This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #1, #40
Understand the role of health care provider (HCP)–patient collaboration in promoting the self-management of health behavior in geriatric patients.
Integrate the principles of self-management into daily clinical practice.
Be able to collaborate with older adults in developing realistic and relevant health goals.
Key Clinical Points
The traditional biomedical model of care follows a top-down format, where HCPs are expected to fix problems, and patients play a passive and compliant role. In contrast, collaborative self-management emphasises the patient-HCP partnership: the patient is an active agent with valuable knowledge, who is involved with (a) identifying the problem, (b) selecting an appropriate treatment regimen, (c) making detailed action plans, and (d) evaluating and providing feedback to the HCP on outcomes.
When working with patients, HCPs should keep in mind the five As advocated by the AMA: assess, advise, agree, assist, and arrange for action.
Older adults engage in self-management in response to a conscious health goal or to remove barriers in the path toward goals; health-related goals most often stem from concerns related to detection or prevention behavior; that is, older adults want to identify, alleviate, or avoid a specific physical or psychological symptom/condition.
The major factors driving self-management include setting a clear standard or goal, self-monitoring progress, feedback, self-evaluation, corrections, and enhancing self-efficacy beliefs.
Groups can be a powerful tool for teaching self-management skills to older adults. In bringing people together with a common problem and/or goal, group members actively collaborate with, learn from, and support one another. With time and practice, older adults develop the skills necessary for self-management. After these skills have been learned, HCPs need to actively transition members away from the group by slowly reducing group dependency.
Self-management is an essential factor for the long-term success of individuals who live with chronic disease and/or physical disability. Approximately 80% of older adults have at least one chronic disease, and the number of aging individuals in North America and throughout the world is growing rapidly. Despite provision of standard care by health care providers (HCPs), distressing statistics related to patient adherence suggest that something is amiss. Consider these few of many examples: only 40% of patients actually have the confidence to make recommended health behavior change; patients only recall about 50% of the information their physician communicates; and, of the 28% of individuals receiving physician advice to change physical activity, fewer than 40% received help related to specific plans and fewer than 42% received follow-up support. The care and treatment of chronic conditions cannot progress unless there is a conscious effort to change HCP’s training and, of equal importance, their practice.
Fortunately, these issues are increasingly being acknowledged in public health settings and by groups like the American Medical Association (AMA). A significant development is the recognition that self-management is a key pathway in improving health system performance. Put simply, patients should be treated as active agents in their health care. Self-management includes provider- and patient-driven behavior to address illness, treatment, and health maintenance; patients are the ones to ultimately decide when to initiate the process and to what extent they will adhere to recommended courses of action as prescribed by HCPs.
Self-management is as important to geriatric medicine as it is to other branches of health care. A guiding assumption of this chapter is that older adults’ self-management of health behaviors is central to understanding the etiology, treatment, and downstream consequences of illness, chronic disease, and disability. Modern geriatric medicine should have as central focus the partnership between HCPs and patients. However, this direction will require HCPs to have a working knowledge of what motivates older adults to initiate health behaviors and the potential reasons for success or failure in self-management. As well, it necessitates that patients become informed and active self-managers.
The early sections of this chapter will define and provide a conceptual framework for self-management; later sections will review key studies in the area and offer HCPs guiding principles and suggestions for incorporating patient self-management into their practices. Applying this knowledge will enable geriatric HCPs to support their patients in a patient-center model of care so that patients attain improved health outcomes and quality of life.
What is meant by self-management, and how does it differ from disease management or self-regulation? While perhaps tempting to use these terms interchangeably, Noreen Clark has argued that each refers to a distinct type of behavior. Thus, establishing clear definitions is an important first step in ensuring that HCPs understand how to integrate self-management in clinical practice.
Using Clark as a definitional guide, self-care involves actions taken by an older adult to promote or maintain a desired health status without the interaction or assistance of a HCP. Examples might include taking herbal supplements or participating in a walking group without receiving any specific advice or monitoring by HCPs.
Although self-care is important to older adults and their health, in this chapter we are specifically interested in health behaviors that either do or should directly involve HCPs. Clearly, older adults managing chronic disease and disability must frequently consult HCPs and adhere to the various therapies prescribed.
In health care settings, adherence refers to the collaborative relationship between patient and HCP. The patient is involved in decision making and carrying out care regimens. In contrast, compliance is an unquestioning and passive response by the patient; the relationship is one-way and top-down. Compared to compliance, adherence is significantly better in promoting persistence, and is particularly important when patients are managing a complex chronic disease. Adherence allows patients to develop a program that is realistic for their lifestyle and abilities.
Disease management refers to the broader context of care and treatment, and involves the HCP, the health care system, and the individual. For example, it includes providing patients with prescriptions, diagnostic testing, and support services. Self-management is a subset of disease management that involves the actions of the older adult, their family and caregivers, and their interactions/relationships with HCPs. Effective self-managers learn to use these human resources toward the goal of minimizing symptoms and optimizing function.
A key tool for self-management is self-regulation: the ability to derive strategies and alter behavior in order to reach a goal—in our discussion, the goal of successfully managing chronic disease. For example, a patient might use a blister pack to help manage their medication, or use a pedometer to monitor their daily physical activity. Though self-regulation is based in the individual, we contend that it should not be limited solely to patient-derived strategies (ie, the domain of self-care). Rather, the HCP must (a) provide opportunities to educate patients about the self-regulatory process, if they are to understand it, and (b) provide guided practice with self-regulation to effectively manage their health behavior.
While learning about and maintaining self-management of chronic disease requires a partnership between the patient/caregivers and the HCP, the partners’ responsibilities may vary over time dependent on both disease developments and the patient’s abilities. However, the ultimate goal should be for the patient to achieve as much independence as possible. These partnerships must strive to help older adults to acquire the self-regulatory skills essential to effective self-management of health behavior.
Health Behaviors Embodied in Self-Management
“Health behavior” refers to actions that influence health. As this encompasses a wide range of activities, it is useful to think of health behaviors as falling into four classes: health promotion, primary prevention, secondary prevention (screening), and tertiary prevention (treatment). Patients’ motives and strategies to engage in each type of behavior differ. Further, the extent of adherence to each class can be influenced by both positive (taking action) and negative (avoiding action) responses. Self-management encompasses both responses. For example, one older adult might attempt to adopt and to maintain a therapeutic regimen of physical therapy for a frozen shoulder, yet another may decide not to go to the therapist to avoid the pain and discomfort of treatment. While avoidance/nonadherence by patients is rarely effective in managing symptoms, HCPs must recognize that self-management does not always involve what they may view as the “correct” response.
Health promotion is intended to maintain or to improve an older adult’s current state of health; for example, healthy eating, regular exercise, engaging with the community, and meditation when used proactively to manage stress. Often, health promotion behaviors do not directly involve the HCP and are better conceptualized as a part of self-care than self-management. On the other hand, primary prevention is performed to reduce the risk of future health problems. Examples of primary prevention include wearing a seat belt, reducing saturated fat intake, and engaging in exercise to help prevent cardiovascular disease (Table 28-1). Secondary prevention, performed by the individual or the HCP, involves the use of screening tests to detect the presence of disease as early as possible, so that its progress can be stalled and its effects managed/reversed. This might include, for example, older women performing breast self-examinations or HCPs ordering mammograms. Finally, tertiary prevention occurs once a patient has received a diagnosis, and focuses on preventing further deterioration and maximizing quality of life. Examples of tertiary prevention include engaging in cardiac rehabilitation following myocardial infarction, monitoring blood glucose in type 2 diabetes, and taking nonsteroidal anti-inflammatory drugs (NSAIDs) to manage arthritis pain.
Table 28-1EXAMPLES OF SELF-MANAGEMENT BEHAVIORS ||Download (.pdf) Table 28-1 EXAMPLES OF SELF-MANAGEMENT BEHAVIORS
|HEALTH PROMOTION ||PRIMARY PREVENTION ||SECONDARY PREVENTION |
|Eating a healthy diet ||Using sunscreen every day ||Performing breast or testicular self-examination |
|Exercising regularly ||Flossing and brushing teeth each day ||Scheduling regular checkups with the dentist, optometrist, and physician |
|Meditating regularly to maintain psychological well-being ||Getting an influenza shot ||Checking blood pressure regularly |
|Maintaining a healthy social network ||Wearing a seat belt every time you are in a car ||Monitoring blood glucose levels in pre-diabetes |
|Volunteering in the community ||Choosing restaurants that serve heart-healthy meals and offer senior-sized portions ||Conducting a home safety inventory for potential tripping hazards |
In geriatric medicine, HCPs must encourage and actively facilitate older adults’ development and practice of self-management skills. They must also work to build adherence to desired detection, prevention, and promotion behaviors, and related self-confidence in these actions. Later in the chapter, we will discuss the research literature in self-management, which holds promise for successful collaborations between older adults and HCPs in achieving these goals.
A CONCEPTUAL FRAMEWORK FOR SELF-MANAGEMENT
Having defined self-management and discussed different types of health behavior, the next step is to ask the following questions: Why is self-management important? What motivates older adults to engage in self-managed health behavior? And, what causes success or failure in effective self-management? In answering these questions, we offer a conceptual framework that will serve two important roles. First, it will be used to examine evidence from research on self-management. What are the features of successful programs designed to promote self-management? What are important gaps in the knowledge? Second, it will provide HCPs with a template for examining current practices and/or developing new practice initiatives that target older adults’ self-management of health behavior.
Today, chronic disease is responsible for about 70% of annual mortality, and costs governments billions in both direct and indirect expenditures. At the level of the individual, chronic disease can have a negative and substantial effect on well-being, such as limiting daily activities (eg, dressing, bathing, and mobility), increased pain and fatigue, and poor mental health.
