Rural Social Worker Develops Internationally Known Anti-Frailty Program

Janice Lundy knew she had to do something. As a social worker at Perry County Memorial Hospital in rural Missouri, she watched too many older residents end up in nursing homes more quickly than they should.

She was also concerned about the number of medications they were taking, and didn’t want to see the progression of frailty and cognitive decline as a one-way ticket to death. But identifying patients in need wouldn’t be much help without a way to intervene.

Lundy, who is Perry County Memorial’s director of social work and geriatric care management, knew this wouldn’t be easy considering the lack of resources in Perryville, a town of 10,000 nestled in Missouri’s farmland. All of Perry County holds about 19,000 people.

“In a rural area, we can say that we have the Alzheimer’s Association, but it’s not like having someone to meet with residents and do case management,” Lundy says.

Still, she was determined to keep Perry County’s older residents functioning well, no matter their health status.

In 2013, Lundy started to see a way she could combat frailty after attending a geriatrics symposium at Saint Louis University (SLU) in St. Louis. She learned that cognitive stimulation therapy, or CST, is a treatment method for people with early to moderate dementia. Done in group sessions, CST aims to improve quality of life by stimulating minds through a series of guided exercises.

Although SLU is now the U.S. center for CST training, at the time, the only place Lundy could receive certification was in London. But she didn’t let that stop her. She enlisted the help of Debbie Hayden, an occupational therapist at Perry County Memorial, and in 2014, the two traveled to the U.K. for training.

Lundy had also been working on both a master’s in social work and health administration.

Not long after, Lundy heard Dr. John Morley, a gerontologist, professor and division chief at the SLU School of Medicine, speak about frailty. Morley developed the Rapid Geriatric Assessment, a questionnaire aimed to score frailty by measuring physical, cognitive and nutritional health.

Lundy introduced herself to Morley and asked if he would speak to Perry County Memorial’s medical staff on early diagnosis and treatment of dementia. She also mentioned that her hospital’s team was using CST.

By then, Lundy and Hayden were becoming the CST-designated trainers for the U.S. Morley, in turn, asked them to join the planning team to train professionals in CST at SLU.

In 2015, Morley asked Lundy and Hayden to be rural collaborative partners for the Geriatric Workforce Enhancement Program (GWEP), a funding program aimed to boost health outcomes for older adults by developing a workforce, and engaging both patients and family members.

By the following year, with Morley’s geriatric assessment and GWEP funding, Lundy could offer doctors in Perry County a way to identify people her team could help, and then provide them an intervention program.

Since that time, in an effort to address frailty and cognitive decline in Perry County’s older residents, Lundy has added stand-alone exercise groups, initiated home meal deliveries, added a caregiver intervention program called Care of Persons with Dementia in their Environment (COPE) and Circle of Friends, a program from Finland designed to address loneliness.

Most referrals to Lundy’s CST and other programs come from doctors after Medicare wellness visits.

She now has 17 groups, including both the CST and the stand-alone exercise sessions, and 120 participants, with some in long-term care facilities and people living in their own homes.

On a recent Thursday morning, Lundy was on the phone in her office checking on a no-show for a CST session. Although retention is high, she always checks on those who miss a group.

Assured that the person was fine and would show up next time, Lundy grabbed a tote bag spilling over with notebooks, a box of cookies and face marking crayons, and headed for an in-patient CST group at the Our Lady of the Miraculous Medal church. She and Hayden worked with retired Vincentian priests, who’ve named their group “The Happy Senior Vins.”

Lundy opened the 60-minute session by asking if anyone wanted to take a guess at what the day, date and year were, and then asked about current news events.

Hayden told the group that Halloween was a week away and there were nine weeks until Christmas. She then gently guided the group into a series of questions meant to pull forward long-term memories. She asked them whether it felt like autumn outside and if the changing color of the trees depended on the weather. Then, she polled the group on how they celebrated Halloween growing up.

Next, she pulled out a lightweight plastic ball and asked the group to think of as many types of candy bars as they could. She tossed the ball to one of the priests, telling him to name a candy bar before tossing the ball to someone else, and so on.

After a couple of other activities, the group did 10 minutes of chair exercises. The session ended after Lundy pulled up the group’s song on her phone and the men sang along to Merle Haggard’s “One Day at a Time,” eyes closed, feet tapping out the rhythm.

The CST activities are meant to bring long-term memories forward and make connections to the present, with the goal of maintaining the cognitive function each individual has when starting the program, for as long as possible.

The CST/exercise sessions are designed to counteract cognitive and physical decline through fun activities that get older people laughing and make them feel good about themselves, says Lundy.

“The main things we see are increased presence,” she says. “Sometimes, participants will say their memory and recall are better, and research shows improvements in activities of daily living with extended CST.”

She and her team keep CST going with a maintenance program; some participants have been in it for five years.

Lundy isn’t a stickler for CST guidelines, which call for people with good vision and hearing, and some of her participants are in later stages of dementia. Her approach is more “real life,” rather than what’s needed in a research setting designed to measure outcomes.

“The hardest part is managing it all, and, as we keep adding in all of the programs, finding space,” Lundy says.

After Lundy and Hayden finished their session with the priests, they headed to another part of town for an exercise group with people of varying physical and cognitive abilities.

In the group was Tom Rowland, who has Parkinson’s disease. He joined the exercise sessions in 2017, after recovering from heart bypass surgery that kept him in the intensive care unit for nearly two months. By then, he lost almost all of his ability to do anything, and his wife, Ronda, had lost muscle strength, too.

Today, the Rowlands, who are Perry County residents in their early 70s, exercise in one of Lundy’s programs almost every weekday.

“Having a group where somebody expects you to be there is really helpful,” says Ronda. “I love this program.”

Tom uses an experimental piece of exercise equipment, sent from Helsinki University Research (HUR) in Finland, which adjusts to each user and helps strengthen sit-to-stand muscles.

The HUR machines came to Perryville thanks to Morley, after he learned of the equipment while speaking in Helsinki. Morley helped arrange to bring the machines to Perry County to aid the hospital’s efforts with frail older adults and exercise.

“We were given the machines for free with the understanding that we would do a quality study comparing traditional or group exercise with the HUR machine,” Lundy says. Researchers from HUR visited Perry County Memorial to observe Lundy’s program before sending the machines.

International visitors are nothing new to this small town. The team has welcomed visitors from Brazil, France, New Zealand, Canada, Singapore, Taiwan, Italy and China, to watch the program in action.

Lundy and Hayden have done their share of traveling, too, beginning with the U.K. to be trained in CST at University College London. They’ve also been to Hong Kong twice to present at the International CST conference, and a second time to train Hong Kong health care professionals in CST. They are tentatively scheduled to go to Singapore next spring to do more training.

Lundy and her team have aspiration beyond the CST/exercise program. She recently met with Perryville’s mayor and Morley to discuss how to make Perry County an age-friendly community.

“Perry County is our demonstration project for how to do geriatrics appropriately in a primary care setting, and it is working wonderfully well,” Morley says.