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Health promotion in the elderly with coronary artery disease Michelle Tinkham, RN, BSN, MS
The number of elderly Americans, those over the age of 65 years of age, continues to climb. A lifetime of poor nutrition and lack of exercise has led many elderly patients to experience coronary artery disease (CAD) later in life, leading to invasive procedures and other forms of disease management that contribute to mounting health care costs and lower quality of life. Although health promotion has been accepted as the necessary answer to this problem by many in the healthcare community, many physicians are still lacking in promoting this concept, often due to the lack of insurance reimbursements. This paper will explore three key disciplines linked to health promotion in the elderly and why this topic is so vital for our future. (J Vasc Nurs 2014;32:151-155)
According to the World Health Organization, health promotion is defined not only as increasing a person’s health, but also giving them control over it.1 According to the US Census,2 there are approximately 40 million persons aged $65 years (13% of the American population). Because of greater longevity of adults in America, there is increased likelihood of the elderly population experiencing coronary artery disease (CAD) and requiring invasive treatments. These patients require complex management of comorbidities, which lessens their autonomy; retirement funds may be inadequate to meet their medical needs. This situation causes a strain, not just on the person and his or her family, but also on insurance carriers and health care facilities struggling to deal with an increasing number of older patients. As a result, many disciplines have focused on health promotion within this population. Depending on the application, health promotion in this aging group can have many focuses, ranging from disease management to secondary prevention. Terms such as wellness, autonomy, health enhancement, injury prevention, and disease management have all been used in reference to health promotion. As a result, an analysis of the concept of health promotion should occur to help caregivers to determine the best mix of interventions to help foster the optimal outcomes in this maturing population.
REVIEW OF LITERATURE According to the American Heart Association,3 an estimated 42.2 million persons who are $60 years of age have some sort of cardiovascular disease. More disciplines are recognizing the From the Department of Cardiac Pulmonary Rehabilitation, Eisenhower Medical Center, Palm Desert, California. Corresponding author: Michelle Tinkham, RN, BSN, MS, Eisenhower Medical Center, Program Coordinator Cardiac Pulmonary Rehabilitation, Palm Desert, CA 92260 (E-mail: Michelle. [email protected]). Declaration of Conflicting Interests: No conflict of interest is declared by the author. 1062-0303/$36.00 Copyright Ó 2014 by the Society for Vascular Nursing, Inc. http://dx.doi.org/10.1016/j.jvn.2014.05.001
need to see patients as a whole person rather than just focusing on components or disease processes. In an effort to find the most complete definition of health promotion among the elderly, published literature from multiple health care professions were explored for evidence of this concept. Antecedents, criteria, and consequences as they relate to health promotion are discussed, which could also be relevant to the in the elderly, specifically with CAD. This article focuses on the review of three of these disciplines—nursing, psychology, and medicine—discussing a minimum of two articles from each discipline. A comprehensive literature review as it applies to these disciplines, as well as instruments used where applicable, is presented.
NURSING The Health Promotion Model was first developed by Dr. Nola Pender in 1982. She made several versions and revisions to address different influences on health behavior for both adolescents and adults focusing on factors she felt were needed for health promotion such as spiritual growth, interpersonal relations, nutrition, physical activity, health responsibility, and stress management.4 This middle-range nursing theory took aspects from the expectancy-value model and the social cognitive theory and created a model employing the nursing metaparadigm of person, environment, nursing, health, and illness.5 This model has been used to help nurses to determine what motivates persons to seek health promotion, or health enhancement. There are three components to the health promotion model: Individual characteristics and experiences, behavior-specific cognitions, and healthpromoting behavior.4 She theorized that several intentions had to be in place for patients to seek and achieve health promotion. For instance, they had to see value in the benefits, they must feel competent to achieve the results, and they need a positive attitude and support from others in their environment.4 These concepts of health promotion are particularly true for elderly patients with CAD because many are resistant to changing behaviors they have employed for a lifetime, especially if they feel it may only have a slight impact on their disease, such as diet improvement or increased activity. Another prevalent term used to describe health promotion is wellness. The term wellness has links as far back as the 19th century, but was not considered a health promotion concept until the
