CARE OF THE OLDER PERSON
Supporting behaviour change in older people with type 2 diabetes Ali Tomlin, Koula Asimakopoulou
Ali Tomlin is Post-Doctoral Fellow, Institute of Diabetes for Older People, Bedfordshire and Hertfordshire Postgraduate Medical School, University of Bedfordshire, Luton; Koula Asimakopoulou is Senior Lecturer in Health Psychology, Unit of Social and Behavioural Sciences, Dental Institute, King’s College London Email: [email protected]
Self-management Type 2 diabetes is often seen in people with a family history of the illness, in people who are obese, in South Asian populations and in areas of deprivation. In all cases, diabetes requires active self-management in order to avoid complications such as retinopathy, nephropathy and cardiovascular disease. The aim of self-management behaviours is lifestyle change, where it is expected that changes will be made to people’s diet, physical activity levels and medication-taking regimens with the aim of achieving tight glycaemic control (Diabetes UK, 2013). It is now widely accepted as a result of the UK Prospective Diabetes Study (UKPDS) findings (American Diabetes Association, 2002) that tight glycaemic control adjusted for individual circumstances (Royal College of General Practitioners Effective Clinical Practice Programme, 2002) is reliably linked with reduced morbidity and mortality. As such, it is one of the cornerstones of diabetes management.
ABSTRACT
This article examines current research on behaviour change in relation to supporting older adults with type 2 diabetes in the community. It outlines the different areas of self-care that older adults with diabetes engage in, argues for the need for behaviour change intervention in adults with the illness and discusses the complexities of diabetes self-care regimens, with particular focus on older adults. A review of current scientific thinking about eliciting behaviour change in areas such as diet, physical activity and medication taking is undertaken. The article concludes with a set of practical recommendations for community health professionals.
KEY WORDS
w Type 2 diabetes w Behaviour change w Self-care w Self-management
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In older people the picture is more complicated (Wagner, 1998). Efforts to self-manage the illness may be compromised by other comorbidities (such as depression or problems that make mobility and exercise difficult), cognitive impairment and, importantly, the need to abandon habits built over a lifetime for new, often difficult, changes in everyday behaviours. An individual approach is key to balancing the need for tight glycaemic control and the risk of hypoglycaemic events in frailer, older individuals who may be more vulnerable to falls and the effects of falls. In this spirit a proposal was made recently to treat the person with diabetes rather than the A1c (McLaren et al, 2013).
Self-care behaviours at home Alongside any medication, self-care is key to the successful management of diabetes, the prevention or delay of diabetesrelated complications, and the maintenance of a good quality of life (Beverly et al, 2013). There is strong evidence to show that self-care, particularly self-care supported by health professionals, peers, family and friends, creates real benefits for people with diabetes, including better glycaemic control (Gao et al, 2013), delayed or fewer complications, and better quality of life (Shrivastava et al, 2013). At diagnosis, people with diabetes are met with an oftenbewildering array of daily tasks and challenges to overcome in order to self-care successfully. Self-management requires education, confidence, motivation, and problem-solving ability in order to apply newly learned behaviours and adopt beneficial coping strategies (American Association of Diabetes Educators, 2011). Such behaviours must be regular and ongoing. At home, people with diabetes must manage food, activity and exercise, monitor blood sugar where appropriate, manage medications, confront diabetes-related problems, strategise to reduce risks, and maintain healthy coping behaviours in the face of daily challenges. Such self-care activities must be carried out several times a day, every day, requiring attention, strategy and planning. Regular meals must be appropriately nutritionally balanced, and this process must start with educated and planned choices made while shopping for food. Cooking at home for guests, and choices made while eating outside the home must also reflect good self-care plans. Those who are prescribed insulin also face the challenge of incorporating medication regimens with food intake (carbohydrate counting), and integrating both with maintaining
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he number of older people with type 2 diabetes is rising, reflecting increases in the prevalent rates of obesity in Western countries and also the ageing population. In 2011, Diabetes UK reported an estimate of just under 3 million people being diagnosed with diabetes in the UK. This figure expected to rise to 5 million by 2025 (Diabetes UK, 2013). Although there are many older people with type 1 diabetes, given that the vast majority of older adults have type 2 diabetes, this article is focuses on the latter patient population.
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CARE OF THE OLDER PERSON or increasing activity levels. Diabetes-related problems will often arise depending on social scenarios and circumstances. Successful self-management often relies on forward-planning, problem-solving ability, maintaining levels of motivation to self-manage and building strategies to beat stress and facilitate healthy ways of coping. Such strategising and planning is most successful when it is personalised (NHS Primary Care Commissioning, 2009). Individual circumstances, preferences, cultures, skills, abilities and available options must all be taken into account when considering how best to self-care. Factors both within and outside the individual can have great impact on self-care success; social context should not be regarded as either a barrier or an aid to self-management (Rosland et al, 2010). Supported self-management can include such personalised planning, and goal setting, as well as advice and understanding from peers, family and friends (Diabetes UK, 2009).