Self-management plays a foundational role in chronic disease management for three main reasons. First, nearly all disease outcomes are mediated by the patient’s own behavior. For example, adherence to medication, medical advice, and a healthy lifestyle are all determinants of health. Second, the nature of chronic disease means that patients might spend years—if not decades—living with a given condition. Though HCPs play a key role in educating, supporting, and guiding patients, contact between HPCs and their patients is limited. Self-management is required for patients to effectively manage their condition and their lives outside of the clinic. Finally, research consistently links empowerment to positive well-being. Empowerment refers to the process of granting autonomy, devolving power, and enabling people to gain control over their health. Though often discussed at the level of the community (eg, empowering minority groups), empowerment is also beneficial to individuals. For instance, individual (psychological) empowerment might manifest as a greater sense of control and self-worth.
What Motivates Self-Management?
Older adults engage in self-management in response to a conscious health goal or to remove barriers in the path toward goals. In geriatric medicine, health-related goals most often stem from concerns related to detection or prevention behavior; that is, older adults want to identify, alleviate, or avoid a specific physical or psychological symptom/condition.
If the symptom is new to them, then older adults’ self-management behavior is frequently encouraged by a family member and begins with seeking a diagnosis. However, in many instances, patients seek follow-up treatment for chronic disease. Here, prevention and management of symptoms becomes the goal. A common example among older adults is the pain associated with osteoarthritis. Often patients perceive chronic pain as being beyond their control: they believe that the HCP has the sole remedy to fix their problem, and discount the role of self-management. In seeking help, they might expect to obtain new medication or an increased dose of their current medication. In short, patients create a commonsense view of what the pain means and how to alleviate it. Likewise, the physician may feel that pain from osteoarthritis is rooted in some underlying pathology (ie, that it is a biological problem), and immediately rule out collaborative self-management. Unfortunately, the HCP’s actions may reinforce patients’ theory about the cause of, and solution to, the pain. Such a decision discourages self-management and reinforces patients’ notion that they have no role to play in treating their chronic condition. This example illustrates that both patients’ common sense understanding of their medical condition and the behavior of HCPs contribute to the motivation to self-manage health behavior. Active partnerships between patients and their HCPs develop the motivation to take action and are essential in shaping patients’ self-management behaviors.
Howard Leventhal and colleagues have been instrumental in promoting a commonsense model of self-regulation for health behavior and have conducted considerable research on what motivates people to seek treatment. Their model also has relevance to adherence/self-management over time. A critical feature is its bottom-up, as opposed to top-down, organization. The focus begins with an older adult’s perceptual experiences (eg, feeling off-balance or weak) and physical symptoms (eg, pain and fatigue)—the raw sensory experience that something is wrong. Moods and emotions related to this raw sensory experience, as well as feelings of competence in being able to manage the problem, are also important in determining higher-order reasoning such as, “I’m in trouble and need help.”
The commonsense model identifies five features of health events that motivate people to act: label/symptom, timeline, consequences, cause, and perceived control. The following scenario provides an explanation of how they operate.
Fred has noticed that he seems to have weakness and some mild discomfort in his upper legs when getting out of the car or rising from a kneeling or sitting position—perceptual experience/symptom. Originally, he thought they might be the result of an overuse injury, the inevitable effects of aging, or a complication related to the tension he has been experiencing with his youngest son—suspected cause. However, the symptoms have persisted for 8 weeks, and he long ago resolved the conflict with his son—timeline. He has also noticed that friends of his age are not reporting this problem. He reasons that if aging were the cause, more of his friends would have the same symptoms. The symptoms are very frustrating because they have all but stopped him from working around the house and seem progressively worse because now he has discomfort when rising from his chair after watching TV—consequences. Fred questions his suspected causes and worries that he may have nerve damage in his spine or a musculoskeletal disease—loss of control.
Fred’s initial cause-and-effect explanations of his symptoms are consistent with his commonsense reasoning about the relationship between stress and illness and age and illness and may have delayed his seeking treatment. However, when their duration and their absence among his peers suggest that they are not a normal problem of aging or stress, he becomes motivated to seek treatment. Leventhal and his group have found that, in addition to these five factors, fear is an important motive for action, but that without an action plan, fear does little to promote constructive behavior. For Fred, an action plan might consist of intending to call his physician tomorrow morning after breakfast to make an appointment for the following week.
Of course, older adults’ commonsense models are not created in a vacuum; they are influenced by the social system: factors at interpersonal, institutional, and cultural levels, and our understanding of self-management has to be considered from a systems-based perspective (Figure 28-1).
Multiple levels of influence that can affect older adults’ self-management. Note that culture indirectly influences all levels in self-management, but can especially influence the individual (intrapersonal) due to prevailing ageist stereotypes.
Factors from multiple aspects of the system can both facilitate and inhibit older adults’ actions. For example, a wife’s insistence may result in her husband going for a prostate examination for potential detection of cancer (interpersonal influence). TV documentaries on the biology of aging may lead older adults to adopt a regimen of vitamin supplementation (institutional influence). Grown children may openly verbalize an emotional objection to their older adult parents seeking treatment for a symptom, convinced that doctors are just trying to collect money on procedures for benign aches and pains, in effect “ripping off” Medicare (cultural influence)! Other powerful cultural stereotypes in our society can discourage physical activity among older adults.
Symptoms do not always lead older adults to seek a solution, even when they are severe and persistent. In many instances, older adults self-manage their symptoms through avoidance. For example, a woman ignored rectal bleeding for more than a year until acute pain forced her to visit the emergency room, where colon cancer was diagnosed. She knew that something was seriously wrong long before this event, but she was afraid that, once she went for a diagnosis, she would be hospitalized, and that would be the end of life as she knew it. In other cases, avoidance can be triggered by older adults’ beliefs about specific health behaviors. For example, older adults may have adopted stereotypes that support their position that they are too old to be physically active or that losing weight is unhealthy for them.
Figure 28-2 provides a conceptual framework for understanding the complexities of self-management. We will elaborate on three features in the following sections: (a) facilitating factors; (b) inhibitory factors; and (c) knowledge, skills, strategies, and resources.
A blueprint for self-management.
Facilitating Factors in Self-Management
More than three decades of research in psychology has identified several factors that promote effective self-management of health behavior. Consider the following example.
Helen is an obese, physically compromised older adult. She is frustrated by several consequences of her poor health, including the fatigue she experiences when moving, the loss of some of her functional independence, and a recent confirmation by her HCP that she has type 2 diabetes. In collaboration with her physician, Helen decides to join a community-based program offered by a regional health alliance. The program treats physical disability and diabetes in older adults using a combination of caloric restriction and increased physical activity. When she first enters the program, the intervention team evaluates her diet and activity patterns, and based on these data, she and an interventionist together establish goals for modifying them over the next month. In addition, they discuss the importance of establishing weekly behavioral goals related to self-monitoring and evaluation of her progress. Together, they decide that Helen will time herself while walking four laps at the local YMCA track (approximately 400 m) each month and also record her fatigue on a simple 10-point scale (0 = no fatigue whatsoever and 10 = as tired as she has ever felt). Helen’s progress and her confidence in being able to complete the prescription are checked weekly. Her goals are adjusted as necessary. On a monthly basis, Helen is asked to reflect on what she has done and to notice what effects, if any, the program is having on various aspects of her life (Table 28-2). As a result of this self-evaluation and a number of successes in pursuing the goals that she helped to set, Helen gained confidence in the skills necessary to make progress in changing her behavior. She could see the changes happening as she practiced these self-regulatory processes to manage her chronic health condition.
Table 28-2FACTORS THAT PROMOTE EFFECTIVE SELF-MANAGEMENT ||Download (.pdf) Table 28-2 FACTORS THAT PROMOTE EFFECTIVE SELF-MANAGEMENT
|SELF-REGULATORY SKILL ||EXAMPLE |
|Establishing proximal and distal goals ||Helen and her HCP discuss her current diet and activity patterns in order to develop realistic, challenging goals together. In addition to long-term goals, proximal (monthly and weekly) goals are also set. |
|Self-monitoring progress toward goal ||Helen logs her diet and her exercise workouts each day. She also “tests” herself each month by walking around a track four times and seeing how much this tires her out. |
|Attaining feedback ||Helen meets with her HCP weekly to discuss her log book. The HCP provides constructive feedback on how Helen is doing. |
|Self-evaluating progress toward goal ||Helen looks back and reflects on her previous log entries to make note of any progress she is making toward her goals, and whether she is noticing any changes in other areas of her life. She notes that it takes less effort for her to walk around the track, and that she can now ride the bike 10 min longer than she could 2 wk ago. All of these changes are seen as progress toward her goal of increasing her physical activity level. |
|Making corrections to goal-directed behavior ||Once Helen has developed confidence of physical activity, the HCP helps Helen think of other ways to reach her health goals. He suggests that Helen gradually increase her fruit and vegetable intake. Helen brainstorms practical ways to reach short-term goals, such as buying precut vegetables for snacks. |
|Raising self-efficacy beliefs ||Helen is encouraged to celebrate the progress she has made and to take pride on her hard work. This increases Helen’s confidence in her abilities to successfully change her health behaviors, regardless of barriers that she encountered along the way. |
The above scenario and the description provided in Table 28-2 illustrate how self-regulation generates effective self-management. The skills inherent in this process warrant repeating since they are part of the tools that both patients and HCPs must engage in and practice when self-managing health behavior. They include the following:
Setting clear, specific, and reasonably challenging goals for behavioral change—setting a clear standard or goal
Monitoring personal behavior and how it influences reaching goals and the rate of change—self-monitoring progress
Providing feedback and information on each health behavior goal that has been collaboratively established between the HCP and the older adult—feedback
Self-evaluating progress related to the goal—collecting the older adult’s personal judgments and emotional reactions about their pursuit of goals and making or not making progress—self-evaluation
Correcting behavior as a result of feedback and self-evaluation, leading to more effective and persistent change in the direction of established goals—corrections
Encouraging belief in the ability to organize and to take action associated with the specific circumstances that they are trying to change in order to achieve specific goals and to persist in and increase behavioral change, despite the setbacks, difficulties, or rate of progress—self-efficacy beliefs
The interaction of these multiple factors influences the success that older adults will have with their health behavior change. However, their collaboration with HCPs influences the entire self-regulatory process: as partners, the HCP and patient can make informed judgments about expectations and outcomes. In the example above, consequences could include Helen’s reduced calorie consumption, increased walking, and better control of blood glucose (outcomes strongly valued by the HCP), but also compliments from family, friends, and HCPs, and personal satisfaction with her accomplishments (outcomes strongly valued by the patient). Regular reflection on progress (feedback) and comments about how it has affected life (outcome information) by both parties characterize a normal self-evaluative process and influence her desire to adhere to the collaborative prescription for change. The HCP’s comments about change in Helen’s outlook and persistence, and Helen’s surprise and pleasure in being able to stick with reduced caloric consumption over a month, jointly contribute to her self-efficacy (confidence) to adhere to their plan over the next month. This scenario follows recommended patient-centred collaborative practice outlined in the AMA’s Physician Resource Guide to Patient Self-Management Support (accessible via http://selfmanagementalliance.org/). Its appendix provides physicians with simple tools that are helpful in encouraging patients and physicians to engage in steps toward patient self-management.