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1950s and then expanded into the wellness movement of the 1970s.6 Dr. Halbert Dunn7 took the concept of wellness and researched what it meant for the elderly specifically. Although he was a physician, his definition was less medical and more nursing, stating that what mattered more than the management of disease was maintaining a person’s dignity and value. He felt that health promotion and wellness meant helping the person to achieve the highest level of functioning the person was capable in an ever-changing environment, which could be achieved in part through personal knowledge and creative expression.8 This later became known as the Dunn Model of High Level Wellness. This model became the basis for further nursing work centering on wellness and the geriatric population. McMahon and Fleury9 wrote a concept analysis paper focusing on wellness in the older adult incorporating both Dunn’s and Miller’s previous work, as well as Rodger’s evolutionary perspective.9 They stated that wellness in the elderly focused on optimizing potential and strengths and used concepts of becoming, integrating, and relating to further describe the term wellness as well as related concepts of health promotion and well-being. Here are several additional nursing theories that have value in any health promotion discussion. For instance, Nightingale’s environmental theory, developed in 1859, can also be used to guide caregivers looking to promote the health of the elderly population. She saw the basics of the environment—clean air, water, and good food—as being the root of healthiness.10 Sadly, many of our older population do not have access to these basic items owing to limited funds. Another theory, Leninger’s transcultural theory, developed in 1968, looked at beliefs regarding self-care and cultural values to determine how to provide holistic care.10 This is an important theory when promoting health among the elderly because their beliefs regarding health can make a huge impact when expecting them to change behaviors. Orem’s selfcare theory (1985) is based around the concept of self-care.11 The ability for an elderly patient to care for themselves is very important in order to maintain dignity and autonomy. The 2009 WHO conference in Thailand supported this concept, stating that self-care needed to be included in the methods of health promotion.10 Finally, Nemcek’s Self Nurturance Model developed in 2003 from the Health Promotion model and Health Belief Model, introduced the concept of self-nurturing into the health promotion discussion, which she felt supported life and growth.10 There are several antecedents, criteria, and consequences of health promotion that could apply to the elderly that were common among the nursing literature. These include the antecedents of dependence and disregard. Criteria focused on improving autonomy and attitude, as well as social contacts, which could help to reduce the antecedents, thereby leading to the consequences of dignity, health enhancement, and growth.
PSYCHOLOGICAL DISCIPLINE Wilhelmson and Eklund12 performed a randomized study evaluating life satisfaction and its effects on health-promoting behavior. The aim of the study was not too necessarily prevent disease in the elderly, but rather to maintain functional status. They concluded that, over time, no matter the healthpromoting behavior, the patient would decline and become frail. This lead to feelings of fear and dependence; however, if the pa-
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tient viewed their health at a higher level, whether it was accurate or not, had positive self-esteem, social support, and sense of worth, they were less disturbed by their functional decline. This study used the Fugl-Meyers Life Satisfaction Assessment questionnaire to measure life satisfaction which asks about the patient’s satisfaction with eleven items including life in general and social connections. In addition, there are many other tools that are often employed in cardiac rehabilitation for elderly patients with CAD, to measure similar characteristics. The Geriatric Depression Scale (GDS), which was created by Yesavage in the 1980s, is one example.13 The transtheoretical model is another psychological tool used in health promotion among the elderly because it helps health professionals to determine what causes people to change.14 This is especially important when determining what motivates adults to change bad behaviors and embrace positive ones, which is essential in controlling CAD. Lach et al14 discussed the use of this tool and its five stages of precontemplation, contemplation, preparation, action, and maintenance in the health promotion of older adults. Specifically the authors used the transtheoretical model steps to help develop health promotion programs for the elderly based on their stage of change readiness. They again looked at the individual’s view of the value of the behavior change as well as their ability to make that change and maintain it over time. Whitehead’s Social Cognitive Model of Health Promotion Practice, developed in 2001, list many of the antecedents and consequences in this manuscript as cues to action and nonaction. For instance, cues to action include motivation, acceptance and support whereas cues to nonaction include anxiety, fear, and denial.10 Many of the antecedents, criteria, and consequences of health promotion in the elderly found in the psychological disciplines were similar to the nursing profession. There was a focus on preventing the antecedents of isolation, dependence, and frailty of the elderly. This requires autonomy, positive attitude, and social support, as well as managing stress and anxiety. As a result, the consequences are similar to the previously discussed discipline: Providing the patient with dignity, wellness, value, and life satisfaction.