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Self-care in older adults Older adults can experience additional challenges to successful self-care (Bai et al, 2009). The myriad daily tasks of diabetes self-management require significant cognitive input, particularly in planning, problem-solving, and memory. Mild cognitive impairment has been associated with diabetes, particularly in those who are older or who have had diabetes for longer (Cukierman et al, 2005; Kumari and Marmot, 2005). Specific domains of cognition associated with diabetes include executive function, memory and psychomotor control (Ryan and Geckle, 2000; Asimakopoulou et al, 2002; Arvanitakis et al, 2006; Thabit et al, 2012). These cognitive abilities have considerable self-management significance. Impaired executive function confers poorer planning and problem solving skills, which could affect all areas of self-care, from meal preparation to stress-reduction strategies. Good memory is required for the management of medication, making and keeping health-care appointments, maintaining vigilance behaviours such as foot checking, and monitoring blood glucose levels. Poorer psychomotor control may make insulin administration more difficult. Furthermore, self-care behaviours must be learned and practised. In order to be most successful they must also be supported. Peers, friends and family are often a good source of support for those faced with the burden of diabetes self-care (Bai et al, 2009), but as people age they often face decreasing levels of social interaction and increasing isolation (Carstensen, 1992). People with diabetes are also at greater risk of experiencing depression, which may be compounded by social isolation. Social isolation and depression have both independently been associated with poorer self-management care (Tomaka et al, 2006; Anderson et al, 2001), and may combine to further influence self-care. Physical factors that may be associated with ageing such as increased frailty, reduced mobility, disability and the presence of comorbidities may make introducing or increasing exercise or activity more difficult (Lawton et al, 2006). Essential areas of care such as checking feet may also be hindered by physical factors (Plummer and Albert, 1996).
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A combination of the additional barriers that older adults with diabetes may face in their self-management may decrease overall motivation to self-care (Schoenberg et al, 2008).
Self-care as part of a behaviourchange programme Success with one area of self-care is often unrelated to success with other areas (Glasgow et al, 1989). In terms of medication, non-adherence in people with diabetes has a fairly high prevalence, with adherence with insulin regimens reported to be around 63% in adults with type 2 diabetes (Cramer, 2004). Furthermore, polypharmacy regimens reduce compliance with medications, with an inverse relationship being observed between number of medications prescribed and compliance rates (Claxton et al, 2001). In terms of dietary self-care, physical activity recommendations and blood glucose testing— notwithstanding the difficulties inherent in assessing these behaviours and the variability in self-care plans—it has been roughly estimated that non-adherence is around 60%, with the exception of physical activity, where non-adherence can be as high as 80% (World Health Organization (WHO), 2003). Due to the apparent poor rates of diabetes self-care plans being followed through, it is suggested that dedicated interventions focusing on behaviour change may be necessary in order to help older adults to self-care.
Behaviour change There is a large amount of psychological literature on the subject of behaviour change, starting from the basic principle that behaviour change consists of three interrelated components as seen in the COM-B model (Michie and West, 2012) (Figure 1). These are as follows: w Capability (C), e.g. the person having the physical and psychological skills to administer an insulin injection w Opportunity (O), e.g. the physical and social environment being such that the person feels able to e.g. administer an insulin injection w Motivation (M), which refers to the person’s conscious (i.e. planning) and automatic (i.e. drives and habits) processes said to underline the emission of any behaviour. It has been argued that for most people motivation may be the most problematic of these three concepts (Michie and West, 2012). However, it is proposed that older people are likely to have issues with capability and opportunity too, so these would need to be checked carefully for each area of the regimen. Assuming that the person has the capability and the opportunity to look after themselves, it has been suggested that motivation is the next most plausible candidate for causing people difficulties with their attempts to follow through with health-behaviour change. It is beyond the scope of this article to fully outline theories of motivation, but PRIME theory (where PRIME stands for ‘plans’, ‘responses’, ‘impulses’, ‘motives’ and ‘evaluations’) may be useful here (West, 2006) (Figure 2). PRIME theory broadly argues that people generally act in pursuit of their most basic needs/wants at that particular moment. People’s beliefs about what is good or bad and any
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CARE OF THE OLDER PERSON lying belief that this medication regimen does not suit), or it could be down to unintentional non-adherence (due to, for example, lack of knowledge, skills and confidence to administer the insulin injection). To understand how to help support behaviour change, one needs to have a sufficient understanding of the factors maintaining the unhealthy behaviour. Once these have been noted, a process of matching the appropriate BCT to the target behaviour can take place.
Capability
Motivation
Behaviour
Available BCTs and their effectiveness
Figure 1. The COM-B model (Michie and West, 2012). Internal and external environment
Pre-formed plans
Beliefs about positive and negative attributes
Reflective
Strongest of competing wants and needs
Strongest of competing impulses and counter impulses
Responses
Automatic
Figure 2. PRIME theory outline (West, 2006).
