A significant development in medicine is the recognition that patients should be treated as active agents in their health care. Contemporary consumers show increased interest in becoming more personally involved in decisions about their health, as evidenced by the popularity of such resources as WebMD and the marketability of health-related products and services. In the context of the traditional office visit, self-management is an inevitable part of treatment, since patients ultimately decide when to initiate the process and to what extent they will adhere to recommended courses of action prescribed by health care professionals.

Geriatric medicine is no exception to this trend. 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. An appropriate model for 21st-century geriatric medicine will focus on creating a partnership between health care professionals and their patients and will require that health care professionals have a working knowledge of what motivates older adults to initiate health behaviors and the potential reasons for success or failure in self-management. 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 guiding principles and suggestions for incorporating patient self-management into practice. Mastering this knowledge will enable geriatric health care professionals to deliver state-of-the-art care to their patients.

In 2003, Noreen Clark noted important distinctions among terms such as self-care, disease management, self-regulation, and self-management. Establishing clear definitions is an important first step in ensuring that health care professionals understand how to integrate self-management with clinical practice.

Using Clark’s distinctions as a guide, self-care involves actions taken by an older adult to maintain a desired health status without the interaction or assistance of a professional. Examples might include taking herbal supplements or participating in a yoga class at the YMCA independently, without any advice or monitoring by health care professionals.

Although self-care is important in the lives of older adults, in this chapter, we are interested in health behaviors that either do or should directly involve health care professionals. Such behavior falls under the rubric of either disease management or self-management. Clearly, older adults managing chronic disease and disability must frequently consult health care professionals and adhere to the various therapies they prescribe. Adherence implies that the older adults perceive that they have an active role in making decisions about, and carrying out, a particular regimen. It implies a collaborative relationship between patient and health provider. In contrast, compliance suggests an unquestioning and passive response by the patient and a provider–patient relationship that is one-way and top–down. Adherence has been shown to be better in promoting persistence and motivation than compliance, underscoring the necessity for collaboration in health care.

How, then, does disease management differ from self-management? Disease management involves both the health care system and the individual. At the system level, disease management refers to what the provider and health care system do to manage chronic disease and disability; for example, making available necessary services and prescriptions. At the individual level, disease management refers to the strategies implemented by patients and their families to manage both the disease and its consequences.

The individual level is the arena of self-management within disease management; it involves a partnership among the older adult, family and caregivers, and the health care professional. Ideally, the patient who self-manages effectively learns to use these human resources toward the goal of minimizing symptoms and optimizing function while living with the chronic disease or disability. In Clark’s view, self-regulation refers to the way that patients derive strategies to handle their chronic disease; it is a process embedded in the larger context of self-management. While we agree that self-regulation is at the core of the self-management process, we contend that it will be strongly influenced by the health care provider. It should not be limited solely to patient-derived strategies, which are in the domain of self-care. In fact, the provider must educate patients about the self-regulation process if they are to understand and use it to manage their health behavior.

In summary, we define self-management as a process that involves self-regulatory strategies taken by patients, who use their personal skills as well as those of health care professionals and supportive others to detect and manage their symptomatology and improve function. While learning about and maintaining self-management of chronic disease require a partnership, the partners’ responsibilities may vary over time, and the eventual goal is for the patient to achieve as much independence as possible. These partnerships must strive to help older adults acquire the self-regulatory skills essential to effective self-management of health behavior.

To explain self-management in geriatric medicine, we must clarify what is meant by health behavior. Generally speaking, older adults’ self-management may involve three broad classes of health behavior: detection, promotion, and prevention. These behaviors must be distinguished because the motives and strategies to encourage each of them 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 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 by patients is rarely effective in managing symptoms in the long run and contributes to nonadherence, health care professionals must recognize that self-management does not always involve what they may view as the “correct” response.

