Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-030411 on 9 July 2019. Downloaded from Ageing as a mindset: a study protocol to rejuvenate older adults with a counterclockwise psychological intervention Francesco Pagnini, 1,2 Cesare Cavalera,1 Eleonora Volpato,1,3 Benedetta Comazzi,3 Francesco Vailati Riboni,1 Chiara Valota,3 Katherine Bercovitz,2 Enrico Molinari,1,4 Paolo Banfi,3 Deborah Phillips,2 Ellen Langer2 To cite: Pagnini F, Cavalera C, ABSTRACT Strengths and limitations of this study Volpato E, et al. Ageing as a Introduction Although ageing is generally perceived as a mindset: a study protocol to biologically determined process, the literature increasingly ► This study explores how changing in mindset could rejuvenate older adults with a points to the importance of psychological factors in the counterclockwise psychological promote changes in the body of older adults. ageing process, specifically age-related stereotypes or intervention. BMJ Open ► It uses a randomised and controlled method, which cognitive mindsets. Such stereotypes reflect self-perceptions 2019;9:e030411. doi:10.1136/ was never used in the past for this kind of studies. and others’ perceptions about the ageing process and bmjopen-2019-030411 ► Participants and the research personnel interacting can have a strong influence on health and life satisfaction, with them are blind to the hypothesis. ► Prepublication history for specifically through self-fulfilling prophecy mechanisms. This this paper is available online. study aimed to investigate whether changes in mindsets can To view these files, please visit change the ageing process. the journal online (http:// dx. doi. Methods and analysis This study replicates in large is projected to increase from 25.4% to 53.5% org/ 10. 1136/ bmjopen- 2019- between 2008 and 2060.1 Similarly, the US 030411). part the original 1979 ‘Counterclockwise’ experiment by 2 Ellen Langer and will involve a group of older adults (aged Census Bureau reported that between the Received 13 March 2019 75+) taking part of a 1-week retreat outside of Milan, Italy. years 2000 and 2010, the rate of growth for Revised 16 May 2019 Participants will be instructed and helped to relive their the nation’s 65-and-older sector surpassed http://bmjopen.bmj.com/ Accepted 12 June 2019 younger selves, acting as if they are living in the year 1989. the rate of increase of the entire population. The week-long residential programme is designed to prime The percentage of the total population that this perception by incorporating a completely retrofitted is over the age of 65 is projected to increase physical environment, as well as providing opportunities to from 15% to 24% between 2014 and 2060.3 engage in social activities that would have been common In OECD (Organisation for Economic in the late 1980s. This ‘counterclockwise’ intervention Co-operation and Development) countries, will be tested as a randomised control trial comprised of the average life expectancy has exceeded 80 the experimental (‘counterclockwise’) group, an active on September 24, 2021 by guest. Protected copyright. © Author(s) (or their years, which is an increase of 10 years since control group (same activities, no time manipulation) and 4 employer(s)) 2019. Re-use a no-treatment group. Ninety participants will be randomly 1970. There is a need to develop innovative permitted under CC BY-NC. No allocated to one of these three conditions. Every participant ideas that can enable older adults to remain commercial re-use. See rights will be assessed for medical, cognitive, psychological independent and in good health given the and permissions. Published by BMJ. and age appearance at four time points: at the time of increased longevity of older adults. Research recruitment, after the intervention (ie, after a week for the 1Department of Psychology, has increasingly turned to improving well- Università Cattolica del Sacro no-treatment group) and again after 6 and 12 months. being in later life, including investigations Cuore, Milano, Italy Ethics and dissemination The study has been approved about how to preserve physical and cogni- 2Department of Psychology, by the Ethics Committees of the Department of Psychology tive functioning, as well as psychological of Università Cattolica del Sacro Cuore and Don Gnocchi Harvard University, Cambridge, health, although further investigations are Massachusetts, USA Foundation. Results will be disseminated through peer- 5 3IRCCS Fondazione Don Carlo reviewed journals, scientific meetings and direct presentation warranted. Gnocchi, Milan, Italy to the general population. 