Inhibitory Factors in Self-Management
For some older adults, behavioral practices that reflect effective self-management of chronic disease are well learned and resistant to threats like competing behaviors and events. Many older adults consistently visit their physicians when they encounter novel physical symptoms, schedule screening examinations and vaccinations as recommended by HCPs, and take supplements and daily walks without fail. However, HCPs must often ask older adults dealing with chronic disease or disability to adopt new remedial or preventive behaviors, or to change dysfunctional patterns of behavior. Under such circumstances, a number of factors can inhibit effective self-management.
Clearly, a major threat to effective self-management is operating automatically. The self-regulation needed to adopt a new behavior or to change an old pattern requires conscious control of thought and action; the patient must have a goal in mind, and actively strive toward it. If an older adult behaves without thinking, opting for the routine path of dysfunctional behavior, hope for change is futile.
Why do older adults persist in seemingly mindless, automatic patterns? According to Walter Mischel’s research, strong emotions—which are common in older adults— shut down their rational thinking and derail attempts at conscious behavior change. In our studies with older adults, these emotions have a variety of causes, including frustration with failed treatments, not wanting to be a burden to caregivers, and acute illness or injury that disrupts action plans. The important lesson from Mischel’s research is that self-management planning cannot ignore these emotions.
An alternative explanation is that automatic behaviors may work to simplify day-to-day life. The problem, of course, is that some customary routines (“I always have a doughnut with my coffee”) run counter to the strategies or prescriptions that HCPs hope to make a part of older adults’ health self-management (“Avoid foods with a high glycemic index”). Well-established routines may be associated with positive outcomes, such as enjoyment or a sense of control or predictability. Replacing well-established behaviors with healthier options (ordering salad instead of fries) could be seen as undesirable or challenging (it doesn’t taste as good; it costs more), or might go against social norms (being the only one to order salad) and cultural traditions (abnormal to eat raw vegetables). Finally, automatic behaviors may be attractive simply because they require less effort.
Overriding established routines takes both attention and perseverance; this may be especially difficult when the older adult is tired or is attempting to manage multiple behaviors simultaneously. In addition, decades of Eastern writings and recent research in Western psychology on mindfulness convincingly argue that North American society encourages automatic responding. Many find it difficult to pay attention to where they are headed and whether or not the direction of their path is consistent with what they value because it is foreign to them. During their younger and middle-aged lives, people are consumed with the demands of their occupational roles and with preparing their children to be “successful” in our fast-paced society. There is little time for self-awareness, and physical symptoms such as fatigue are viewed as barriers that need to be suppressed. This behavior pattern continues into old age.
Slips, relapses, and intergoal conflict
A second general threat to effective self-management is the occurrence of slips and relapses in behavior and intergoal conflict. The failure to remain true to personal goals is often distressing, and older adults are no exceptions to this experience. For this reason, slips and relapses often spark negative emotions that contribute to giving up on adopting or maintaining new self-regulatory behavior that can facilitate self-management. For example, Byrne, Cooper, and Fairburn conducted a qualitative study comparing obese women who were either successful or unsuccessful in maintaining weight loss after an initial intensive treatment. They found that relapse was related to (a) the failure to achieve weight goals and dissatisfaction with the weight achieved, (b) the tendency to evaluate self-worth in terms of weight and shape, (c) a lack of vigilant weight control, (d) a dichotomous (black-and-white) thinking style, and (e) the tendency to use eating to regulate mood. The theme that emerges is that relapse is often triggered by negative thoughts and feelings about self-management, which can arise from (a) unrealistic expectations about outcomes, (b) eliminating a behavior that is used to cope with life stress, or (c) having zero tolerance for slips.
We have also found that slips in self-management are often related to competing events—intergoal conflict. A common example for older adults is vacation or family gatherings, which compete for time and priority with preventive actions. In these situations, self-management takes a back seat and can even lead to negative thoughts, such as “I just don’t have time for this program on vacation,” or “I don’t like the feeling of guilt that I am suddenly experiencing; something’s got to give.” Notice the black-and-white thinking style, where other goals and active self-management of health behavior are incongruent. However, with the development of appropriate self-regulatory skills, two goals need not be in conflict. HCPs should encourage patients to see goals as complementary rather than competing. For example, an older adult could spend time with grandchildren by going on a walk or cooking a healthy meal together.
Barriers and toxic environments
Barriers are obstacles that make self-management difficult or impossible. According to Marcia Ory and her colleagues, barriers often evolve from negative stereotypes related to the six most common myths of aging (Table 28-3). These ageist stereotypes are reflected in the media and social and health care services. Expert witnesses who testified before the US Senate Special Committee on Aging reported that the media and marketing often depicts older adults as helpless, feeble, and ineffective. In the realm of health care, Ory and her colleagues found that doctors tend to provide less aggressive treatments to older patients, and that self-management programs typically target younger populations. Furthermore, behavioral and lifestyle interventions are believed to have only minimal impact on older adults, despite accumulating evidence to the contrary.
Table 28-3POPULAR MYTHS OF AGING ||Download (.pdf) Table 28-3 POPULAR MYTHS OF AGING
| ||MYTH ||REALITY |
|1 ||To be old is to be sick ||Although chronic illnesses and disabilities do increase with age, the majority of older people are able to perform functions necessary for daily living and to manage independently until very advanced ages. The effects of population aging are mediated, in part, by declining disability rates. |
|2 ||You can’t teach an old dog new tricks ||People are capable of learning new things over the entire life course—including into old age. This relates to cognitive vitality as well as the adoption of new behaviors. |
|3 ||The horse is out of the barn ||The benefits of adopting recommended lifestyle behaviors continue into the later years. It is never too late to gain benefit from highly recommended behaviors, such as increasing physical activity or quitting smoking. |
|4 ||The secret to successful aging is to choose your parents wisely ||Genetic factors play a relatively small role in determining longevity and quality of life. Social and behavioral factors play a larger role in one’s overall health status and functioning. |
|5 ||The lights may be on, but the voltage is low ||The majority of older people with partners and without major health problems are sexually active, although the nature and frequency of their activities may change over time. |
|6 ||Older adults don’t pull their own weight ||The majority of older adults who do not work for pay are engaged in productive roles within their families (eg, assisting with child care) or the community at large (eg, volunteering or activism). |
Poor physical and social environments, as well as lack of resources for effective self-management, can also interfere with health behavior. For example, unsafe neighbourhoods may discourage walking, and living in a food desert makes healthy eating difficult. Other barriers might be rooted in the more-immediate environment or the patient themselves: for example, their level of motivation, their commonsense understanding of their disease, or their home and family. Consider an older woman with hypertension, who has been advised to lower her sodium intake. When she attempts to change her cooking style, she receives negative feedback from her husband and promptly reverts to her old method. To remove this barrier, it may be necessary for the HCP to educate the patient’s husband on hypertension and/or advise the patient on cooking strategies (eg, gradually reduce sodium levels). It is important to note that identifying and reducing the effect of barriers by arming the patient with adjustment strategies is an ongoing process, and some trial-and-error may be necessary before a successful solution is found.
Costs and the problems of distant benefits
Psychological research from multiple theoretical perspectives illustrates that the anticipated costs of behavior weigh heavily on the decision to seek or to persist with a treatment. For example, research has shown that the fear of a medical procedure, without a plan to deal with the fear, is a significant barrier to treatment. Not surprisingly, in our own work on lifestyle behavior, we find that negatively interpreted physical symptoms during activity are barriers to older adults’ continued involvement with exercise programs.
Another common challenge for older adults is what researchers have described as temporal discounting or the delay of gratification necessary to reach some outcomes. Willingness to persist with treatment for weeks and sometimes months before any major outcome is realized may wane. Many older adults may be faced with delayed gratification both in achieving desired distant outcomes and in the heavy, daily costs of treatment (eg, fatigue, following a complex medication and supplement schedule). No wonder patients may perceive self-management as complex and stressful, which may lead to avoidance or nonadherence.
Knowledge, Skills, and Strategies
The final component of our conceptual blueprint for self-management addresses the knowledge, skills, and strategies that inform self-regulation and, in turn, promote effective forms of self-management. Patients’ knowledge about illness, chronic disease, and disability is important from at least two perspectives. First, patients must know about the origin and course of the disease itself. For example, it has been well documented that adults are better at managing diabetes when they understand the importance of self-monitoring their blood glucose level and have specific action plans to implement when values are below or above the target. As such, it is essential for HCPs to explain disease in a way that corresponds with patients’ background (eg, ethnicity, education) and current cognitive abilities rather than the HCP’s view of the management of the disease. Second, consistent with Leventhal’s commonsense model of illness and disease, older adults’ personal views of their health conditions must be explored and expanded. As we saw in Figure 28-1, important areas that these personal views can include are (1) symptoms, (2) perceived causes, (3) anticipated consequences, (4) degree of perceived control over the process and course of the disease, and (5) the timeline for disease progression and achieving symptom management.