plans/goal-setting will only influence their immediate actions if they generate sufficiently powerful, identity-driven wants or needs that can overcome competing automatic wants or needs arising from more direct sources such as past associations and habits. For example, where an older person with diabetes is seeking to make the healthy choice at a restaurant and reject the high-fat dessert for the low-fat option, this will only occur where their need to satisfy the craving for high-fat food is replaced by a fresh, new-identity-fuelled need, to be seen as a person making healthy choices in their old age. It should be obvious that in the case of the older person with diabetes, eating habits, which have been built up over a lifetime are thus likely to be resistant to change. Physical activity targets are also likely to interfere with an age-generated preference for a sedentary lifestyle for some. Medication-taking, especially where this is a new, added task, will also require support in changing it from a newly designed plan to a habitual response. In order to be able to support people with behaviour change by intervening in their everyday behaviours, it has been shown that one needs to match the most appropriate behaviour-change technique (BCT) with the current, undesirable, behaviour pattern (Michie et al, 2011a). Key to this process is an understanding of what fuels, for example, unhealthy eating, reluctance to take up exercise or medication non-adherence. Careful, individualised analysis of current, poor self-care patterns will be required here. It follows that a person’s non-adherence with insulin injections, for example, could be because of intentional non-adherence (because of their under-
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The result of intensive, expert work on reaching a consensus on what constitutes a specific BCT and how one differs from another (Michie et al, 2013) has led to developments such as the Coventry, Aberdeen, London-Refined (CALO-RE) Taxonomy (Michie et al, 2011b) and the Behaviour Change Wheel (Michie et al, 2011a). The former is a set of BCTs specifically designed to support people in following a healthy diet and engaging in physical activity. This, and the Behaviour Change Wheel (Michie et al, 2011a), which considers a framework of BCTs (see Table 1) and wider societal policies (Table 2), are currently the most up-to-date tools available to health-care professionals wishing to assist adults with behaviour change. Although these tools have not been designed with older adults in mind, the section below attempts to place them in a perspective that might be applicable to older adults.
Behaviour change in older adults with diabetes In terms of supporting behaviour change in older people with diabetes, the three basic areas of the self-care regimen (medication-taking, dietary and physical activity self-care) need to be considered separately given the independence of each in terms of adherence rates (Glasgow et al, 1989).
Specifying behaviours to address The first issue to be considered is how many behaviours health professionals working with older adults should seek to address. For example, where a person with diabetes has difficulties with following a healthy diet and with physical activity and with following through their medication regimen, should one undertake behaviour change in all three areas or one at a time? Some literature suggests that interventions targeting both dietary and physical activity changes rather than only one of these behaviours produces better outcomes, such as weight loss (Greaves et al, 2011). However, at the same time, a recent systematic review examining behaviour-change interventions specifically in older adults (Nigg and Long, 2012) concluded that older adults ‘respond well to behaviourchange interventions delivered one behaviour at a time’.
Selecting an area for change Assuming that one area of the self-care regimen among many is selected for change, the next issue to be addressed is which area to select. This is best decided by bearing in mind the overall approach under which diabetes is managed. Assuming a patient-centred, choice-supporting approach, which has long been advocated in the field (Asimakopoulou, 2007; Asimakopoulou et al, 2011; Asimakopoulou and Scambler,
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Opportunity
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CARE OF THE OLDER PERSON 2013), the choice of self-care area to be supported first should be the result of a patient-centred conversation about which area the patient feels they wish to tackle. Gentle guidance by the health professional to ensure that the behaviour targeted is not too ambitious and likely to lead to failure may be required in such situations. The remainder of this section considers each of the main diabetes self-care areas and reviews the literature suggesting which BCT appears best suited for each one of the broad areas of diabetes self-care. This is only generic guidance and obviously, individual circumstances will influence the extent to which these are applied in practice.
Diet
In a recent systematic review of systematic reviews of interventions aimed to enhance healthy dietary behaviours, usually with a weight loss target, Greaves et al (2011) showed that giving dietary advice in the absence of a behavioural support technique was not as effective as supporting people behaviourally in addition to offering dietary advice. In particular, enlisting the social support of family members, establishing self-monitoring of dietary behaviour, and use of relapse-prevention techniques were effective BCTs to support dietary changes once these had been initiated succesfully. BCTs aimed to encourage self-talk were effective in helping people maintain dietary changes. Furthermore, high-intensity interventions, i.e those including more than one BCT, more contact time or a longer duration were found to be more effective, with a positive relationship found between dietary change at 12 months and the number of patient–health professional contacts. The same review concluded that targeting both dietary and physical activity changes at the same time was more effective than targeting single behaviours. However, this conclusion needs to be generalised with caution given that the review did not focus on older adults.
Table 1. Behaviour Change Wheel techniques Level within Behaviour Change Wheel
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Examples
Education
Increasing knowledge or understanding
Providing information to promote healthy eating
Persuasion
Using communication to induce positive or negative feelings or stimulate action
Using imagery to motivate increases in physical activity
Incentivisation
Creating expectation of reward
Using vouchers to motivate smoking cessation
Coercion
Creating expectation of punishment or cost
Raising the financial cost to reduce excessive alcohol consumption
Training
Imparting skills
Advanced driver training to increase safe driving
Restriction
Using rules reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing behaviours
Prohibiting sales of solvents to people under 18 to reduce use for intoxification
Environment restructuring
Changing the physical or social context
Providing on-screen prompts for GPs to ask about smoking behaviour
Modelling
Providing an example for people to aspire to or imitate
Using TV drama scenes involving safe-sex practices to increase condom use
Enablement
Increasing means/ reducing barriers to increase capability beyond education and training
Behavioural support for smoking cessation medication for cognitive deficits, surgery to reduce obesity, prostheses to promote physical activity
Physical activity In terms of physical activity, reviews have considered BCTs for healthy, non-obese (Williams and French, 2011) and obese individuals (Olander et al, 2013). For healthy adults, action planning (i.e. detailed planning of what the person will do, when and where), providing instruction on how to perform the behaviour and reinforcing their effort or progress towards the behaviour were seen to be associated with increases not only in physical activity but also in people’s belief that they could engage in physical activity, i.e. their self-efficacy. The latter technique was also seen to be helpful in the review of interventions with obese individuals (Olander et al, 2013). Obese individuals attempting to enhance their physical activity also benefitted from interventions such as keeping a record of measures influenced by the physical activity (e.g. physical fitness/blood pressure), planning on ways to elicit social support to help them with the change in their physical activity levels, being taught to identify environmental prompts used to remind them to engage in physical activity and, finally, identifying prompts to rehearse and repeat the physical activity numerous times. Neither of these reviews examined older adults with diabetes in particular, so their findings would need to be adapt-
Definition of intervention/policy
Source: Michie and West, 2012
ed to the life of an older adult coping with several diabetes regimen demands. Trials specifically aimed at testing these BCTs on older adults with diabetes are therefore necessary.