MEDICAL DISCIPLINE From the medical perspective, health promotion is linked more with maintenance of disease processes through primary and secondary prevention. Richardson15 looked at health promotion and disease prevention in the elderly. He used a quote from Mark Twain that is often the view of what being healthy means: ‘‘The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not,16p137. Richardson stated that health professionals often focus on health recommendations that are meant for a younger generation, especially because there are few preventive guidelines for the elderly and even fewer that Medicare covers. Throughout his article, he used various screening procedures to guide what clinicians should focus on for health promotion of older adults, but very little was mentioned regarding the focuses that fell into the previously discussed disciplines. For example, for the chosen population of this paper, fasting cholesterol levels, blood glucose
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testing, and electrocardiograms were linked with health promotion. There is one tool created for physicians that focuses more on a holistic approach and is often used in health promotion of the elderly, the Dartmouth Primary Care Cooperative Information Project scale.17 This questionnaire was developed by the Department of Community and Family Medicine at Dartmouth Medical School in the 1980s as a screening tool for primary doctors. Although the original tool also included quality-of-life and social support questions, they were omitted when it was revised to only include pain, activities of daily living feelings, physical fitness, social activities, and current overall health perceptions.17 Unlike simple screenings for disease processes, use of the Dartmouth Primary Care Cooperative Information Project scale also examined the patient’s functional status and impressions of his or her health. Finally, Badertscher et al18 published a qualitative study regarding issues that both improved and hindered health promotion of the elderly from a general practitioner’s perspective. This study defined health promotion exclusively as prevention of disease, thereby keeping the patient out of an assisted care living situation. The researchers found that there was a bias toward focusing on health promotion with the elderly owing to time physician restraints, lack of effectiveness, and the previously mentioned lack of Medicare reimbursement for preventive actions, although participants did acknowledge that the general practitioner was the best first contact for health promotion in elderly patients. They did feel that the use of short questionnaires, such as those that focused on diet, were of value to health promotion of this group. The self-reported questionnaire known as Rate Your Plate is an example of short tool used in Cardiac Rehabilitation to determine the elderly CAD patient’s current diet and help clinicians to promote health.19 The antecedents, criteria, and consequences of health promotion in the elderly were physical in nature. Antecedents of disease and dependence were identified. The criteria for dependence from the medical perspective was different from the two previously mentioned because its focus of autonomy was more on preventing the patient from being placed in a facility and preventing health care costs, rather than the patient actually feeling independent. Health enhancement consequences were based more on criteria of management and maintenance of disease processes in this discipline.
SUMMARY OF LITERATURE REVIEW Throughout the nursing discipline, the view of health promotion is one of holistic care. Rather than focusing on freedom of disease, nursing seeks to promote autonomy, growth, preservation of dignity, and positive connection with others to foster wellness in the elderly (Table 1). For example, cardiac rehabilitation nurses caring for older adults with CAD spend half of the time in the program educating patients so they may make appropriate changes to their risk factors and take ownership of their health care becoming more independent and valued, and preserving their dignity.20 This was also true of the psychological disciplines, which also viewed the patient a whole person rather than just symptoms of diseases. Their focus was more on the mental health of the patient. Rather than focusing on true disease prevention, this discipline focused on helping patients to feel supported and have a
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TABLE 1 HIGHLIGHTS OF HEALTH PROMOTION IN THE ELDERLY WITH CORONARY ARTERY DISEASE (CAD) In 2010, the US Census determined that 13% of the American population was >65 years of age, and the number continues to climb. A lifetime of poor nutrition and lack of exercise has led many elderly patients to experience CAD later in life, leading to invasive procedures and other forms of disease management, that contribute to mounting health care costs. Although health promotion has been accepted as the necessary answer to this problem by many in the health care community, many physicians are still lacking in promoting this concept owing to lack of insurance reimbursements. Antecedents to health promotion in the elderly during the literature review included dependence, anxiety, and isolation. Health promotion in the elderly leads to dignity, value, and life satisfaction.
positive attitude regarding their condition; it is known that eventually, no matter the preventive methods, the elderly will become more frail.12 The medical discipline seemed to focus on physical attributes. Although there was some discussion of health promotion, it was based on a more monetary goal, and the desire to keep the patient free from physical illness, rather than looking at the patient’s emotional and spiritual health. The use of time-saving questionnaires dealing with health status seemed to be of value to this group, rather than those employed by the psychological disciplines, which seemed to focus more on the patient’s perspective of his or her health. Many terms relating to health promotion in the elderly were listed throughout this manuscript based on the reviewed literature. Six terms were chosen that seemed to describe the main concept of health promotion. Table 2 lists selected antecedent, criteria, and consequence terms as they relate to health promotion in the elderly with CAD.
Rationale for selected terms There were many terms that seemed synonymous with health promotion throughout this literature review; with each new concept, the antecedent, criteria, and consequence lists grew. After careful selection, the list was narrowed down to six terms, each of which seemed to embody the concept of health promotion for the elderly with CAD across the three disciplines discussed herein.