Skills and strategies refer to intervention methods that have been proven effective in promoting the self-regulation of positive and negative factors toward health behavior change. As we review selected examples from the literature, we will identify elements that are consistent markers of success and indicate how the methods fit into the blueprint.
LESSONS FROM THE LITERATURE ON SELF-MANAGEMENT
The following section will showcase examples of self-management research and programs, which illustrate their potential for encouraging positive health behavior. Although some of the research does not directly involve physicians as the HCP, these programs work best when physicians understand and support their goals and know about their evidence-based effectiveness.
Selected Research by Investigators From Stanford University
Some of the most visible and rigorously studied programs of comprehensive self-management have come from Stanford University’s Patient Education Research Center. For example, Kate Lorig has published widely on the Arthritis Self-Management Program (ASMP) that has since evolved into a generic Chronic Disease Self-Management Program (CDSMP). ASMP and CDSMP are led by individuals with chronic health conditions who receive 20 hours of training based on detailed manuals for group facilitation. ASMP is disease-specific, emphasizing the management of arthritic pain. It is delivered in 2-hour group sessions (10–15 individuals) that meet once a week for 6 weeks. Major topics include pain and stress management, exercise, problem solving, communication skills, especially for physician/patient interactions, nutrition, medications, and nontraditional treatments.
CDSMP is designed to treat people who have a range of chronic diseases and is delivered in 2.5-hour sessions every week for 7 weeks. Topics include managing physical symptoms and negative emotions, exercise, problem solving and decision making, communication skills, nutrition, medication use, and the use of community resources. In both programs, leaders function as facilitators, rather than lecturers, actively engaging participants to develop personal goals and specific action plans for each week. Regular feedback is a crucial component, and the objective is to enhance patients’ confidence in their ability to acquire specific behaviors or skills in each area of content.
Despite the limited time allotted to address such a broad range of complex health behaviors, data from randomized clinical trials of both ASMP and CDSMP have been encouraging. Figure 28-3 summarizes 12 years of research on ASMP as reported by Lorig. Note that the 6-week ASMP interventions lead to enduring positive changes in self-efficacy, as well as reductions in level of pain and frequency of physician visits.
Twelve years of research on the Arthritis Self-Management Program. (Data from Lorig K, Holman H. Arthritis self-management studies: A twelve-year review. Health Educ Q. 1993;20:17.)
In a 6-month randomized trial of CDSMP, intervention patients experienced statistically significant increases in weekly minutes of exercise, frequency of cognitive symptom management, improved communication with physicians, and enhanced self-reported health as compared to control patients. Other improvements favoring intervention patients were lower levels of health distress, fatigue, disability, and fewer limitations in social/role activities. They also had fewer hospitalizations and days in the hospital. However, they did not differ from controls in their pain or physical discomfort, shortness of breath, or psychological well-being.
While self-efficacy beliefs appear to play an important role in the apparent success of ASMP and CDSMP, establishing proximal, weekly goals and providing feedback on goal attainment are also important. These latter steps help to create short-term incentives and to guide behavior in the desired direction. The mastery experienced in reaching these goals is a source of information that reinforced self-efficacy, the confidence to continue with these successful actions. Moreover, to sustain efforts in the face of inevitable barriers and to assist with problem solving, the interventions encourage participants to enlist support from HCPs, peer groups, and significant others.
The same self-regulation principles that facilitate self-management can be found in other types of interventions that employ an individual, as opposed to a group, format yet are designed to reach large segments of the population. One example of this approach is the case management system for health care originally developed by DeBusk and his colleagues at Stanford University to modify and to reduce coronary risk factors. The program is run by nurses who receive 80 hours of special training by multidisciplinary experts to deliver interventions for smoking cessation, exercise training, and dietary-drug therapy for hyperlipidemia. Scheduled interventions during a 1-year period include (1) questionnaires that patients complete and then mail to the nurse case manager; (2) computerized progress reports mailed to patients, based on those questionnaires; (3) 14 nurse-initiated phone contacts; (4) four one-on-one patient visits to the nurse case manager; and (5) eight patient visits to the blood chemistry laboratory. Figure 28-4 illustrates the interdependence of physician, case manager (implementer), and patient using phone contacts and the computerized system to facilitate self-management. Note that the computerized system serves a dual role, one for data management and another in providing knowledge and information on self-regulatory skills that are essential to health behavior change.
Case management model for coronary risk modification. (Data from DeBusk RF, Miller NH, Superko HR, et al. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994;120:721.)
The initial study using this system was conducted on adults with a mean age of 57 who were hospitalized for acute myocardial infarction. Patients were randomized to this treatment or usual care and then followed for 1 year. At the 1-year assessment visit, biochemically determined rates of smoking cessation were significantly higher in the case-managed group (CMG—70%) than in the usual care control group (UC—53%), and on a treadmill test performed at 6 months, patients in CMG had higher cardiovascular fitness. At 1 year, lipid-lowering drugs had been prescribed to approximately 80% of patients in CMG but only 21% in UC. While corresponding differences in plasma cholesterol favored those in CMG, patients in both groups experienced decreasing levels of dietary cholesterol and fat from baseline to the 1-year assessment.
Haskell and his colleagues at Stanford conducted a related study of risk-reduction in middle-aged to older adults who had coronary atherosclerosis. Their study was a randomized trial with two groups: UC and intensive risk management (IRM). Their trial design did not include a computerized management system but did have an objective measure of disease progression and 4 years of follow-up. Patients were provided with short- and long-term goals and an individualized action plan for risk reduction. Progress was tracked, and short-term goals were adjusted using telephone and mail contacts as well as face-to-face clinic visits every 2 to 3 months across the 4 years of the study. The staff included experts in the content areas of interest, such as nutrition, exercise, smoking, and lipid management.
After 4 years of treatment, patients who were randomly assigned to UC showed little or no change in study outcomes. By comparison, those in IRM showed dramatic changes in their health, improving their cholesterol profile, lowering saturated fats, losing weight, increasing their physical activity, and improving the functional capacity of their cardiovascular system (Figure 28-5). This shift in health behavior was reflected in significant reductions in cumulative cardiac deaths at the 4-year assessment visit (Figure 28-6). As in the case management study by DeBusk, at some point during the course of this study, 93% of those in the IRM condition were placed on drugs for lipid management, compared to only 30% in the UC condition. Since patients in both studies improved in areas unrelated to blood lipids, not all of the observed effects could be attributed to the introduction of lipid-lowering drugs into treatment. The superiority of results for the intervention groups in both studies hold the positive implication that drug therapy can be enhanced by being embedded in a program that establishes clear goals for therapy and provides more frequent evaluation of patients’ health status.
A comparison of a self-regulatory system for self-management with usual care. (Data from Haskell WL, Alderman EL, Fair JM, et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation. 1994;89:975.)
Four-year cumulative cardiac events with a self-regulatory intervention as compared to usual care. (Data from Haskell WL, Alderman EL, Fair JM, et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease: the Stanford Coronary Risk Intervention Project (SCRIP). Circulation. 1994;89:975.)
One other study that deserves mention is a workplace project described by Bandura. Although it was not conducted on older adults, it underscores the potential value of social support in self-management. The goal of this project was to lower cholesterol in workers by reducing foods high in saturated fats. A nutritionist supervised the self-management system that was conceptually similar to the previously described programs conducted at Stanford. At the 3-month assessment, plasma cholesterol between those assigned to an experimental group dropped about 10 mg/dL as compared to a control group; however, this difference increased to approximately 17 mg/dL when spouses participated in the program (Figure 28-7). Whereas the effects of the intervention appear to have been compromised somewhat by the inclusion of individuals who had relatively low plasma cholesterol (ie, thus were less susceptible to change) at the onset of the program (Figure 28-7), they also suggest that self-managing lipids is particularly beneficial to those who need it most—those with more severe disease or disability.
The effects of spouse support and the law of initial values on plasma cholesterol. (Reproduced with permission from Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004;31:143.)
The research at Stanford is exceptional in combining sound social cognitive theory with creative translational models. Kate Lorig’s use of group-based interventions conducted by lay health leaders and Robert DeBusk’s use of a computerized system to deliver a program of self-management exemplify creative approaches. These research teams have also been conscious of what Bandura calls social diffusion, or the promotion and adaptation of efficacious programs to diverse cultural contexts. Bandura highlights these three components of translational research on self-management as essential to society-wide health promotion.
Individual Versus Group-Based Interventions
The work at Stanford indicates the benefits of incorporating groups into programs to instill self-management of health behavior for older adults when appropriate and possible. In our research, in three different randomized controlled trials (RCTs), we have compared the effects of group-mediated cognitive-behavioral self-management (GMCB) among (a) apparently healthy but inactive older adults (b) older patients who qualified for cardiac rehabilitation with a standard model, and (c) frail, overweight older adults at cardiovascular risk. In each of these RCTs, the treatments involved either usual care center–based exercise (ie, appropriate for older adults), standard center–based rehabilitation exercise (ie, cardiac rehabilitation), or comparison to an education group, interventions involved center-based exercise therapy. In the usual or standard therapy, patients met two to three times a week for exercise only. For the exercise plus counseling GMCB treatment, patients met less often for center-based exercise to promote home-based exercise, but when they did exercise at the center, they also met afterward in small counseling groups, designed to provide the knowledge, motivation, self-regulatory skills, and resources to be more physically active and to reduce self-perceived mobility disability (Table 28-4). Toward the end of the intensive phase months of treatment, the group facilitator focuses the participant on the participants’ role as dominant in their successful progress. As participants self-manage much of their own activity during that period, the facilitator gradually diminishes their role and contact until older adults are managing completely independently. The results of the studies show that after standard and GMCB groups had been heavily involved in their respective treatment plans, older adults who had been more compromised at entry into each study achieved greater reductions in self-perceived mobility disability in the GMCB condition than those who had been randomly assigned to usual or standard exercise therapies (see Figure 28-8). In addition, at the end of reduced follow-up or no contact periods, those in the GMCB treatment group sustained their greater improvements compared to the comparison groups (ie, improved MET capacity, a measure of cardiovascular fitness), physical activity, and confidence to perform a timed walk test than those in standard treatment.