Medication-taking In terms of interventions aimed at enhancing adherence with medication-taking, a systematic review examining interventions designed to enhance medication adherence in people with chronic medical conditions (Kripalani et al, 2007) concluded that decreasing dosing demands was by far the best way to enhance adherence with medication-taking. This is likely to be a challenge, however, in diabetes regimens where
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CARE OF THE OLDER PERSON
Level within Behaviour Change Wheel
Definition of intervention/policy
Examples
Communication/ marketing
Using print, electtronic, telephonic or broadcast media
Conducting mass media campaigns
Guidelines
Creating documents that recommend or mandate practice. This includes all changes to service provision
Producing and disseminating treatment controls
Fiscal
Using the tax system to reduce or increase the financial cost
Increasing duty or increasing anti-smuggling activities
Regulation
Establishing rules or principles of behaviour or practice
Establishing voluntary agreements on advertising
Legislation
Making or changing laws
Prohibiting sale or use
Environmental/ social planning
Designing and/ or controlling the physical or social environment
‘Traffic-calming’ measures; use of prompts and reminders
Service provision
Delivering a service
Establishing support services in workplaces, communities etc
Source: Michie and West, 2012
Box 1. Practical suggestions for supporting older adults with diabetes at home w Check education needs are met w Make personalised care plans and set goals w Make periodic contact to maintain motivation w Consider setting up peer-support groups, especially for the more isolated w Consider online support for those with less mobility w Check for cognitive impairment w Check for depression age and diabetes duration are related to polypharmacy rather than dose reduction. For this reason, one should consider behavioural interventions. The same review concluded that behavioural interventions involving increased contact with health professionals, patient monitoring, feedback and reinforcement are helpful for enhancing medication adherence in this group of adults. Interestingly, although medication adherence appears to improve with these interventions, any improvement seen in clinical outcomes was not proportionate to improvements in adherence (Kripalani et al, 2007). The discussion of research in this area would seem to suggest that different areas of the diabetes regimen may
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require and possibly benefit from different BCTs in order to best support older adults with diabetes.
Practical suggestions for health professionals supporting older adults at home Some practical suggestions for health professionals supporting older adults at home have been summarised in Box 1. A first step towards supporting older adults at home in their diabetes self-care may be to confirm that any educational needs are met. Diabetes education may not have been received for some time and individual needs may change over time. Although many formalised packages of education are available, those tailored to older adults may be more effective in this group, or some patients may benefit further from individualised education in specific areas (Sperl-Hillen et al, 2013). Such an approach would ensure that the capability aspect of the COM-B model was addressed. Personalised care planning between patients and nurses is important, and goal setting, among other techniques, has been shown to positively influence the frequency and outcomes of some areas of self-care (Langford et al, 2007). Regular or periodic contact from health professionals will help to support self-management in an older group in most diabetes self-care areas (de Silva, 2011). Notwithstanding the importance of human contact seen in research described earlier, several studies have evaluated the efficacy of telephonic support and have found mixed evidence for its success in aiding self-care (Krishna and Boren, 2008). Web-based support and interventions have been evaluated in older adults, with some studies finding clear benefits for diabetes selfmanagement, although others have highlighted the decreased likelihood of this group having computer resources or proficiency (Ralston et al, 2004). A personalised approach here could identify those individuals who would benefit from online resources. Encouraging peer-group support may be of particular use in a group that is at greater risk of social isolation, increasing motivation to self-manage (Heisler, 2007). Although healthcare professionals working in the community may face additional challenges of resources for group support, and issues of mobility in an older population with diabetes may affect attendance, peer-group support has been shown to be effective for older adults with diabetes (Heisler, 2007). For those able to access internet resources, peer-group support online may be a possibility (Eysenbach et al, 2004). Finally, when considering the particular challenges older adults face, health professionals working in the community may also wish to consider issues of cognitive impairment, and of depression. Quick and simple tests are available to assess cognition and depression in an older population (Borson et al, 2000; Marc et al, 2008). Identifying those in these groups would allow community nurses to direct their support for self-care on an individual, personalised basis.