Antecedents The antecedents, or terms leading to the concept of health promotion of the elderly with CAD based on the reviewed
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TABLE 2 ANTECEDENT, CRITERIA, AND CONSEQUENCES FOR THE CONCEPT OF HEALTH PROMOTION IN THE ELDERLY Antecedents
Criteria
Dependence stress/anxiety
Autonomy Management/ maintenance Holistic Prevention/change Positive connections/ attitude Self-determination
Disregard Disease Isolation Frailty
Consequences Dignity Wellness Value Growth Health enhancement Life satisfaction
literature, are dependence, stress/anxiety, disregard, disease, isolation, and frailty. In all the literature reviewed, there is an acknowledgment that, as one ages, disease becomes increasingly likely. As a result, the elderly lose their independence owing to illness or other disease modalities. With disease, the older adult can also become frail and not be able to perform activities of daily living. In addition, isolation can be an issue; older adults might not be able to be as mobile or may have lost a spouse or friends owing to advanced age. All of these terms combined can lead the elderly to feel disrespected and disregarded. Terms that related to specific diseases or habits that lead to disease were removed from the list, to encompass a more complete view of health promotion as it was discussed in the literature reviewed.
Criteria The criteria chosen for the selected concept were autonomy, management/maintenance as it relates to disease comorbidities, holistic, prevention/change, positive connections/attitude, and self-determination. Autonomy was chosen rather than independence because one can be autonomous and make decisions without being independent of others. In fact, a prevailing subject in the literature review was the need to not only have a positive attitude, but also to have meaningful support from one’s environment and social circle. It is important in any discussion of health promotion to state disease management and health maintenance as important criteria, but so is prevention and willingness to change unhealthy behaviors. These terms were more encompassing than the term of injury prevention, which was dropped from the final list and replaced with holistic, because health promotion is more than just prevention of physical ailments. Finally, selfdetermination was added along with autonomy because, although one needs to be able to have the freedom to make decisions, it is also important to follow through and act on those choices.
Consequences The final area is consequences, or what occurs as a result of the chosen concept of health promotion in the elderly with CAD.
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The final chosen terms were dignity, wellness, value, growth, health enhancement, and life satisfaction. The terms that were replaced in the final list, such as energy, were replaced with more board terms, such as health enhancement and wellness, because health promotion may be different for every individual, and especially the elderly, depending on his or her current health state. In addition, the reviewed literature showed that elderly patients who felt in control saw more value and dignity in their lives, and thereby reported greater satisfaction with life.12
Theoretical definition The concept of health promotion in the elderly with CAD is a holistic technique that focuses on disease management and prevention, comorbidity maintenance, and lifestyle change to help the older patient maintain positive connections, attitude, autonomy, and self-determination.
Operational definition Health promotion in the elderly with CAD is directed toward helping older adults achieve wellness and increased life satisfaction in light of their current health status. The Dartmouth Primary Care Cooperative Information Project scale is an example of a tool that encompasses health promotion in the elderly with CAD by looking at activity level, smoking status, and health perception.
CONCLUSION Health promotion is a key concept in improving wellness, not just in the elderly, but in all populations. No longer is the focus of being healthy just on the absence of disease; health care providers must see the patient as a whole person, addressing physical, mental, emotional, and spiritual health. This was an issue encountered when performing the medical discipline literature review. Because the increased longevity of the population, physicians and third-party payers, such as Medicare, need to acknowledge the value of health promotion in the elderly, not just as a means for better life satisfaction, but also as a moneysaving strategy.20 Ultimately a happier, more valued population will lead to a healthier future for America.
REFERENCES 1. World Health Organization. Health promotion. http://www.who. int/topics/health_promotion/en/. Accessed April 18, 2014. 2. US Census. Population. Federal interagency forum on aging related statistics. 2010; http://www.agingstats.gov/aging statsdotnet/Main_Site/Data/2012_Documents/Population.aspx. Accessed May 8, 2014. 3. American Heart Association. Statistical fact sheet 2013 update older Americans & cardiovascular diseases. 2013; http://www. heart.org/idc/groups/heart-public/@wcm/@sop/@smd/docum ents/downloadable/ucm_319574.pdf. Accessed May 8, 2014. 4. Pender N. Health promotion model. 1982; http://deepblue.lib. umich.edu/bitstream/handle/2027.42/85350/HEALTH_PRO MOTIONMANUAL_Rev_5-2011.pdf?sequence=1. Accessed April 18, 2014. 5. McEwen M, Wills EM. Theoretical basis for nursing. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins; 2011.