Table 28-4GROUP MOTIVATED SELF-REGULATORY SKILLS TAUGHT IN GMCB INTERVENTIONS ||Download (.pdf) Table 28-4 GROUP MOTIVATED SELF-REGULATORY SKILLS TAUGHT IN GMCB INTERVENTIONS
|WEEK IN PROGRAM ||SELF-REGULATORY GOAL ||EXAMPLE ACTIVITY |
|Week 1 ||Promote and develop group identity ||Participants create and adopt a group name. |
|Week 2 ||Learn how to self-monitor effort, symptoms, and behavior ||Participants are taught how to log physical activity and assess the perceived effort of an activity. |
|Week 3 ||Set individual and group goals ||Participants are taught how to set specific, realistic, yet challenging goals for themselves and the group as a whole. |
|Week 4 ||Planning how to exercise independently ||Participants are paired with a buddy and asked to brainstorm solutions to barriers that they may encounter when attempting to exercise. |
|Weeks 5 & 6 ||Foster social support for individual and group goals ||Each participant presents their individual goal to the group, and indicates how it will help the group achieve the group goal. Group members offer feedback on the goal and how to best achieve it. |
|Week 7 ||Encourage self-reinforcement and self-evaluation ||Participants are taught how to use self-reinforcement to achieve future goals. |
|Week 8 ||Increasing exercise independence ||Participants work in pairs to design individualized exercise plans for the next week. |
|Week 9 ||Recognition of environmental cues ||Participants are asked to brainstorm what cues they can use to facilitate home-based activity (benefit of broader recognition through group involvement than by any one individual). |
|Week 10 ||Develop coping strategies ||Participants report their past week’s successes and failures. Group members are encouraged to suggest ways in which others can improve or avoid barriers. |
|Week 11 ||Learn how to prevent and deal with relapses ||The group identifies signs of relapse and develops strategies for overcoming relapse. |
|Week 12 ||Increasing self-efficacy ||Participants are reminded of their successes and improvements. They develop specific goals for their first week of totally independent home-based activity, and a general plan for their first month. |
Three-month changes in self-reported physical function in traditional versus a group-mediated cognitive-behavioral intervention. (Adapted with permission from Rejeski WJ, Foy CG, Brawley LR, et al. Older adults in cardiac rehabilitation: a new strategy for enhancing physical function. Med Sci Sports Exerc. 2002;34:1705–1713.)
These successful examples show that groups are useful in developing participant self-regulatory skills. The group is developed to foster an active, collaborative learning of rehabilitation and self-regulation not only between HCP and patient but also between patient group members. Over the course of the group intervention, patients are encouraged, to integrate the skills they learn and, with mutual input, to test and to evaluate their successes and failures in using these skills in their home-based activity. Belonging to a group whose members’ goal is active involvement and collective change is a powerful agent that creates the impetus for, and, eventually, the practice of, effective self-management. Results from cancer research have shown that it is not group contact per se but how the group is leveraged that promotes effective self-regulation.
How can group potential for health care improvements be maximized? As Yalom noted in his classic text on the use of groups for psychological therapy, group cohesiveness must be developed. In the preceding example on cardiac rehabilitation, we used classic formative techniques to optimize the dynamics of these small groups (n = 7–10 members). Older adults suffering from cardiovascular disease or other chronic diseases have a common motivation for uniting in a group. This disease is theirs, and they have elected this approach to treatment. Older adults best suited to groups are receptive to the concept of therapy and (a) discussing their disease, (b) learning from other members, (c) developing group goals, and (d) interacting with other members in practicing self-regulatory skills. Within this receptive context, group goal-setting and social support can emerge. HCPs can assist in enhancing these properties during the limited life of the group. For example, a group norm of strong attendance is essential. Occasional absences must be expected; however, general sporadic attendance makes a group difficult, if not impossible, to manage. This failure is more likely when patients are passively carrying out their therapy, group mission and identity are not emphasized, and the partnership between HCP and patient members is minimal.
This kind of therapeutic group must also aim for its members’ eventual departure so that they can become more independent in their self-management. This is why, for the GMCB treatments in all three studies, there was practice of independent activity outside the center while participants were still in the intensive training phase. It is also why contact with the facilitator was gradually reduced in that phase, then continued to be reduced in the transition of participants to full self-management. Later in the follow-up a few additional “booster” training and education sessions were used to aid/sustain self-management and encourage adherence to their program. The group or alumni group can be the magnet that draws former members back for “reinoculation” sessions to assist in long-term maintenance of self-management behavior.
Although the group can be used to foster self-management and the learning of self-regulatory skills, practitioners should be mindful of caveats. First, as Bandura and others have noted, groups can create dependency, and older adults may quickly revert to their old ways when their group terminates. However, this phenomenon is far more probable when groups are used as a passive form of delivery, and the HCP makes no systematic attempt to coalesce a unique agent of change. Cancer research suggests that if groups have no specific purpose other than to allow patients to meet with their peers, then the effects on self-management are nil. However, when transition from the group to independent self-management is planned, as was the case in the group-mediated cognitive-behavioral counseling research previously described, dependency is first reduced, then eliminated.
Heterogeneity in Symptoms and Health States
Self-management programs frequently target chronic diseases, such as diabetes, asthma, chronic obstructive pulmonary disease (COPD), or arthritis that require managing medications and lifestyle in response to specific symptoms. In such instances, the outcomes of effective self-management are often clear and reinforcing to patients. They realize that their active involvement in disease management makes a difference. They experience increased confidence in managing their symptoms, and enhanced perceptions of personal control become a central part of their commonsense model of the disease process.
Unfortunately, this success does not come to everyone with a chronic disease. For example, if the disease or symptom becomes worse and/or they experience a considerable loss in function, older adults may perceive a loss of control that understandably inhibits the motivation for active self-management. Ample research has shown that when doubt surrounding the effectiveness of behavior is strong, the impetus either to expend effort on action plans or to pursue goals for change is weak.
Before we discuss possible solutions to such challenges, it is useful to recognize that goals exist in a hierarchy. In the current context, a common goal for older adults is “to maintain a healthy state.” However, its pursuit is not necessarily conscious and active until it is threatened by either the loss of function or the emergence of physical symptoms. Once this occurs, then older adults are inclined to institute “do goals,” such as taking medication to relieve symptoms or participating in physical therapy to improve their balance. Because such “do goals” are more specific than the global goal of a healthy state, their achievement requires an action plan or a sequence of steps to follow. If medication is prescribed, it may involve going to the medicine cabinet at a specific time of day, opening the bottle, and taking the medication as well as monitoring medication use and impact over time. In the case of physical therapy, it involves making appointments, scheduling transportation to the appointment, clarifying the physiotherapist’s teaching of exercises for balance improvement, trying the exercises at home at a specific time of day, and monitoring the impact of the regimen on personal balance control.
With a better understanding of goal hierarchy, we can propose ways to help older adults whose motivation to engage in self-management has been depleted. Scheier and Carver have emphasized that Western culture frowns on giving up on goals, yet they argue that in some contexts, goal disengagement is an important coping process. Aging inevitably presents some insoluble problems. Our physical systems deteriorate, yielding predictable declines in mental and physical functioning. From a self-management perspective, detaching from an unrealistic goal allows the HCP and patient to recalibrate less ambitious goals that still point the patient in the same persistent direction, while enhancing their sense of partnership. For example, a physical activity goal of 150 min/week may be trimmed to 80 min/week. Experts believe that following this principle of partial disengagement—moving from an unrealistic to a more realistic and achievable goal without totally abandoning a particular behavioral domain—is essential because it keeps the person engaged with life and may well delay the onset of further health problems.
Unfortunately, some circumstances may dictate total elimination of activities that provide older adults with a purpose for living. We have seen many older, chronically diseased individuals who eventually have to give up valued activities due to a variety of impairments in the later stages of functional decline. In these instances, some older adults disengage and cope effectively by redirecting their energies into other domains, such as spirituality. In effect, they redefine or reprioritize their higher-order goals to accommodate their limited health state. Others fail to cope: they cling to old concepts, are unwilling to let go, and create enormous suffering for themselves and their families. Indeed, contemporary research suggests that failing to disengage from past goals that are no longer feasible creates intense regret among older adults and predisposes them to depression and physical symptoms like constipation and skin disease. HCPs may be terribly frustrated in attempting to pursue a partnership on a treatment path that is unacceptable to the patient.
Mindfulness-based interventions may be particularly beneficial in this realm of self-management for older adults, and they are being offered more and more as part of either hospital outpatient or community outreach programs. They teach centering skills, designed around breathing, assist with learning how to relate differently to activities of the mind, and they foster insights designed to promote acceptance of life experiences that are not subject to personal control. Although further discussion of this topic is beyond the scope of this chapter, interested readers may consult the Further Reading section by Baer (2006).
Complexity of Evaluating Research on Self-Management: An Illustration
To date, several hundred studies have been conducted in the area of self-management, but the set of adequately designed experiments is smaller. A recent paper in the Annals of Internal Medicine tackled the onerous challenge of providing a statistically based review of 53 randomized trials of chronic disease management programs for older adults. It concluded that programs targeting diabetes and hypertension produced clinically important benefits, but to determine which elements of the interventions were actually responsible for the observed effects was impossible. Although this paper did not find a beneficial effect of self-management in patients with osteoarthritis, a more focused literature review suggests that its effect on their pain and function is statistically significant but small in magnitude.