Conclusion It is important that personalised, evidence-based behaviourchange support is offered to older adults with diabetes self-
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Table 2. Behaviour Change Wheel techniques
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CARE OF THE OLDER PERSON
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KEY POINTS
w Supporting older adults with diabetes self-care at home is a challenge due to the complexity of the self-care regimen, the additional needs of older people and the adverse effects that tight glycaemic control may have in this group w A single behaviour at a time (rather than many) should be targeted for behaviour change in older adults w There are multiple behaviour-change techniques available but one size does not fit all; different areas of the regimen are likely to benefit from the application of different techniques
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Supporting behaviour change in older people with type 2 diabetes Ali Tomlin, Koula Asimakopoulou
Ali Tomlin is Post-Doctoral Fellow, Institute of Diabetes for Older People, Bedfordshire and Hertfordshire Postgraduate Medical School, University of Bedfordshire, Luton; Koula Asimakopoulou is Senior Lecturer in Health Psychology, Unit of Social and Behavioural Sciences, Dental Institute, King’s College London Email: [email protected]
Self-management Type 2 diabetes is often seen in people with a family history of the illness, in people who are obese, in South Asian populations and in areas of deprivation. In all cases, diabetes requires active self-management in order to avoid complications such as retinopathy, nephropathy and cardiovascular disease. The aim of self-management behaviours is lifestyle change, where it is expected that changes will be made to people’s diet, physical activity levels and medication-taking regimens with the aim of achieving tight glycaemic control (Diabetes UK, 2013). It is now widely accepted as a result of the UK Prospective Diabetes Study (UKPDS) findings (American Diabetes Association, 2002) that tight glycaemic control adjusted for individual circumstances (Royal College of General Practitioners Effective Clinical Practice Programme, 2002) is reliably linked with reduced morbidity and mortality. As such, it is one of the cornerstones of diabetes management.
ABSTRACT
This article examines current research on behaviour change in relation to supporting older adults with type 2 diabetes in the community. It outlines the different areas of self-care that older adults with diabetes engage in, argues for the need for behaviour change intervention in adults with the illness and discusses the complexities of diabetes self-care regimens, with particular focus on older adults. A review of current scientific thinking about eliciting behaviour change in areas such as diet, physical activity and medication taking is undertaken. The article concludes with a set of practical recommendations for community health professionals.
KEY WORDS
w Type 2 diabetes w Behaviour change w Self-care w Self-management
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In older people the picture is more complicated (Wagner, 1998). Efforts to self-manage the illness may be compromised by other comorbidities (such as depression or problems that make mobility and exercise difficult), cognitive impairment and, importantly, the need to abandon habits built over a lifetime for new, often difficult, changes in everyday behaviours. An individual approach is key to balancing the need for tight glycaemic control and the risk of hypoglycaemic events in frailer, older individuals who may be more vulnerable to falls and the effects of falls. In this spirit a proposal was made recently to treat the person with diabetes rather than the A1c (McLaren et al, 2013).
Self-care behaviours at home Alongside any medication, self-care is key to the successful management of diabetes, the prevention or delay of diabetesrelated complications, and the maintenance of a good quality of life (Beverly et al, 2013). There is strong evidence to show that self-care, particularly self-care supported by health professionals, peers, family and friends, creates real benefits for people with diabetes, including better glycaemic control (Gao et al, 2013), delayed or fewer complications, and better quality of life (Shrivastava et al, 2013). At diagnosis, people with diabetes are met with an oftenbewildering array of daily tasks and challenges to overcome in order to self-care successfully. Self-management requires education, confidence, motivation, and problem-solving ability in order to apply newly learned behaviours and adopt beneficial coping strategies (American Association of Diabetes Educators, 2011). Such behaviours must be regular and ongoing. At home, people with diabetes must manage food, activity and exercise, monitor blood sugar where appropriate, manage medications, confront diabetes-related problems, strategise to reduce risks, and maintain healthy coping behaviours in the face of daily challenges. Such self-care activities must be carried out several times a day, every day, requiring attention, strategy and planning. Regular meals must be appropriately nutritionally balanced, and this process must start with educated and planned choices made while shopping for food. Cooking at home for guests, and choices made while eating outside the home must also reflect good self-care plans. Those who are prescribed insulin also face the challenge of incorporating medication regimens with food intake (carbohydrate counting), and integrating both with maintaining
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T
he number of older people with type 2 diabetes is rising, reflecting increases in the prevalent rates of obesity in Western countries and also the ageing population. In 2011, Diabetes UK reported an estimate of just under 3 million people being diagnosed with diabetes in the UK. This figure expected to rise to 5 million by 2025 (Diabetes UK, 2013). Although there are many older people with type 1 diabetes, given that the vast majority of older adults have type 2 diabetes, this article is focuses on the latter patient population.
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CARE OF THE OLDER PERSON or increasing activity levels. Diabetes-related problems will often arise depending on social scenarios and circumstances. Successful self-management often relies on forward-planning, problem-solving ability, maintaining levels of motivation to self-manage and building strategies to beat stress and facilitate healthy ways of coping. Such strategising and planning is most successful when it is personalised (NHS Primary Care Commissioning, 2009). Individual circumstances, preferences, cultures, skills, abilities and available options must all be taken into account when considering how best to self-care. Factors both within and outside the individual can have great impact on self-care success; social context should not be regarded as either a barrier or an aid to self-management (Rosland et al, 2010). Supported self-management can include such personalised planning, and goal setting, as well as advice and understanding from peers, family and friends (Diabetes UK, 2009).