4 Ageing: a mere physical process? Istituto Auxologico Italiano Trial registration number NCT03552042; Pre-results. Istituto di Ricovero e Cura a The ageing process is typically explained Carattere Scientifico, Milano, as a process of inevitable physiological and Italy INTRODUCTION psychological decline,6 as ‘[w]hen biolog- Correspondence to The need for a new active ageing paradigm ical gerontologists and laypersons use the Professor Francesco Pagnini; In the European Union, the ratio of people term ageing, they are most often referring francesco. pagnini@ unicatt. it over age 65 to those between ages 15 and 64 to… the progressive deterioration during Pagnini F, et al. BMJ Open 2019;9:e030411. doi:10.1136/bmjopen-2019-030411 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-030411 on 9 July 2019. Downloaded from the adult period of life’.7 This description of inevitable with subsequent global cerebral metabolic decline.18 decline does not explain the variability across cultures Brain modifications associated with Alzheimer’s disease, or in other measures found in older individuals’ health, such as hippocampal volume loss and accumulation of raising a need to develop approaches that include psycho- neurofibrillary tangles and amyloid plaques, is correlated logical and social factors to better understand the ageing with the negative age stereotypes earlier in life.19 Similarly, process. There is increasing direct evidence that ageing is positive attitudes towards age protect against dementia, governed by a combination of psychological, behavioural even when there is a genetic disposition.20 and environmental factors within the individual’s control.8 Over the last 20 years, many studies have demonstrated The ‘counterclockwise’ experiment and the role of perceived the importance of age-related stereotypes.9 These stereo- control types form a key construct to be further explored in this One of the major mechanisms of the stereotype embodi- study. ment is the reduction of perceived control, as older adults who feel more in control are able to offset the ‘negative’ The effects of age-related stereotypes effects of the stereotypes.21 In one early study on personal Like any label, the term ‘elderly’ tends to confound a control and ageing in a nursing home, residents who population that can be very different from each other— were instructed to think of themselves as more indepen- for example, the 92-year-old yogi versus the wheelchair dent and had more responsibility for their daily activities, user patient with dementia, indiscriminately ascribing a rather than relying purely on caregiver or nursing staff, lack of personal control and both physical and mental lived longer than those who were treated just as nicely decline, essentially similar to chronic illness labels. The but were not provided with activities that would increase development of research on ageing stereotypes focuses their perceived independence.22 The study demonstrated as well on including negative attributes (eg, being a significant improvement in the experimental group ‘forgetful’, ‘weak’, ‘rigid’),9 10 as well as positive charac- over the comparison group on alertness, active partici- teristics (eg, being ‘warm’). These terms prime implicit pation and a general sense of well-being.22 23 Moreover, and explicit stereotypes of older adults in both older and those afforded more independence were twice as likely to younger cohorts. be alive 18 months later.23 This and other research took Stereotypical images of ageing are recalled and used issue with the concept of ‘learned helplessness’,24 intro- as they were initially learned, and there is evidence ducing ‘self-induced dependence’, in which helplessness to suggest that as a person ages these stereotypes may may result from the labels one is given, even when there become a self-perception.11 The long-term effects of was prior success on the task in question.25 As applied to these self-perceptions were demonstrated by a pair of the elderly, the implication was fairly obvious: if a simple studies based on data from the Ohio Longitudinal Study label can induce dependence in a typical work situation http://bmjopen.bmj.com/ of Ageing and Retirement, in which participants aged 50 (eg, ‘assistant’ vs ‘boss’), then it is similarly apparent that or older at baseline were followed for over two decades.12 as older adults are put in roles with decreasing expecta- Participants with more positive self-perceptions of ageing tions for performance, learned helplessness increases, at baseline had better functional health over the course fostering an ‘illusion of incompetence’.25 As a group, of the study and lived an average of 7.5 years longer than older people stop engaging in activities once performed, those with more negative self-perceptions of ageing. they ‘bear negative labels’, and often end up in posi- These health advantages remained