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6. Miller JW. Wellness: the history and development of a concept. Spektrum Freiziet 2005;27:84-106; http://www.fh-joanneum.at/ global/show_document.asp?id=aaaaaaaaaabdjus&. Accessed April 18, 2014. 7. Dunn HL. Points of attack for raising the levels of wellness. J Natl Med Assoc 1957;49(4):225-35; http://www.ncbi. nlm.nih.gov/pmc/articles/PMC2641304/pdf/jnma007160025.pdf. Accessed April 18, 2014. 8. Dunn HL. High level wellness for man and society. Am J Public Health 1959;49(6):766-92; http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1372807/pdf/amjphnation00322-0058.pdf. Retrieved April 18, 2014. 9. McMahon S, Fleury J. Wellness in older adults: a concept analysis. Nursing Forum 2012;47(1):39-51. http://dx.doi.org/10.1111/j.1744-6198.2011.00254.x. 10. Raingruber B. Contemporary health promotion in nursing practice. Burlington (VT): Jones & Bartlett; 2013. 11. Parissopoulos S, Kotzabassaki S. Orem’s Self-Care Theory, Transactional Analysis and the Management of Elderly Rehabilitation. ICUS NURS WEB J 2004;(17); JAN-MAR. Retrieved from http://www.researchgate.net/publication/ 253650815_Orem%27s_Self-Care_Theory_transactional_ analysis_and_the_management_of_elderly_rehabilitation_ %28citations_32%29. 12. Wilhelmson K, Eklund K. Positive effects on life satisfaction following health- promoting interventions for frail older adults: a randomized controlled study. Health Psychol Res 2013;1(12):44-50; http://dx.doi.org/10.4081/hpr.2013.e12. 13. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982;17(1):37-49.
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14. Lach HW, Everard KM, Highstein G, et al. Application of the transtheoretical model to health education for older adults. Health Promot Pract 2004;5(1):88-93. http://dx.doi.org/10. 1177/1524839903257305. 15. Richardson J. Considerations for health promotion and disease prevention in older adults. Perspectives in Prevention from the American College of Preventive Medicine, http:// www.medscape.com/viewarticle/531942; 2006; Accessed April 18, 2014. 16. Twain M. Pudd’nhead Wilson’s new calendar. Following the equator, Vol. II. New York: Harper & Brothers; 1907:137. 17. Haywood K, Garratt AM, Schmidt LJ, et al. Health status and quality of life in older people: a review. Patient-Reported Health Instruments Group. 2004; http://phi.uhce.ox.ac.uk/ pdf/phig_older_people_report.pdf. Accessed April 19, 2014 18. Badertscher N, Rossi PO, Rieder A, et al. Attitudes, barriers and facilitators for health promotion in the elderly in primary care: a qualitative focus group study. Swiss Med Wkly 2012;142:w13606. http://dx.doi.org/10.4414/ smw.2012.13606. 19. Brown University Institute for Community Health Promotion. Rate your plate. 2005; from http://brown.edu/academics/ public-health/centers/community-health-promotion/sites/brown .edu.academics.public-health.centers.community-health-promo tion/files/uploads/Rate%20Your%20Plate.pdf. Accessed April 20, 2014. 20. American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac rehabilitation: low cost, low technology, great medicine! 2013; https://www.aacvpr.org/Portals/0/ resources/professionals/CRPresentationforPhysiciansAHA_ Jan2013.pdf. Accessed April 23, 2014.
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Health promotion in the elderly with coronary artery disease Michelle Tinkham, RN, BSN, MS
The number of elderly Americans, those over the age of 65 years of age, continues to climb. A lifetime of poor nutrition and lack of exercise has led many elderly patients to experience coronary artery disease (CAD) later in life, leading to invasive procedures and other forms of disease management that contribute to mounting health care costs and lower quality of life. Although health promotion has been accepted as the necessary answer to this problem by many in the healthcare community, many physicians are still lacking in promoting this concept, often due to the lack of insurance reimbursements. This paper will explore three key disciplines linked to health promotion in the elderly and why this topic is so vital for our future. (J Vasc Nurs 2014;32:151-155)
According to the World Health Organization, health promotion is defined not only as increasing a person’s health, but also giving them control over it.1 According to the US Census,2 there are approximately 40 million persons aged $65 years (13% of the American population). Because of greater longevity of adults in America, there is increased likelihood of the elderly population experiencing coronary artery disease (CAD) and requiring invasive treatments. These patients require complex management of comorbidities, which lessens their autonomy; retirement funds may be inadequate to meet their medical needs. This situation causes a strain, not just on the person and his or her family, but also on insurance carriers and health care facilities struggling to deal with an increasing number of older patients. As a result, many disciplines have focused on health promotion within this population. Depending on the application, health promotion in this aging group can have many focuses, ranging from disease management to secondary prevention. Terms such as wellness, autonomy, health enhancement, injury prevention, and disease management have all been used in reference to health promotion. As a result, an analysis of the concept of health promotion should occur to help caregivers to determine the best mix of interventions to help foster the optimal outcomes in this maturing population.