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Self-care in older adults Older adults can experience additional challenges to successful self-care (Bai et al, 2009). The myriad daily tasks of diabetes self-management require significant cognitive input, particularly in planning, problem-solving, and memory. Mild cognitive impairment has been associated with diabetes, particularly in those who are older or who have had diabetes for longer (Cukierman et al, 2005; Kumari and Marmot, 2005). Specific domains of cognition associated with diabetes include executive function, memory and psychomotor control (Ryan and Geckle, 2000; Asimakopoulou et al, 2002; Arvanitakis et al, 2006; Thabit et al, 2012). These cognitive abilities have considerable self-management significance. Impaired executive function confers poorer planning and problem solving skills, which could affect all areas of self-care, from meal preparation to stress-reduction strategies. Good memory is required for the management of medication, making and keeping health-care appointments, maintaining vigilance behaviours such as foot checking, and monitoring blood glucose levels. Poorer psychomotor control may make insulin administration more difficult. Furthermore, self-care behaviours must be learned and practised. In order to be most successful they must also be supported. Peers, friends and family are often a good source of support for those faced with the burden of diabetes self-care (Bai et al, 2009), but as people age they often face decreasing levels of social interaction and increasing isolation (Carstensen, 1992). People with diabetes are also at greater risk of experiencing depression, which may be compounded by social isolation. Social isolation and depression have both independently been associated with poorer self-management care (Tomaka et al, 2006; Anderson et al, 2001), and may combine to further influence self-care. Physical factors that may be associated with ageing such as increased frailty, reduced mobility, disability and the presence of comorbidities may make introducing or increasing exercise or activity more difficult (Lawton et al, 2006). Essential areas of care such as checking feet may also be hindered by physical factors (Plummer and Albert, 1996).
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A combination of the additional barriers that older adults with diabetes may face in their self-management may decrease overall motivation to self-care (Schoenberg et al, 2008).
Self-care as part of a behaviourchange programme Success with one area of self-care is often unrelated to success with other areas (Glasgow et al, 1989). In terms of medication, non-adherence in people with diabetes has a fairly high prevalence, with adherence with insulin regimens reported to be around 63% in adults with type 2 diabetes (Cramer, 2004). Furthermore, polypharmacy regimens reduce compliance with medications, with an inverse relationship being observed between number of medications prescribed and compliance rates (Claxton et al, 2001). In terms of dietary self-care, physical activity recommendations and blood glucose testing— notwithstanding the difficulties inherent in assessing these behaviours and the variability in self-care plans—it has been roughly estimated that non-adherence is around 60%, with the exception of physical activity, where non-adherence can be as high as 80% (World Health Organization (WHO), 2003). Due to the apparent poor rates of diabetes self-care plans being followed through, it is suggested that dedicated interventions focusing on behaviour change may be necessary in order to help older adults to self-care.
Behaviour change There is a large amount of psychological literature on the subject of behaviour change, starting from the basic principle that behaviour change consists of three interrelated components as seen in the COM-B model (Michie and West, 2012) (Figure 1). These are as follows: w Capability (C), e.g. the person having the physical and psychological skills to administer an insulin injection w Opportunity (O), e.g. the physical and social environment being such that the person feels able to e.g. administer an insulin injection w Motivation (M), which refers to the person’s conscious (i.e. planning) and automatic (i.e. drives and habits) processes said to underline the emission of any behaviour. It has been argued that for most people motivation may be the most problematic of these three concepts (Michie and West, 2012). However, it is proposed that older people are likely to have issues with capability and opportunity too, so these would need to be checked carefully for each area of the regimen. Assuming that the person has the capability and the opportunity to look after themselves, it has been suggested that motivation is the next most plausible candidate for causing people difficulties with their attempts to follow through with health-behaviour change. It is beyond the scope of this article to fully outline theories of motivation, but PRIME theory (where PRIME stands for ‘plans’, ‘responses’, ‘impulses’, ‘motives’ and ‘evaluations’) may be useful here (West, 2006) (Figure 2). PRIME theory broadly argues that people generally act in pursuit of their most basic needs/wants at that particular moment. People’s beliefs about what is good or bad and any
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CARE OF THE OLDER PERSON lying belief that this medication regimen does not suit), or it could be down to unintentional non-adherence (due to, for example, lack of knowledge, skills and confidence to administer the insulin injection). To understand how to help support behaviour change, one needs to have a sufficient understanding of the factors maintaining the unhealthy behaviour. Once these have been noted, a process of matching the appropriate BCT to the target behaviour can take place.
Capability
Motivation
Behaviour
Available BCTs and their effectiveness
Figure 1. The COM-B model (Michie and West, 2012). Internal and external environment
Pre-formed plans
Beliefs about positive and negative attributes
Reflective
Strongest of competing wants and needs
Strongest of competing impulses and counter impulses
Responses
Automatic
Figure 2. PRIME theory outline (West, 2006).
