align cardiovascular disease prevention

efforts around public health and clinical goals that have been researched and proven effective strategies of

intervention. This program presents really great guidelines of prevention that are based on statistically

proven health habits and interventions to decrease the occurrence of heart disease and stroke in at-risk

populations. This program does not target populations specifically over the age of 55, but does target

adults which should translate well into older populations. This, and other programs, emphasize a lot of the
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same modifiable risk factors: obesity, cholesterol, high blood pressure, and physical inactivity. These will

be the factors that also guide our prevention program led for older adults.

Our intervention program will focus on both increasing participant’s awareness of risk factors for

cardiovascular disease as well as teaching them ways to reduce and manage these risk factors. We have

organized a four-week community-based healthy living course to help teach these principles. Each session

will be one hour long, and will consist of educational components, and individualized implementation of

the interventions. This course will focus on what we believe are the most modifiable risk factors for this

population. These are physical activity, healthy dieting, and stress management. As occupational

therapists, our background in providing client-centered service will help us collaborate with participants

to maximize our programs effectiveness. By tailoring unique interventions on an individual level, we can

implement modifications to meaningful occupations that promote a healthier lifestyle. We believe that age

should not be a barrier to participating in meaningful occupations. Through helping participants adopt

healthy lifestyle changes, we can help them expand their capability to experience occupational justice

even in their old age.

The first week of our program will focus on physical activity. Regular physical activity has been

associated with a 20-30% reduction in coronary heart disease (Wannamethee, 2002). It is also directly

related to other risk factors like hypertension and obesity and alternately helps manage these factors. This

session of our program will first focus on teaching participants these important benefits in reducing risk

for cardiovascular disease. We will help participants assess their own individual physical activity levels

and how they compare to recommended levels. We will then teach a number of simple strategies and

methods to increase physical activity that can be incorporated into a daily routine.

The second week will cover healthy dieting. This will primarily focus on education and

implementation of the DASH diet. The DASH diet is a dietary pattern promoted by the National Institutes

of Health designed to help treat or prevent hypertension. It has been shown to reduce systolic blood

pressure up to 14 mm (Elliot, 2011). This diet focuses on consuming moderate amounts of whole grains,

fruits and vegetables, and lowering fat and sodium intake. In this session of our wellness program, we
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will educate the participants on this diet and help them plan ways that they can implement this into their

daily lives. This will include a segment in which participants will prepare a meal plan for one whole day

using the principles of the DASH diet. With the help of a therapist, they will then compile a grocery list of

the items needed to make the meals that they have planned.

Our third session will cover the importance of stress management and how it relates to

cardiovascular risk. We will teach the participants the importance of mindfulness techniques and good

sleep habits in managing stress. Evidence shows that stress levels are correlated with negative affect.

“Negative affect, which may manifest itself as depression, anxiety, anger, or hostility, has similarly been

related to hypertension and coronary heart disease.” (Pickering, 2001) This session will also include

active participation in a few mindfulness techniques to help participants become familiar enough with

them to be able to implement them on their own.

Our last session will be a wrap up session in which the key points of the previous three sessions

will be addressed. This will be a time for the therapists to perform in depth follow ups on the participant’s

current progress in implementing the principles of the class. This will also be a time for participants to

have personal questions and concerns addressed more thoroughly if needed.

We realize that routines and schedules are very important for this specific age group. Many older

adults rely heavily on a set patterns and routines which are not easily changed. Our program is designed

to balance the adoption of new lifestyle changes with already established patterns of living. We hope to

take a client centered approach that will incorporate these new strategies into participant’s individual

patterns of occupation in order to make them balanced and sustainable over time.

Session Outline

Week 1: Physical Activity

With this being our first session in the course, we will begin by giving a brief introduction of

ourselves which will include an explanation of our background and the services we provide as

occupational therapists. We want to make sure we help the participants understand how our skills and

training as OT’s are of benefit in a wellness program such as this one. After our introduction, we will
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begin the general education portion of our class session on heart attack and stroke and the risk factors for

these. It is important that each participant realize the reality of the risks and the severity of the conditions.

As we educate, we will provide time for self-reflection and assessment so each participant can identify

their own personal risk of developing these conditions.

After the general overview of cardiovascular disease and its risk factors, we will move

specifically into the portion on engaging in regular physical activity. This will be the main focus for the

rest of this session. We will begin by educating the participants on the benefits of regular physical activity

in reducing risk for cardiovascular disease. We will spend a relatively small amount of time on this

education portion in order to make more time for the application portion that will follow. We feel that the

biggest barrier to engaging in physical activity for this population lies in the practical application of

exercise into their daily routine. We realize that it is not realistic to expect these elderly individuals to

make drastic changes to their schedule and routines to accommodate an intensive exercise program.

Instead, we want to focus on simple, yet effective strategies that they can implement into an existing

routine in order to meet the recommended levels of physical activity.