Detection behavior, performed by the individual or the provider, provides information about the presence or absence of unhealthy or potentially unhealthy chronic conditions, for example older women performing breast self-examinations or health care professionals ordering mammograms. Promotion behavior is intended to maintain or improve an older adult’s current state of relatively good health, for example healthy eating, regular exercise, and meditation when used proactively to manage stress. Often, health promotion behaviors do not involve the health care provider and are best conceptualized as part of self-care than self-management. On the other hand, prevention behavior is performed either to reduce or prevent the risk of future health problems or to facilitate recovery from a health event. Examples of preventive self-management include reducing saturated fat in the diet to lower cholesterol and the risk for cardiovascular disease (primary prevention) or engaging in exercise therapy to facilitate recovery following a myocardial infarction (secondary prevention) (Table 28-1).

In geriatric medicine, health providers must encourage and actively facilitate older adults’ development of self-management skills. They must also work to build the adherence of older adults toward desired detection, prevention, and promotion behaviors and thus strengthen and reinforce older adults’ related self-confidence for managing those behaviors. Later in the chapter, we will discuss the research literature in self-management, which holds promise for successful collaborations between older adults and health care professionals in achieving these goals.

Having defined self-management and discussed different classes of health behavior, the next logical step is to ask the following questions: What motivates older adults to engage in self-managing health behaviors? 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 health care professionals with a template for examining current practices or designing new initiatives that target self-management of health behavior for older adults.

Older adults engage in self-management in response to a conscious goal or to remove barriers in the path toward goals. For geriatric medicine, health-related goals most often stem from concerns related to detection or prevention behavior; that is, older adults want to identify and to 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 treatment for chronic disease, and a diagnosis is not needed. Here, prevention of the symptom becomes the goal. A common example among older adults is the pain associated with osteoarthritis. Quite often, they may not view pain management as self-management because they may perceive chronic pain as beyond their control. They believe that the health care provider has the sole remedy to fix their problem and prevent it in the future. For example, they might expect to obtain new medication or an increased dose of their current medication to alleviate arthritic pain. The physician’s actions may reinforce this passive solution to the pain. The physician may feel that pain from osteoarthritis is rooted in some underlying pathology and that it is a biological problem and immediately rule out collaborative self-management. Such a decision and subsequent behavior either knowingly or unwittingly discourage self-management, reinforcing patients’ notion that they have no role to play in treating their chronic condition. This example illustrates that both patients’ understanding of their medical conditions and the behavior of health care professionals contribute to the motivation to self-manage health behavior. Active partnerships between patients and their health care professionals develop the motivation to take action and are essential in shaping patients’ self-management behaviors.

Commonsense Model of Self-Regulation

Howard Leventhal and his 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 to 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 (feeling off-balance or weak) and physical symptoms (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 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 these features 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: the perceptual experience/symptom. Originally, he thought that these 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 younger son: the suspected cause. However, the symptoms have persisted for 8 weeks, and he long ago resolved the conflict with his son: the 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 those have all but stopped him from working around the house and seem progressively worse because he now has discomfort when rising from his chair after watching TV. Consequently, Fred questions his original, suspected causes and now concludes 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 personal 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 these are not a normal problem of aging or stress, these become prompts 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. Individual health behavior is influenced by 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).

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 elderly parents seeking treatment for a symptom, being convinced that physicians 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 department, 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 her life as she knew it. Such avoidance can also 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.

Conceptual Framework for Understanding the Complexities of Self-Management

We will elaborate on three features in the following sections: (1) facilitating factors, (2) inhibitory factors, and (3) knowledge, skills, strategies, and resources (Figure 28-2).

Facilitating Factors in Self-Management

More than two decades of research in psychology have 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 physician that she has type-2 diabetes. In collaboration with her physician, Helen decides to join a research study that is treating physical disability and diabetes in older adults using a combination of caloric restriction and increased physical activity. When she first enters the study, 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, each month, Helen will time herself while walking four laps at the local YMCA track (∼400 m) 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 change happening as she engaged in these self-regulatory processes to manage her chronic health condition (see Table 28-2).