The results of self-management programs that target objective measures of physical disability among older adults with multiple chronic diseases are more encouraging. Several critical reviews have shown that strength training and walking programs produce robust improvements in physical functioning and small-to-moderate clinical effects on various functional tasks, such as rising from a chair, climbing stairs, and walking 400 m. For example, in a pilot study of adults 70+ years who had compromised function at baseline, we demonstrated a clinically significant change in scores on the Short Physical Performance Battery (SPPB), a well-validated measure of physical functioning that includes very basic tests of balance, strength, and mobility disability (Figure 28-9). In fact, results of the full-scale multicenter trial on this population reported in JAMA in 2014 demonstrated that a multicomponent physical activity program, anchored with walking, was effective in lowering the incidence of major mobility disability across a period of 42 months as compared to a health education control group. Other studies demonstrate that training older adults for balance has noticeable effects on preventing falls.
Comparison of a physical activity intervention with a successful aging intervention on SPPB scores. Means estimated from repeated-measures analysis of covariance adjusted for gender, field center, and baseline values. (Pahor M, Blair SN, Espeland M, et al. Effects of a physical activity intervention on measures of physical performance: results of the lifestyle interventions and independence for elders pilot (LIFE-P) study. J Gerontol A Biol Sci Med Sci. 2006;61A:1157.)
Thus, research findings on the topic of self-management vary considerably. Why do they differ so widely both within and between diseases? What conclusions can we draw for clinical practice?
First of all, the value of attributing clinical meaning to the strength of effects that are statistically averaged across studies, even after grouping them according to specific characteristics, such as tailored treatment or group versus individual treatment, is questionable. Among the many reasons for this concern, three stand out: (a) varying lengths and intensities of the interventions, from 6 weeks to 42 months; (b) targeting multiple outcomes; and (c) including patients with a broad range of disease severity. These variable elements preclude making many useful clinical generalizations. For example, we know from our extensive research in weight management that the intensity and duration of treatment are critical factors in the success of behavior change. Also, when studies target multiple outcomes, individual behaviors are rarely given the attention that is required for behavior change to occur The clinical effectiveness of self-management on osteoarthritis pain is much greater in intensive studies of pain management, such as those of Frank Keefe, a leader in this area, than in short-term community programs that target multiple outcomes, such as the arthritis self-management program. While both programs have benefits, comparing them is not clinically appropriate because they are inherently different.
As for disease severity, both the chronic disease and disability literatures reflect good evidence that people with mild disease have less room for improvement in function than those with more severe disease or disability. Of course, for most health conditions, there comes a point where severity offers little room for hope, but this sad state represents only a minority of the older adult population. Reviews that include studies without controlling for the severity of patients’ conditions are obviously misleading. Severely ill or disabled individuals require different treatments that may not be classified as self-management.
Perhaps more important for geriatric HCPs is the clinical utility of the information presented both in this section dedicated to research and the previous section on a conceptual blueprint for change. How does the geriatrician use the information we have presented? Can specific principles and suggestions be proposed to optimize self-management in geriatric medicine?
PRINCIPLES AND SUGGESTIONS FOR INTEGRATING SELF-MANAGEMENT INTO GERIATRIC MEDICINE
Self-management is good medicine. If the huge benefits of these few habits were put into a pill, it would be declared a scientific milestone in the field of medicine. Albert Bandura
Partnerships in Self-Management: A Description and Conceptual Rationale
A central position of this chapter is the importance of establishing partnerships between patients and HCPs. An inherent quality of any effective self-management program is that the patient is an active partner in treatment. This position is supported by the American Medical Association. Their suggestions are clearly outlined in their Physician Resource Guide, an excellent resource for physicians who have any chronic disease patients as part of their practice, specifically older adults. What is actually meant by the term partnership? How does traditional care differ from collaborative care? How do these two approaches influence the approach a HCP should take to patient education?
Traditional Versus Collaborative Patient Care
Bodenheimer and his colleagues have offered an excellent description of traditional and collaborative care paradigms in chronic disease management. Table 28-5 identifies their six key questions about patient care, together with examples based on each of these paradigms. In a traditional medical model, patients take a passive role; while HCPs identify the problem, provide solutions, and expect patients to comply with recommendations and prescriptions. Under this system, noncompliance is viewed as a dysfunctional patient problem. In contrast, when partnerships are established in collaborative care, patients are allowed to define their problems; the patient and HCP share responsibility for the creation of treatment plans; HCPs facilitate and guide treatment; and noncompliance is viewed as a shared problem to be solved. Indeed, in some instances (most obviously involving side effects from pharmacologic therapy) noncompliance may be a wise and rational step, indicating that treatment plans should be modified or expanded.
Table 28-5SIX KEY QUESTIONS ||Download (.pdf) Table 28-5 SIX KEY QUESTIONS
| ||TRADITIONAL CARE ||COLLABORATIVE CARE |
|What is the relationship between patient and health professionals? ||Professionals are the experts who tell patients what to do. Patients are passive. ||Professionals are experts about the disease and patients are experts about their lives. |
|Who is the problem solver? Who is responsible for outcomes? ||The professional. ||The patient and professional share responsibility for solving problems and for outcomes. |
|What is the goal? ||Compliance with instructions. Noncompliance is a personal deficit of the patient. ||The patient and the professional make informed choices and realistic goals. Lack of goal achievement is a problem to be solved by modifying strategies. |
|How is behavior changed? ||External motivation. ||Internal motivation. Through partnerships and HCP encouragement, patients gain understanding and confidence for self-management. |
|How are problems identified? ||By the professional, eg, changing unhealthy behaviors. ||By the patient, eg, pain or inability to function; and by the professional |
|How are problems solved? ||Professionals solve problems for patients. ||Professionals teach problem-solving skills and help patients in solving problems. |
In suggesting that patients be allowed to help to define and solve their problems, we do not mean that they should supplant HCPs as diagnosticians, surgeons, occupational therapists, pharmacists, etc. Likewise, collaboration may not be a viable or realistic option in certain circumstances: for instance, during an emergency procedure or when interpreting test results. However, these circumstances represent only a small portion of total HCP/patient interactions. In regular, day-to-day practice, the patient can be involved in many aspects of chronic disease management.
Listening forms the foundation of collaborative care. HCPs must listen carefully to what patients are saying about their health status and treatment. Consider the example of an older patient in cardiac rehabilitation: While the HCP was primarily focused on his heart health, the patient’s main concern was his impotence. After considerable dialogue, close examination of his medications, and consultation with his cardiologist, his beta-blocker was changed. Within a very brief time, his erections improved, and his entire attitude toward treatment changed. He was now emotionally able and willing to consider how he could prevent further disease. In fact, what motivated him to exercise, take lipid-lowering medication, and watch his diet was the realization that the vessels that served the penis were also subject to atherosclerosis. The benefit of listening to the patient’s concerns and then collaborating on a solution provided huge gains in adherence to the traditional goals of cardiac rehabilitation. This process also contributed to his understanding of the system-wide impact of both disease and adherence on the rehabilitation prescription.
Part of this process includes the tell-back collaborative inquiry where patients describe their understanding of their conditions and treatment, followed by the physician supplying additional information as needed, again followed by the physician inquiring about the patients’ understanding/feelings about the added information. The mutual sharing of information increases understanding. Traditional and collaborative medical care leads to entirely different sets of goals and strategies for patient education. According to Bodenheimer and colleagues, the traditional model is delivered by HCPs and reinforces patients’ need to follow “what the doctor orders.” By contrast, in a partnership model, education is synonymous with the concept of self-management (Table 28-6). Geriatric HCPs are part of a larger network of services, professionals, and advocates that promote the health of older adults. Thus, an important goal of geriatric medicine is to teach patients to leverage resources in their communities and within the health care system. Using such resources enables older adults to reach effective solutions for their current problems—and possibly compress future disability and morbidity into the last few months or years of life. This perspective is at the heart of what the Healthy Aging Research Network concluded in 2006:
Healthy aging is most easily achieved when physical environments and communities are safe and support the adoption and maintenance of attitudes and behavior known to promote health and well-being and by the effective use of health services and community programs to prevent or minimize the impact of acute and chronic disease on function.
Table 28-6CONTRASTS BETWEEN TRADITIONAL AND COLLABORATIVE MEDICINE ||Download (.pdf) Table 28-6 CONTRASTS BETWEEN TRADITIONAL AND COLLABORATIVE MEDICINE
| ||TRADITIONAL PATIENT EDUCATION ||SELF-MANAGEMENT EDUCATION |
|What is taught? ||Information and technical skills about the disease. ||Skills on how to overcome problems. |
|How are problems formulated? ||Problems reflect inadequate control of the disease. ||The patient identifies problems he/she experiences. These may or may not be directly related to the disease. |
|Relation of education to the disease ||Education is disease-specific and focuses on disease information and technical skills. ||Education provides problem-solving skills that are relevant to self-management and reducing the consequences of chronic conditions in general. |
|What is the theory underlying the education? ||Disease-specific knowledge creates behavior change, which in turn produces better clinical outcomes. ||Greater patient confidence (self-efficacy) in their capacity to make life-improving changes yields better clinical outcomes. |
|What is the goal? ||Improved disease management via compliance with the prescribed therapeutic regimen. ||Improved clinical outcomes via increased self-efficacy for adherence behaviors. |
|Who is the educator? ||A health professional. ||A health professional, peer leader, or other patients, often in group settings. |
The Conceptual Importance of Partnerships in Health Care
Partnerships have immense significance to the development and maintenance of effective self-management and health in older adults for several reasons. First, older adults’ commonsense models play a key role in determining health behaviors. For example, consider research by Halm and colleagues on minority, inner-city adults with chronic asthma. More than half of patients believed that they only had asthma when they were experiencing acute symptoms; these individuals were less likely to take corticosteroids and use peak flow meters. In the absence of a partnership between patients and their HCPs, these—and other—commonsense beliefs risk going unnoticed.