One of these strategies is using stairs when possible instead of elevators. Research has shown that

through increasing the number of staircases climbed a day, one can significantly reduce their risk for

cardiovascular disease (Meyer, 2010). We will encourage participants to use stairs as much as possible

when they are in multi-floored buildings. For individuals who spend most of their time at home, we will

teach them methods to increase stair use at home by storing frequently used items like kitchen or cleaning

supplies in the basement instead of on the main floor. We will also focus on increasing participant’s steps

per day. Studies have shown that an increase in the number of steps per day is directly associated with a

decrease in obesity thus reducing risk for cardiovascular disease (Dwyer, 2006). Simple strategies we will

address in order to increase steps per day include parking in the back of parking lots instead of trying to

find the closest spot to the entrance, walking around the house when talking on the phone, and

periodically taking short walking breaks around the block or at the office. We believe that these are very

practical methods that over time will increase participant’s fitness level and help them decrease their risk
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for cardiovascular disease. At the end of the session, we will give participants time to make a personal

plan on how they can implement these methods and any others of their own into a daily routine in order to

increase their engagement in physical activity.

The practice models and theories that we will be using to support our assessments and

interventions will be the Health Belief Model (HBM), Lifestyle Redesign (LR), and mindfulness. These

models can be applied to our intervention in a multitude of ways, and fit nicely with our objectives and

goals for treatment in this at-risk population for heart disease and stroke. The HBM is a psychological

model that attempts to explain and predict health behaviors by focusing on the ideas and beliefs of

individuals. The main principle is that individuals will heed action to prevent, and control illness if: they

believe that they are susceptible to it, that it has serious consequences, they believe that a course of action

can reduce this vulnerability, and the benefits of taking this course of action outweigh the costs. One

systematic review of the effectiveness of this model in relation to patient adherence to interventions

reported that “Of 18 eligible studies, 14 (78%) reported significant improvements in adherence, with 7

(39%) showing moderate to large effects” (Jones, 2014). This model will be applied in our strategies of

intervention by highlighting the direct risk factors for heart disease and stroke, and addressing the

modifiable variables of these risk factors. By accenting these modifiable variables (i.e. Hypertension,

obesity, salt intake, diet), we can then implement an intervention that addresses these issues.

The Lifestyle Redesign program was designed to address populations who are at risk for

occupational decline and who can learn, generalize, and participate in ongoing self-analysis. This model

is designed to be preventative, and promote healthy lifestyle changes. It focuses on identifying individual

needs, strengths, and barriers and then learning to maintain and enhance mental, social, and physical

ability to achieve superior occupational functioning. We can channel the postulates and main outcomes of

this model by addressing people’s weaknesses and strengths, and areas that can be improved (i.e. Physical

inactivity) and promoting healthier lifestyles to improve overall well-being

The final theory that we will be implementing is that of mindfulness. This theory promotes

consciousness and awareness of one’s mental and physical state at the present moment. This will be used
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as a tool to guide the piece of our intervention which addresses stress management skills. “Mindfulness-

based interventions have also been associated with improved health outcomes in patients with and at risk

for CVD. Research suggests that mindfulness training can promote weight loss among patients with

obesity; improve disease management and HbA1c levels among patients with diabetes; and improve

coping and blood pressure in patients with hypertension.” (Kaar, 2017) This provides positive supporting

evidence to use this type of intervention with this population.

Our intervention will be addressing the Occupational Therapy Framework and the AOTA

Position Paper on Health Promotion. For example, if a participant works on the 4th floor of their office

building and takes the elevator every day, we can introduce using the stairs at least three out of five work

days. We will be using the occupations that the participants identify as meaningful to them, to formulate a

personalized way they can improve their lifestyle according to activities they already participate in and

enjoy. We will also be addressing client factors of consciousness, energy and drive (AOTA, 2014). By

addressing awareness, and motivation we can facilitate self-driven, client-centered interventions. We will

also be addressing performance patterns like habits, and routines to magnify where changes can be made

to improve overall mental and physical health.

The AOTA Position Paper on Health Promotion suggests that improving well-being and quality

of life begins with the implementation of prevention strategies. The paper also states the idea that,

“Occupational therapy practitioners promote positive mental health through competency

enhancement strategies, such as skill development, environmental supports, and task adaptations,

and they prevent mental illness through risk reduction strategies, such as establishing healthy

habits and routines and providing training in relaxation and coping techniques” (AOTA, 2010).

We will be introducing competency improvement tactics to participants by providing them with

up-to-date statistics and evidence-based information on risk factors for heart disease and stroke. We will

also be teaching participants ways to establish healthier habits in their current routines, and finally, we

will be training individuals in relaxation and coping strategies to reduce the effects of stress mentally, and

physically.
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Our goals for the program will address awareness of risk factors, and then follow-through of our

discussed interventions. This will be important in demonstrating an understanding of how these risk

factors can be modified, and how each participant can fit them into their daily routines.

Long-Term Goal: To increase self-efficacy in implementing lifestyle changes and awareness of

risk factors involved with heart disease and stroke.

Objective 1: Within 3 weeks, 75% of participants will implement at least 2 of 5 suggested positive

lifestyle changes in daily routine.

Objective 2: By the end of the program, 80% of participants will self-report more personal risk factors for

stroke and heart disease compared to when they entered the class (Likert Scale)

The value of this program will first and foremost be manifested in the health of the participant.