The 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 health care professionals must share with older adults in self-managing health behavior. They include:

1. 
   

   setting clear, specific, and reasonably challenging goals for behavioral change;

   
   
2. 
   

   monitoring personal behavior and how it influences reaching goals and the rate of change;

   
   
3. 
   

   providing feedback and information on each health behavior goal that has been collaboratively established between the health care professional and the older adult;

   
   
4. 
   

   self-evaluating progress related to the goal—collecting the older adults’ personal judgments and emotional reactions about their pursuit of goals and making or not making progress;

   
   
5. 
   

   correcting behavior as a result of feedback and self-evaluation, leading to more effective and persistent change in the direction of established goals;

   
   
6. 
   

   encouraging belief in their ability to organize and to take actions associated with the specific circumstances that they are trying to change, in order to achieve specific goals. These beliefs foster the persistence necessary to 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 health behavior change. However, their collaboration with health care professionals as their partners influences the entire self-regulatory process. The partners can make informed judgments about expectations and outcomes. In the example above, consequences could include not only Helen’s reduced calorie consumption and increased walking but also compliments from family and friends, and the personal satisfaction with her own accomplishments. Regular reflection on progress (feedback) and comments about how it has affected life (outcome information) by both parties characterize a self-evaluative process and influence the desire of older adults to adhere to the collaborative prescription for change. The health care professional’s comments about change in Helen’s outlook and persistence and Helen’s pleasure in being able to stick with reduced caloric consumption for more than a month jointly contribute to her self-efficacy (confidence) to adhere to their plan over the next month.

Inhibitory Factors in Self-Management

For some older adults, behavioral practices that reflect effective self-management of chronic disease are well learned and help to resist threats, such as 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 health care professionals, and take recommended supplements and daily walks without fail. However, health care professionals 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 inhibit effective self-management.

Operating on Automatic Pilot

Clearly, a major threat to self-regulation and 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. If an older adult behaves without thinking, opting for the easier, routine path that allows dysfunctional behavior, hope for change is futile. Why do older adults persist in 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 the frustration with failed treatments, the concern that they are a burden for their caregivers, and the acute illness or injury that disrupts the action plans that they use to self-manage their behavior change. The important lesson from Mischel’s research is that self-management planning cannot ignore these emotions and their related causes.

In addition, decades of eastern writings and recent research in western psychology on mindfulness convincingly argue that North American society encourages automatic responding. Many individuals find it difficult to pay attention in the present moment to where they are headed and whether or not the direction of their path is consistent with what they value. It has been suggested that we have this difficulty because we spend much of our young and middle adult years striving to get somewhere or to complete the next task. This behavior pattern continues into old age. Some customary routines do not require that older adults consciously monitor what they are doing, and their inclination is not to alter what seems to be working for them in day-to-day situations. The problem, of course, is that many customary routines run counter to the strategies or prescriptions that health care professionals hope to make a part of older adults’ health self-management: “I always have a doughnut with my coffee.” More will be said about how health care professionals can counter the phenomenon of “operating on automatic pilot” later in the chapter.

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, which contribute to giving up the adoption or maintenance of 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 (1) the failure to achieve weight goals and dissatisfaction with the weight achieved, (2) the tendency to evaluate self-worth in terms of weight and shape, (3) a lack of vigilant weight control, (4) a dichotomous (black-and-white) thinking style, and (5) 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 (1) unrealistic expectations about outcomes, (2) eliminating a behavior that is used to cope with life stress, or (3) 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 behavior 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.” The black-and-white thinking style posits that vacation and active self-management of health behavior are incongruent. However, with the development of appropriate self-regulatory skills, the two goals need not be in conflict.

Toxic Environments

Poor physical and social environments as well as lack of resources for effective self-management can interfere with diagnosis, prevention, and promotion. According to Marcia Ory and her colleagues, barriers often evolve from negative stereotypes related to six common myths of aging. These ageist stereotypes are reflected in the media and social and health care services. Expert witnesses who testified before the U.S. Senate Special Committee on Aging reported that the media and marketing depict older adults as helpless, feeble, and ineffective. In the realm of health care, Ory and her colleagues found that physicians 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 28-3).

Costs and the Problems of Distant Benefits

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. 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, and having to eliminate favorite foods in caloric and fat restriction prescriptions for weight loss is, at times, difficult for older adults to accept.