Second, the importance of partnerships is also supported by epidemiologic studies indicating that physician advice can strongly enhance older adults’ desire and confidence in their ability to perform specific health behaviors. Third, many older adults choose not to discuss health-related self-care with physicians because they are unsure whether they will approve of what they are doing. Thus, geriatricians are often unaware of whether or not their patients are in counseling, dieting, exercising, or receiving other forms of health-related treatment. A lack of awareness about other treatments may severely compromise the process of disease self-management.
When HCPs engage their older patients as partners in a health care plan, discussions are more likely to be open and mutually enlightening. Finally, through partnerships, HCPs are in a good position to teach patients effective self-regulation of health behavior. Communication and buy-in occur when goals are clearly specified and action plans are articulated, monitored, and evaluated on a regular basis to enhance patients’ motivation and confidence in various treatment regimens.
How do HCPs best promote self-management in the context of their own practices? Are particular target behaviors of interest? The following section describes several fundamental principles that can—and should—be common to chronic disease self-management efforts. In addition, HCPs may wish to consider connecting their patients to inpatient and/or outpatient self-management programs, such as the Arthritis Self-Management Program. In situations where programs aren’t available or accessible, an online or telehealth version may be a potential favorable alternative.
How to Develop a Self-Management Partnership
HCPs can use the contrast noted between traditional and collaborative styles of interaction (see Table 28-5) as a guide to set concrete goals for themselves to establish a consistent model of care with patients and then to formulate plans of action in conducting their practice. If these steps sound familiar, it is because they are identical to those we suggested earlier for patients.
Because HCP/patient interaction is a two-way street, HCPs should also examine their own behavior to ensure that they are contributing to, rather than detracting from, the partnership to promote self-management. The same factors that limit the patient’s contribution to self-management also pose challenges for HCPs trying to stick to their own plans of action to contribute to the partnership’s achievement of goals. For example, consider HCPs’ automatic behavior when meeting with patients. Faced with years of training and experience, HCPs are well-practiced in what questions to ask and what responses are indicative of trouble. Defaulting to autopilot may be an efficient way to “get the job done,” but is not necessarily the same as patient-centered care. As with older adults attempting to break habits, HCPs must become aware of their behaviors and critically assess whether they are listening to patients or simply responding to them. Small, purposeful changes, such as warmly greeting the patient prior to turning to your computer/charts, can have a powerful, positive effect on the relationship as a whole. By definition, partnerships require cooperation between two or more people. An extremely important facet of promoting partnerships in geriatric medicine is enlisting patients’ support and educating them about the skills and commitment required of both parties. Clearly, a major challenge for HCPs is that, in the traditional biomedical model, patients are relatively passive, expecting physicians, nurses, and other HCPs to fix their problems. While health care remains a problem-solving enterprise, the partnership model must (a) identify problems collaboratively; (b) specify options and choose a treatment together; (c) make detailed action plans; and (d) clarify for patients the steps for evaluation, including feedback to the HCP. Communication between HCPs and patients should reinforce the patients’ active role in health care, underscoring diverse behaviors that include adhering to medication regimens, monitoring symptoms, or altering lifestyle behaviors.
Meichenbaum and Turk’s classic text, Facilitating Treatment Adherence: A Practitioner’s Guidebook, offers HCPs the following practical advice to facilitate collaboration in self-management:
Ascertain the patient’s preference for each aspect of the treatment regimen.
Assess the patient’s previous experience with self-management.
Ensure that the patient has the requisite skills and resources for implementation.
Introduce change gradually over the course of several visits, so as to learn together how the patient is doing.
Break complex tasks that require more demanding adherence into actions that can be handled sequentially.
Begin the collaboration with a step that can be readily accomplished to foster immediate patient control and direction.
Enlist support of family or other strong allies.
As the patient assumes an increasing level of self-management, gradually reduce the HCP’s role in order to foster greater patient responsibility.
All of these suggestions imply frequent, ongoing contact with patients—a necessary aspect of managing chronic disease. Physicians and nurses must carefully plan how they use contact time with patients to most efficiently build the collaboration. HCPs could benefit from following the many practical, evidence-based guidelines suggested for a variety of patients to foster treatment adherence. We also suggest the HCP follow the five As (ie, assess, advise, agree, assist, arrange) that the AMA advocates for use in the visits to the physician’s office to develop the self-management process over time. These practical suggestions characterize a physician tip sheet for self-management support and can be learned by all members of a health care team that are in the physicians’ offices and extend to their health care network.
With the exception of smoking, physicians are not aggressive in giving patients advice about lifestyles, despite the profound effect that changes in lifestyle behaviors have in accruing, preventing, and treating chronic disease and disability. For adults aged 65+ who report on their physician’s guidance, only 31.3% are told to get more exercise; 41.5% are given advice to eat more fruits and vegetables; 38.2% are instructed to reduce their dietary fat; 25.5% are told to reduce stress; and 82.8% of current tobacco users are advised to stop smoking. Keep in mind that these eye-opening statistics only concern one of the most prevalent forms of physician behavior—providing advice—not teaching or actively changing patient behavior. The number of older adults who are assisted in self-managing lifestyle behaviors is disappointingly low.
Implementing a Framework for Effective Self-Management
Self-management is heavily influenced by older adults’ commonsense models of health-related problems and treatment options. When they are unclear about the meaning of their symptoms and conditions, they may experience anxiety and/or avoid important self-management behavior. Incorrectly interpreting a symptom as “nothing to worry about—it’s old age” can lead patients to be passive, and they may fail to take action that could prevent downstream morbidity. On the other hand, overreacting to the single occurrence of a symptom may result in overcompensation; for example, resting, when the correct reaction should be increased physical activity. Clarifying and documenting the type, intensity, frequency, and duration of symptoms that older adults are experiencing should be a priority of any practice. These data should be updated on follow-up contact calls or at scheduled visits.
Any diagnosis should also be accompanied by information about both the disease/health state and the patients’ role in managing the health event. Simply asking older adults whether or not they understand the problem they are encountering, and promptly moving on if they say they do, is unadvisable for two reasons. First, they may be embarrassed to admit that they don’t understand common disease states, such as hypertension or diabetes. Second, even if patients think they understand a specific diagnosis, components of their commonsense models may well be in error (see Figure 28-1) and detract from adherence to recommended and agreed-upon action. HCPs discussing self-management with older adults in relation to these diagnoses can underscore the importance of their partnership, using it as a platform for mutual understanding (a) to set concrete goals in specific areas, (b) to establish action plans, and (c) to discuss the importance and means of providing feedback about these action plans (see Table 28-2). For these latter three steps, we refer the reader to an easy-to-use tool: the Ultra-Brief Personal Action Plan, outlined in the appendix of the AMA’s Physician Resource Guide. This tip sheet outlines five straightforward elements that address the specifics of planning and provide a good beginning for the patient and HCP to work together. The plan also uses patient self-efficacy to complete the action plan as an initial marker of whether the plan should be modified and it engages the patient in ways to adjust the plan so they have joint ownership of it, thereby encouraging the likelihood of greater adherence.
Once the HCP is assured that patients are getting the idea of self-management and are actively participating in it, HCPs should be able to link their older patients to resources in either their own network or the community that might be valuable in managing their health states. For example, someone who is obese and has elevated glucose should be referred for weight loss. Referrals should be proactive when possible; that is, if patients are receptive, HCPs should arrange the initial contact with resource personnel. They must also be aware of whether or not patients have the economic means, time, and transportation required to take advantage of the proposed resources. Taking time to match and plan greatly increases the likelihood that older adults will follow up on recommendations. Once enrolled, HCPs must monitor patients’ progress with outpatient programs if they really are to function as active partners in self-management.
Targets for Self-Management: General Practices
HCPs must specify behavioral targets and have concrete goals for self-management that patients can understand and accomplish. For example, a number of screening behaviors should be a part of every geriatric practice. These include colon screens, breast examinations, skin cancer screening, prostate examinations, bone mineral density, and physical disability. Without having specific action plans in place to ensure participation in these screenings, adherence rates will suffer. Here are some suggestions, based on the framework we proposed earlier:
Underscore the threat of electing not to be screened.
Educate the patient on what the screening involves, such as details of the procedure, whether it is/isn’t painful, and any potential side effects. Combined with Step 1, aim to highlight why screening is important (eg, early detection), while reducing fear of the screening procedure itself.
Schedule visits for patients, as opposed to simply suggesting that screening be completed.
Systematically monitor screening tests for each patient and be certain that feedback is provided immediately.
Schedule follow-up visits immediately when test scores are abnormal.
Display rates of participation in screening tests by patients in your practice in highly visible areas. Set goals of 100% participation.
With older adults, take time to evaluate and to advise on lifestyle health behaviors, such as (a) caloric consumption, (b) healthy eating practices, (c) smoking behavior, (d) level of physical activity, and (e) depression/anxiety. An efficient way to do this is asking patients to complete a basic lifestyle self-report questionnaire prior to their appointment (eg, while in the waiting room). If electronic, results, scored by computer, can provide a clearer picture for both partners, and build the foundation for ongoing interaction that effective self-management requires.
How HCPs summarize and communicate patients’ health status can have powerful repercussions on self-management. Simply telling the patient, “You seem to be doing fine,” might be well intended, but it lacks clarity and may be deceiving. For example, when older adults have two comorbidities, they are at risk for future decline in functional independence. If they consider this risk normative, and the HCP says they “seem to be doing fine,” they may not try to do anything to improve their condition; in fact, they may conclude that they are overreacting. Feedback and guidance must be specific for individuals to understand their health status. General, nonspecific feedback can unintentionally reinforce a counterproductive commonsense model of older adults’ health status.
Targets for Self-Management: Assessing and Acting on Physical Disability
Because the loss of mobility is such a catastrophic health event for older adults, we feel strongly that every office visit should include a brief assessment of physical function with specific recommendations promoting active lifestyles. Such programs have preventive value not only for mobility loss but in managing multiple health problems. According to data from the Centers for Disease Control and Prevention (CDC), physicians ask 56.6% of 65- to 79-year-old adults about their level of physical activity, but only ask 38.9% of those age 80 or older—an apparent age bias. Even more disappointing is the fact that physicians only give 12.6% of adults aged 65+ assistance in structuring an exercise program; when assistance is given, no information is provided on how to successfully self-manage it, and systematic follow-up is very poor. Physicians report that they do not counsel patients because they lack practical tools, time, reimbursement, and confidence that counseling will trigger behavior change essential to the self-management process.