By implementing the principles of this program, participants will improve physical and metabolic health

factors that will contribute to an increase in occupational performance and overall well-being. This is not

only a benefit to the participants themselves, but also removes a large burden on caregivers and care

facilities. These preventative measures also have the potential to save thousands of dollars for participants

and healthcare facilities by avoiding costly medical procedures associated with heart disease and stroke.

The adoption of the healthy lifestyle strategies that our program promotes will help extend the years of

functional, healthy living into old age

We will be measuring our program’s effectiveness using a couple different methods. One method

is to survey participants at the beginning of the program on their knowledge of potential risk factors,

amount of preventative measures they are taking currently, and overall satisfaction with their health and

lifestyle. These questions will all be delivered using a Likert Scale. We will administer this same survey

at the end of the program to gauge our effectiveness of teaching participants what the possible risk factors

are and diverse ways to modify their current lifestyle to incorporate healthier choices. These survey

results will be used to create statistics for future research and program initiatives. We hope that most

participants will self-report knowledge of more personal risk factors and be implementing more

preventative measures than when they started. This is one of our main objectives of the course, to teach
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people what the risk factors are and which variables can be modified to promote a healthier lifestyle. The

second way we will be measuring our effectiveness will be by interviewing, and administering a feedback

questionnaire at the end of the program to each of our participants. We will do this on an individual basis,

and reserve at least 15 min for each participant to go over the questionnaire. This feedback form will

include questions like: Did you find this program helpful? If yes, how? and If, no how could we improve

this program. Was there one specific part of your daily routine you found easier to modify than others?

Why? What was most surprising to you while learning about the statistics of heart disease and stroke? Is

there anything else you would like to suggest or tell us about the program? The goal is to always be

improving the delivery of this program so that people can live longer, healthier lives using

knowledgeable, informed decisions.

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References

American Occupational Therapy Association. (2014). Occupational therapy practice framework: domain
and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48.

Aldana, S. G. (2005). The culprit and the cure: why lifestyle is the culprit of Americas poor health and
how transforming that lifestyle can be the cure. Mapleton, UT: Maple Mountain Press.

CDC, 2005. Prevalence of Heart Disease. Retrieved June 25, 2017, from
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5606a2.htm

Dwyer, T., Hosmer, D., Hosmer, T., Venn, A. J., Blizzard, C. L., Granger, R. H., . . .
Dunstan, D. (2006). The inverse relationship between number of steps per day
and obesity in a population-based sample – the AusDiab study. International
Journal of Obesity, 37, 797-804. doi:10.1038/sj.ijo.0803472

Elliott, W. (2011). Effects of the DASH diet alone and in combination with exercise and
weight loss on blood pressure and cardiovascular biomarkers in men and
women with high blood pressure: The ENCORE study. Yearbook of Cardiology,
2011, 93-95. doi:10.1016/j.ycar.2011.01.119

Elliott, W. J. (2016). Blood Pressure Control and Primary Prevention of Stroke: Summary of Clinical
Trial Data. Hypertension and Stroke, 39-59. doi:10.1007/978-3-319-29152-9_3

Heart Disease and Stroke Statistics—2017 Update: A report from the American Heart
Association. (2017). Circulation, 135(10). doi:10.1161/cir.0000000000000491

Jones, C. J., Smith, H., & Llewellyn, C. (2013). Evaluating the effectiveness of health belief model
interventions in improving adherence: a systematic review. Health Psychology Review,8(3), 253-
269. doi:10.1080/17437199.2013.802623

Kaar, J. L., Luberto, C. M., Campbell, K. A., & Huffman, J. C. (2017). Sleep, health behaviors, and
behavioral interventions: Reducing the risk of cardiovascular disease in adults. World Journal of
Cardiology,9(5), 396. doi:10.4330/wjc.v9.i5.396

Lagiou, P. (2009). Faculty of 1000 evaluation for salt intake, stroke, and cardiovascular disease:
meta-analysis of prospective studies. F1000 - Post-publication peer review of the biomedical
literature. doi:10.3410/f.1346961.818059

Meyer, P., Kayser, B., Kossovsky, M. P., Sigaud, P., Carballo, D., Keller, P., Mach,
F. (2010). Stairs instead of elevators at workplace: cardioprotective effects of a
pragmatic intervention. European Journal of Cardiovascular Prevention &
Rehabilitation, 17(5), 569-575. doi:10.1097/hjr.0b013e328338a4dd

Occupational Therapy in the Promotion of Health and Well-Being. (2013). American Journal of
Occupational Therapy,67(6_Supplement). doi:10.5014/ajot.2013.67s47

Pickering, T. G. (2001). Mental stress as a causal factor in the development of hypertension and
cardiovascular disease. Current Hypertension Reports,3(3), 249-254. doi:10.1007/s11906-001-
0047-1
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Wannamethee, S. G., & Shaper, A. G. (2002). Physical activity and cardiovascular disease.
Seminars in Vascular Medicine,02(03). doi:10.1055/s-2002-35400