plans/goal-setting will only influence their immediate actions if they generate sufficiently powerful, identity-driven wants or needs that can overcome competing automatic wants or needs arising from more direct sources such as past associations and habits. For example, where an older person with diabetes is seeking to make the healthy choice at a restaurant and reject the high-fat dessert for the low-fat option, this will only occur where their need to satisfy the craving for high-fat food is replaced by a fresh, new-identity-fuelled need, to be seen as a person making healthy choices in their old age. It should be obvious that in the case of the older person with diabetes, eating habits, which have been built up over a lifetime are thus likely to be resistant to change. Physical activity targets are also likely to interfere with an age-generated preference for a sedentary lifestyle for some. Medication-taking, especially where this is a new, added task, will also require support in changing it from a newly designed plan to a habitual response. In order to be able to support people with behaviour change by intervening in their everyday behaviours, it has been shown that one needs to match the most appropriate behaviour-change technique (BCT) with the current, undesirable, behaviour pattern (Michie et al, 2011a). Key to this process is an understanding of what fuels, for example, unhealthy eating, reluctance to take up exercise or medication non-adherence. Careful, individualised analysis of current, poor self-care patterns will be required here. It follows that a person’s non-adherence with insulin injections, for example, could be because of intentional non-adherence (because of their under-
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The result of intensive, expert work on reaching a consensus on what constitutes a specific BCT and how one differs from another (Michie et al, 2013) has led to developments such as the Coventry, Aberdeen, London-Refined (CALO-RE) Taxonomy (Michie et al, 2011b) and the Behaviour Change Wheel (Michie et al, 2011a). The former is a set of BCTs specifically designed to support people in following a healthy diet and engaging in physical activity. This, and the Behaviour Change Wheel (Michie et al, 2011a), which considers a framework of BCTs (see Table 1) and wider societal policies (Table 2), are currently the most up-to-date tools available to health-care professionals wishing to assist adults with behaviour change. Although these tools have not been designed with older adults in mind, the section below attempts to place them in a perspective that might be applicable to older adults.
Behaviour change in older adults with diabetes In terms of supporting behaviour change in older people with diabetes, the three basic areas of the self-care regimen (medication-taking, dietary and physical activity self-care) need to be considered separately given the independence of each in terms of adherence rates (Glasgow et al, 1989).
Specifying behaviours to address The first issue to be considered is how many behaviours health professionals working with older adults should seek to address. For example, where a person with diabetes has difficulties with following a healthy diet and with physical activity and with following through their medication regimen, should one undertake behaviour change in all three areas or one at a time? Some literature suggests that interventions targeting both dietary and physical activity changes rather than only one of these behaviours produces better outcomes, such as weight loss (Greaves et al, 2011). However, at the same time, a recent systematic review examining behaviour-change interventions specifically in older adults (Nigg and Long, 2012) concluded that older adults ‘respond well to behaviourchange interventions delivered one behaviour at a time’.
Selecting an area for change Assuming that one area of the self-care regimen among many is selected for change, the next issue to be addressed is which area to select. This is best decided by bearing in mind the overall approach under which diabetes is managed. Assuming a patient-centred, choice-supporting approach, which has long been advocated in the field (Asimakopoulou, 2007; Asimakopoulou et al, 2011; Asimakopoulou and Scambler,
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Opportunity
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CARE OF THE OLDER PERSON 2013), the choice of self-care area to be supported first should be the result of a patient-centred conversation about which area the patient feels they wish to tackle. Gentle guidance by the health professional to ensure that the behaviour targeted is not too ambitious and likely to lead to failure may be required in such situations. The remainder of this section considers each of the main diabetes self-care areas and reviews the literature suggesting which BCT appears best suited for each one of the broad areas of diabetes self-care. This is only generic guidance and obviously, individual circumstances will influence the extent to which these are applied in practice.
Diet
In a recent systematic review of systematic reviews of interventions aimed to enhance healthy dietary behaviours, usually with a weight loss target, Greaves et al (2011) showed that giving dietary advice in the absence of a behavioural support technique was not as effective as supporting people behaviourally in addition to offering dietary advice. In particular, enlisting the social support of family members, establishing self-monitoring of dietary behaviour, and use of relapse-prevention techniques were effective BCTs to support dietary changes once these had been initiated succesfully. BCTs aimed to encourage self-talk were effective in helping people maintain dietary changes. Furthermore, high-intensity interventions, i.e those including more than one BCT, more contact time or a longer duration were found to be more effective, with a positive relationship found between dietary change at 12 months and the number of patient–health professional contacts. The same review concluded that targeting both dietary and physical activity changes at the same time was more effective than targeting single behaviours. However, this conclusion needs to be generalised with caution given that the review did not focus on older adults.
Table 1. Behaviour Change Wheel techniques Level within Behaviour Change Wheel
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Examples
Education
Increasing knowledge or understanding
Providing information to promote healthy eating
Persuasion
Using communication to induce positive or negative feelings or stimulate action
Using imagery to motivate increases in physical activity
Incentivisation
Creating expectation of reward
Using vouchers to motivate smoking cessation
Coercion
Creating expectation of punishment or cost
Raising the financial cost to reduce excessive alcohol consumption
Training
Imparting skills
Advanced driver training to increase safe driving
Restriction
Using rules reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing behaviours
Prohibiting sales of solvents to people under 18 to reduce use for intoxification
Environment restructuring
Changing the physical or social context
Providing on-screen prompts for GPs to ask about smoking behaviour
Modelling
Providing an example for people to aspire to or imitate
Using TV drama scenes involving safe-sex practices to increase condom use
Enablement
Increasing means/ reducing barriers to increase capability beyond education and training
Behavioural support for smoking cessation medication for cognitive deficits, surgery to reduce obesity, prostheses to promote physical activity
Physical activity In terms of physical activity, reviews have considered BCTs for healthy, non-obese (Williams and French, 2011) and obese individuals (Olander et al, 2013). For healthy adults, action planning (i.e. detailed planning of what the person will do, when and where), providing instruction on how to perform the behaviour and reinforcing their effort or progress towards the behaviour were seen to be associated with increases not only in physical activity but also in people’s belief that they could engage in physical activity, i.e. their self-efficacy. The latter technique was also seen to be helpful in the review of interventions with obese individuals (Olander et al, 2013). Obese individuals attempting to enhance their physical activity also benefitted from interventions such as keeping a record of measures influenced by the physical activity (e.g. physical fitness/blood pressure), planning on ways to elicit social support to help them with the change in their physical activity levels, being taught to identify environmental prompts used to remind them to engage in physical activity and, finally, identifying prompts to rehearse and repeat the physical activity numerous times. Neither of these reviews examined older adults with diabetes in particular, so their findings would need to be adapt-
Definition of intervention/policy
Source: Michie and West, 2012
ed to the life of an older adult coping with several diabetes regimen demands. Trials specifically aimed at testing these BCTs on older adults with diabetes are therefore necessary.