REVIEW OF LITERATURE According to the American Heart Association,3 an estimated 42.2 million persons who are $60 years of age have some sort of cardiovascular disease. More disciplines are recognizing the From the Department of Cardiac Pulmonary Rehabilitation, Eisenhower Medical Center, Palm Desert, California. Corresponding author: Michelle Tinkham, RN, BSN, MS, Eisenhower Medical Center, Program Coordinator Cardiac Pulmonary Rehabilitation, Palm Desert, CA 92260 (E-mail: Michelle. [email protected]). Declaration of Conflicting Interests: No conflict of interest is declared by the author. 1062-0303/$36.00 Copyright Ó 2014 by the Society for Vascular Nursing, Inc. http://dx.doi.org/10.1016/j.jvn.2014.05.001
need to see patients as a whole person rather than just focusing on components or disease processes. In an effort to find the most complete definition of health promotion among the elderly, published literature from multiple health care professions were explored for evidence of this concept. Antecedents, criteria, and consequences as they relate to health promotion are discussed, which could also be relevant to the in the elderly, specifically with CAD. This article focuses on the review of three of these disciplines—nursing, psychology, and medicine—discussing a minimum of two articles from each discipline. A comprehensive literature review as it applies to these disciplines, as well as instruments used where applicable, is presented.
NURSING The Health Promotion Model was first developed by Dr. Nola Pender in 1982. She made several versions and revisions to address different influences on health behavior for both adolescents and adults focusing on factors she felt were needed for health promotion such as spiritual growth, interpersonal relations, nutrition, physical activity, health responsibility, and stress management.4 This middle-range nursing theory took aspects from the expectancy-value model and the social cognitive theory and created a model employing the nursing metaparadigm of person, environment, nursing, health, and illness.5 This model has been used to help nurses to determine what motivates persons to seek health promotion, or health enhancement. There are three components to the health promotion model: Individual characteristics and experiences, behavior-specific cognitions, and healthpromoting behavior.4 She theorized that several intentions had to be in place for patients to seek and achieve health promotion. For instance, they had to see value in the benefits, they must feel competent to achieve the results, and they need a positive attitude and support from others in their environment.4 These concepts of health promotion are particularly true for elderly patients with CAD because many are resistant to changing behaviors they have employed for a lifetime, especially if they feel it may only have a slight impact on their disease, such as diet improvement or increased activity. Another prevalent term used to describe health promotion is wellness. The term wellness has links as far back as the 19th century, but was not considered a health promotion concept until the
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1950s and then expanded into the wellness movement of the 1970s.6 Dr. Halbert Dunn7 took the concept of wellness and researched what it meant for the elderly specifically. Although he was a physician, his definition was less medical and more nursing, stating that what mattered more than the management of disease was maintaining a person’s dignity and value. He felt that health promotion and wellness meant helping the person to achieve the highest level of functioning the person was capable in an ever-changing environment, which could be achieved in part through personal knowledge and creative expression.8 This later became known as the Dunn Model of High Level Wellness. This model became the basis for further nursing work centering on wellness and the geriatric population. McMahon and Fleury9 wrote a concept analysis paper focusing on wellness in the older adult incorporating both Dunn’s and Miller’s previous work, as well as Rodger’s evolutionary perspective.9 They stated that wellness in the elderly focused on optimizing potential and strengths and used concepts of becoming, integrating, and relating to further describe the term wellness as well as related concepts of health promotion and well-being. Here are several additional nursing theories that have value in any health promotion discussion. For instance, Nightingale’s environmental theory, developed in 1859, can also be used to guide caregivers looking to promote the health of the elderly population. She saw the basics of the environment—clean air, water, and good food—as being the root of healthiness.10 Sadly, many of our older population do not have access to these basic items owing to limited funds. Another theory, Leninger’s transcultural theory, developed in 1968, looked at beliefs regarding self-care and cultural values to determine how to provide holistic care.10 This is an important theory when promoting health among the elderly because their beliefs regarding health can make a huge impact when expecting them to change behaviors. Orem’s selfcare theory (1985) is based around the concept of self-care.11 The ability for an elderly patient to care for themselves is very important in order to maintain dignity and autonomy. The 2009 WHO conference in Thailand supported this concept, stating that self-care needed to be included in the methods of health promotion.10 Finally, Nemcek’s Self Nurturance Model developed in 2003 from the Health Promotion model and Health Belief Model, introduced the concept of self-nurturing into the health promotion discussion, which she felt supported life and growth.10 There are several antecedents, criteria, and consequences of health promotion that could apply to the elderly that were common among the nursing literature. These include the antecedents of dependence and disregard. Criteria focused on improving autonomy and attitude, as well as social contacts, which could help to reduce the antecedents, thereby leading to the consequences of dignity, health enhancement, and growth.