Fortunately, there are some simple tools for assessing physical capacities of older adults. One is the SPPB, developed by Dr. Jack Guralnik and his colleagues at the National Institute of Aging. It takes about 10 minutes to complete, can be easily conducted by a nurse or trained volunteer, and only involves three tasks: walking 4 m (13 ft), completing a simple chair-sitting exercise, and performing two very brief static balance tests. As shown in Table 28-7, scores on each test range from 0 to 4—total scores range from 0 to 12—with a higher score indicating better function. This test has been shown to predict both morbidity and rates of nursing home admissions.
Table 28-7THE SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) ||Download (.pdf) Table 28-7 THE SHORT PHYSICAL PERFORMANCE BATTERY (SPPB)
|COMPONENT ||SCORE ||TASK |
|Balance tests || |
0—unable to hold for 10 s
1—held for 10 s
|Side-by-side stand—participant stands with feet side by side and attempts to hold for 10 s without moving feet. |
| || |
0—unable to hold for 10 s
1—held for 10 s
|Semi-tandem stand—participant stands with one side of heel touching the big toe of the other foot and attempts to hold for 10 s without moving feet. |
| || |
0—held for < 3 s
1—held for 3–9 s
2—held for 10 s
|Tandem stand—participant stands with one heel directly in front of toes of other foot and attempts to hold for 10 s without moving feet. |
|Gait speed test || |
Range of 0–4, where:
0—unable to do the walk
4—took < 4.82 s
|Participant walks 4 m at their usual pace while a HCP times them with stopwatch. |
|Chair stand test ||If the patient cannot complete the task, end the test here. If they can do it, move to repeated chair stand test. ||Participant folds arms across chest while sitting in a chair, and then attempts to stand up without use of arms. |
|Repeated chair stand test || |
Range of 0–4, where:
0—cannot perform 5 in a row or took longer than 60 s
4—performed 5 in < 11.19 s
|Participant folds arms across chest while sitting in a chair and attempts to stand up and sit back down as quickly as possible. |
|SPPB Score: ||Range: between 0 and 12. || |
Our own research has found that SPPB test results have a motivational effect on older adults. Given this specific feedback, they are more responsive to receiving and seeking information about remedial physical activity to enhance their basic performance. Fortunately, an increasing number of community-based programs offer physical activity for seniors. Also, physical therapy referrals are valuable for patients who have severe deficits in balance or lower-leg strength. Physical therapy generally helps to improve function in older adults who have physical limitations. Improvement is sustained through supportive resources in the community when older adults subsequently participate in structured physical activity programs. Note that the SPPB was not designed to assess functioning in more-fit individuals; other tests are more appropriate for them. Also, whereas clinicians often argue that they have neither the time, space, nor staff to administer performance-based tests of function such as the SPBB, we have developed an innovative, computer-animated, self-report test of mobility that can be completed on an iPad is just 3 to 5 minutes—the mobility assessment tool-short form (MAT-sf;). It has excellent clinical utility as demonstrated by several recent publications.
Following from the feedback given through the SPPB or the MAT-sf, a companion suggestion, is to have older adults engage in a highly specific action plan, that they are willing to do themselves and that they are reasonably confident they can carry out by a certain date. Once again we refer the reader to The Ultra-Brief Personal Action Planning Tool from the AMA’s Physician Resource Guide. It is useful and provides opportunity for the HCP to interact with the older adult. Together, they develop a simple and specific action plan that is achievable and enhances the self-management mastery so necessary for older adults to gain confidence with self-management. The tool builds on the plan by (1) assessing the older adult’s confidence in carrying it out; (2) adapting the plan by problem solving and using other strategies and supports to increase the person’s confidence in execution; and (3) arranging a follow-up HCP visit so both patient and HCP can evaluate plan progress.
This section on implementation should make clear that optimal self-management can only be attained if both partners adhere to its collaborative practices. This means that the person with chronic conditions must be engaged in and adherent to self-management behaviors and providers must be engaged in and adherent to the practice of helping this person increase their self-management capacity. As a closing guide, we offer additional practical suggestions on how to maintain adherence from the classic textbook by Meichenbaum and Turk.
Anticipate nonadherence: There are variety of reasons for nonadherence; some of which neither the HCP nor the patient can control. Do not treat it as a sign of failure on your part or typecast older adults who struggle with self-management as nonadherers. Either response is destructive to the process of mutual problem solving.
Consider self-management from the patient’s perspective and establish a collaborative relationship: Carefully study the inhibitory factors discussed earlier in this chapter. Understanding them can lead to a renewed appreciation of the challenges that patients face and result in renegotiating more realistic self-management goals. Meichenbaum and Turk remind us that “An acceptable regimen that is carried out appropriately is better than an ideal one that is ignored”.
Be patient-oriented: HCPs should gain knowledge of their patients’ commonsense understanding of their disease or functional problem and the proposed treatment. Listen carefully to what patients say and to what they do not say. For example, are patients really not listening when they say nothing? Perhaps they are embarrassed about their lack of understanding. In addition to clear instruction from the HCP, patients should articulate their understanding of what the HCP said.
Customize treatment: When an older adult has a chronic problem, a reasonable question is whether standard treatment really exists. As part of self-management, the HCP must be prepared to work with the patient to adjust and to modify standard protocols. Needs vary from person to person. Frail people, the cognitively impaired, or those with language or educational barriers may need additional supports within the health care system to encourage/facilitate their self-management. Self-management cannot be a one-size-fits-all goal.
Use family or significant other support: Because other people can facilitate or hinder older adults’ self-management, family and/or significant others must be included in the health care partnership. They should understand the chronic disease, the nature of the treatment, and the goals of self-management. The obvious benefit is their support for the approach being taken without eliminating or blocking the older adults’ role in the self-management process. Assess what these “providers” are doing to help the older adult be more engaged in their self-management.
Provide accessibility and continuity of care: If patients find difficulty gaining access to HCPs, if your staff do not show the same interest and care as you, and if you do not draw on other HCPs and community programs that could assist in treatment (eg, psychosocial specialists for depression, exercise rehabilitation specialists for older adults), self-management has a greater risk of failure. Developing an integrated, highly communicative group of HCPs is essential for effective self-management. Older adults are likely to need acute care as well as community care. They move in and out of different parts of the system. Keeping track of these movements provides opportunity for continuity of care as well as an informed health care team and informed older adults.
Repeat everything, and don’t give up: Intervention research in a variety of areas suggests that for chronic problems, patients must be “reinoculated.” Long-term maintenance requires repeating education and behavioral practice about treatment regimens and modifying the self-management approach to counter declines or lapses in adherence.
Building on the suggestions of points 5 to 7 specifically, progressive HCPs whose practice serves a geriatric population with its higher incidence of chronic disease may improve their practices. They can assess their resources and evaluate their available support for chronic disease self-management. Once again we refer the reader to the AMA’s Physician Resource Guide. The appendix for this guide includes a tool that is useful for assessment of primary care resources and supports for chronic disease self-management. The tool suggests two categories of assessment: patient support and organizational support. Guidance is provided on how to score HCPs’ primary care resources to determine adequacy as well as identify areas for improvement. The tool is designed to be used for immediate feedback and also for comparison to ensure quality is sustained and identified need for improvement of areas is addressed.
RA. Mindfulness-Based Treatment Approaches: Clinician’s Guide to Evidence Base and Applications. New York, NY: Academic Press; 2006.
A. Health promotion by social cognitive means. Health Educ Behav
WT. Social cognitive changes following weight loss and physical activity interventions in obese, older adults in poor cardiovascular health. Ann Behav Med
NA. Evaluation of health promotion programs for older adults: an introduction. J Appl Gerontol. 2006;25:197.
H. The Self-Regulation of Health and Illness Behavior. New York, NY: Routledge; 2003.
et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med
NM. Management of chronic disease by patients. Annu Rev Public Health
et al. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med
BM. Efficacy of a self-management group intervention for older adult persons with chronic pain. Clin J Pain
WT. Group-mediated activity counseling and traditional exercise therapy programs: effects on health-related quality of life among older adults in cardiac rehabilitation. Ann Behav Med
RC. Physician advice and support for physical activity. Am J Prev Med
H. No symptoms, no asthma: the acute episodic disease belief is associated with poor self-management among inner-city adults with persistent asthma. Chest
et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation
B. Making healthy choices easy choices: the role of empowerment. Eur J Clin Nutr
H. Arthritis self-management studies: a twelve-year review. Health Educ Q
HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med
P. Self-regulation assessment and intervention in physical health and illness: a review. Appl Psychol. 2005;54:267.
DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. New York, NY: Plenum; 1987.
R. Challenging aging stereotypes: Strategies for creating a more active society. Am J Prev Med. 2003;25(3):164–171.
et al. Effects of a physical activity intervention on measures of physical performance: results of the lifestyle interventions and independence for elders pilot (LIFE-P) study. J Gerontol A Biol Sci Med Sci. 2006;61(11):1157–1165.
WL. Physical activity: preventing physical disablement in older adults. Am J Prev Med
. 2003;25(suppl 2):107–109.
RT. Development and validation of a video-animated tool for assessing mobility. J Gerontol A Biol Sci Med Sci
et al. The lifestyle interventions and independence for elders pilot (LIFE-P): 2-year follow-up. J Gerontol A Biol Sci Med Sci
MA. The development and psychometric analyses of ADEPT: an instrument for assessing the interactions between doctors and their older adult patients. Ann Behav Med
DH. Arthritis self-management education programs: a meta-analysis of the effect on pain and disability. Arthritis Rheum