Medication-taking In terms of interventions aimed at enhancing adherence with medication-taking, a systematic review examining interventions designed to enhance medication adherence in people with chronic medical conditions (Kripalani et al, 2007) concluded that decreasing dosing demands was by far the best way to enhance adherence with medication-taking. This is likely to be a challenge, however, in diabetes regimens where
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CARE OF THE OLDER PERSON
Level within Behaviour Change Wheel
Definition of intervention/policy
Examples
Communication/ marketing
Using print, electtronic, telephonic or broadcast media
Conducting mass media campaigns
Guidelines
Creating documents that recommend or mandate practice. This includes all changes to service provision
Producing and disseminating treatment controls
Fiscal
Using the tax system to reduce or increase the financial cost
Increasing duty or increasing anti-smuggling activities
Regulation
Establishing rules or principles of behaviour or practice
Establishing voluntary agreements on advertising
Legislation
Making or changing laws
Prohibiting sale or use
Environmental/ social planning
Designing and/ or controlling the physical or social environment
‘Traffic-calming’ measures; use of prompts and reminders
Service provision
Delivering a service
Establishing support services in workplaces, communities etc
Source: Michie and West, 2012
Box 1. Practical suggestions for supporting older adults with diabetes at home w Check education needs are met w Make personalised care plans and set goals w Make periodic contact to maintain motivation w Consider setting up peer-support groups, especially for the more isolated w Consider online support for those with less mobility w Check for cognitive impairment w Check for depression age and diabetes duration are related to polypharmacy rather than dose reduction. For this reason, one should consider behavioural interventions. The same review concluded that behavioural interventions involving increased contact with health professionals, patient monitoring, feedback and reinforcement are helpful for enhancing medication adherence in this group of adults. Interestingly, although medication adherence appears to improve with these interventions, any improvement seen in clinical outcomes was not proportionate to improvements in adherence (Kripalani et al, 2007). The discussion of research in this area would seem to suggest that different areas of the diabetes regimen may
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require and possibly benefit from different BCTs in order to best support older adults with diabetes.
Practical suggestions for health professionals supporting older adults at home Some practical suggestions for health professionals supporting older adults at home have been summarised in Box 1. A first step towards supporting older adults at home in their diabetes self-care may be to confirm that any educational needs are met. Diabetes education may not have been received for some time and individual needs may change over time. Although many formalised packages of education are available, those tailored to older adults may be more effective in this group, or some patients may benefit further from individualised education in specific areas (Sperl-Hillen et al, 2013). Such an approach would ensure that the capability aspect of the COM-B model was addressed. Personalised care planning between patients and nurses is important, and goal setting, among other techniques, has been shown to positively influence the frequency and outcomes of some areas of self-care (Langford et al, 2007). Regular or periodic contact from health professionals will help to support self-management in an older group in most diabetes self-care areas (de Silva, 2011). Notwithstanding the importance of human contact seen in research described earlier, several studies have evaluated the efficacy of telephonic support and have found mixed evidence for its success in aiding self-care (Krishna and Boren, 2008). Web-based support and interventions have been evaluated in older adults, with some studies finding clear benefits for diabetes selfmanagement, although others have highlighted the decreased likelihood of this group having computer resources or proficiency (Ralston et al, 2004). A personalised approach here could identify those individuals who would benefit from online resources. Encouraging peer-group support may be of particular use in a group that is at greater risk of social isolation, increasing motivation to self-manage (Heisler, 2007). Although healthcare professionals working in the community may face additional challenges of resources for group support, and issues of mobility in an older population with diabetes may affect attendance, peer-group support has been shown to be effective for older adults with diabetes (Heisler, 2007). For those able to access internet resources, peer-group support online may be a possibility (Eysenbach et al, 2004). Finally, when considering the particular challenges older adults face, health professionals working in the community may also wish to consider issues of cognitive impairment, and of depression. Quick and simple tests are available to assess cognition and depression in an older population (Borson et al, 2000; Marc et al, 2008). Identifying those in these groups would allow community nurses to direct their support for self-care on an individual, personalised basis.
Conclusion It is important that personalised, evidence-based behaviourchange support is offered to older adults with diabetes self-
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Table 2. Behaviour Change Wheel techniques
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CARE OF THE OLDER PERSON
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KEY POINTS
w Supporting older adults with diabetes self-care at home is a challenge due to the complexity of the self-care regimen, the additional needs of older people and the adverse effects that tight glycaemic control may have in this group w A single behaviour at a time (rather than many) should be targeted for behaviour change in older adults w There are multiple behaviour-change techniques available but one size does not fit all; different areas of the regimen are likely to benefit from the application of different techniques
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