PSYCHOLOGICAL DISCIPLINE Wilhelmson and Eklund12 performed a randomized study evaluating life satisfaction and its effects on health-promoting behavior. The aim of the study was not too necessarily prevent disease in the elderly, but rather to maintain functional status. They concluded that, over time, no matter the healthpromoting behavior, the patient would decline and become frail. This lead to feelings of fear and dependence; however, if the pa-
DECEMBER 2014
tient viewed their health at a higher level, whether it was accurate or not, had positive self-esteem, social support, and sense of worth, they were less disturbed by their functional decline. This study used the Fugl-Meyers Life Satisfaction Assessment questionnaire to measure life satisfaction which asks about the patient’s satisfaction with eleven items including life in general and social connections. In addition, there are many other tools that are often employed in cardiac rehabilitation for elderly patients with CAD, to measure similar characteristics. The Geriatric Depression Scale (GDS), which was created by Yesavage in the 1980s, is one example.13 The transtheoretical model is another psychological tool used in health promotion among the elderly because it helps health professionals to determine what causes people to change.14 This is especially important when determining what motivates adults to change bad behaviors and embrace positive ones, which is essential in controlling CAD. Lach et al14 discussed the use of this tool and its five stages of precontemplation, contemplation, preparation, action, and maintenance in the health promotion of older adults. Specifically the authors used the transtheoretical model steps to help develop health promotion programs for the elderly based on their stage of change readiness. They again looked at the individual’s view of the value of the behavior change as well as their ability to make that change and maintain it over time. Whitehead’s Social Cognitive Model of Health Promotion Practice, developed in 2001, list many of the antecedents and consequences in this manuscript as cues to action and nonaction. For instance, cues to action include motivation, acceptance and support whereas cues to nonaction include anxiety, fear, and denial.10 Many of the antecedents, criteria, and consequences of health promotion in the elderly found in the psychological disciplines were similar to the nursing profession. There was a focus on preventing the antecedents of isolation, dependence, and frailty of the elderly. This requires autonomy, positive attitude, and social support, as well as managing stress and anxiety. As a result, the consequences are similar to the previously discussed discipline: Providing the patient with dignity, wellness, value, and life satisfaction.
MEDICAL DISCIPLINE From the medical perspective, health promotion is linked more with maintenance of disease processes through primary and secondary prevention. Richardson15 looked at health promotion and disease prevention in the elderly. He used a quote from Mark Twain that is often the view of what being healthy means: ‘‘The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not,16p137. Richardson stated that health professionals often focus on health recommendations that are meant for a younger generation, especially because there are few preventive guidelines for the elderly and even fewer that Medicare covers. Throughout his article, he used various screening procedures to guide what clinicians should focus on for health promotion of older adults, but very little was mentioned regarding the focuses that fell into the previously discussed disciplines. For example, for the chosen population of this paper, fasting cholesterol levels, blood glucose
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testing, and electrocardiograms were linked with health promotion. There is one tool created for physicians that focuses more on a holistic approach and is often used in health promotion of the elderly, the Dartmouth Primary Care Cooperative Information Project scale.17 This questionnaire was developed by the Department of Community and Family Medicine at Dartmouth Medical School in the 1980s as a screening tool for primary doctors. Although the original tool also included quality-of-life and social support questions, they were omitted when it was revised to only include pain, activities of daily living feelings, physical fitness, social activities, and current overall health perceptions.17 Unlike simple screenings for disease processes, use of the Dartmouth Primary Care Cooperative Information Project scale also examined the patient’s functional status and impressions of his or her health. Finally, Badertscher et al18 published a qualitative study regarding issues that both improved and hindered health promotion of the elderly from a general practitioner’s perspective. This study defined health promotion exclusively as prevention of disease, thereby keeping the patient out of an assisted care living situation. The researchers found that there was a bias toward focusing on health promotion with the elderly owing to time physician restraints, lack of effectiveness, and the previously mentioned lack of Medicare reimbursement for preventive actions, although participants did acknowledge that the general practitioner was the best first contact for health promotion in elderly patients. They did feel that the use of short questionnaires, such as those that focused on diet, were of value to health promotion of this group. The self-reported questionnaire known as Rate Your Plate is an example of short tool used in Cardiac Rehabilitation to determine the elderly CAD patient’s current diet and help clinicians to promote health.19 The antecedents, criteria, and consequences of health promotion in the elderly were physical in nature. Antecedents of disease and dependence were identified. The criteria for dependence from the medical perspective was different from the two previously mentioned because its focus of autonomy was more on preventing the patient from being placed in a facility and preventing health care costs, rather than the patient actually feeling independent. Health enhancement consequences were based more on criteria of management and maintenance of disease processes in this discipline.
SUMMARY OF LITERATURE REVIEW Throughout the nursing discipline, the view of health promotion is one of holistic care. Rather than focusing on freedom of disease, nursing seeks to promote autonomy, growth, preservation of dignity, and positive connection with others to foster wellness in the elderly (Table 1). For example, cardiac rehabilitation nurses caring for older adults with CAD spend half of the time in the program educating patients so they may make appropriate changes to their risk factors and take ownership of their health care becoming more independent and valued, and preserving their dignity.20 This was also true of the psychological disciplines, which also viewed the patient a whole person rather than just symptoms of diseases. Their focus was more on the mental health of the patient. Rather than focusing on true disease prevention, this discipline focused on helping patients to feel supported and have a
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TABLE 1 HIGHLIGHTS OF HEALTH PROMOTION IN THE ELDERLY WITH CORONARY ARTERY DISEASE (CAD) In 2010, the US Census determined that 13% of the American population was >65 years of age, and the number continues to climb. A lifetime of poor nutrition and lack of exercise has led many elderly patients to experience CAD later in life, leading to invasive procedures and other forms of disease management, that contribute to mounting health care costs. Although health promotion has been accepted as the necessary answer to this problem by many in the health care community, many physicians are still lacking in promoting this concept owing to lack of insurance reimbursements. Antecedents to health promotion in the elderly during the literature review included dependence, anxiety, and isolation. Health promotion in the elderly leads to dignity, value, and life satisfaction.
positive attitude regarding their condition; it is known that eventually, no matter the preventive methods, the elderly will become more frail.12 The medical discipline seemed to focus on physical attributes. Although there was some discussion of health promotion, it was based on a more monetary goal, and the desire to keep the patient free from physical illness, rather than looking at the patient’s emotional and spiritual health. The use of time-saving questionnaires dealing with health status seemed to be of value to this group, rather than those employed by the psychological disciplines, which seemed to focus more on the patient’s perspective of his or her health. Many terms relating to health promotion in the elderly were listed throughout this manuscript based on the reviewed literature. Six terms were chosen that seemed to describe the main concept of health promotion. Table 2 lists selected antecedent, criteria, and consequence terms as they relate to health promotion in the elderly with CAD.
Rationale for selected terms There were many terms that seemed synonymous with health promotion throughout this literature review; with each new concept, the antecedent, criteria, and consequence lists grew. After careful selection, the list was narrowed down to six terms, each of which seemed to embody the concept of health promotion for the elderly with CAD across the three disciplines discussed herein.
Antecedents The antecedents, or terms leading to the concept of health promotion of the elderly with CAD based on the reviewed
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TABLE 2 ANTECEDENT, CRITERIA, AND CONSEQUENCES FOR THE CONCEPT OF HEALTH PROMOTION IN THE ELDERLY Antecedents
Criteria
Dependence stress/anxiety
Autonomy Management/ maintenance Holistic Prevention/change Positive connections/ attitude Self-determination
Disregard Disease Isolation Frailty
Consequences Dignity Wellness Value Growth Health enhancement Life satisfaction
literature, are dependence, stress/anxiety, disregard, disease, isolation, and frailty. In all the literature reviewed, there is an acknowledgment that, as one ages, disease becomes increasingly likely. As a result, the elderly lose their independence owing to illness or other disease modalities. With disease, the older adult can also become frail and not be able to perform activities of daily living. In addition, isolation can be an issue; older adults might not be able to be as mobile or may have lost a spouse or friends owing to advanced age. All of these terms combined can lead the elderly to feel disrespected and disregarded. Terms that related to specific diseases or habits that lead to disease were removed from the list, to encompass a more complete view of health promotion as it was discussed in the literature reviewed.
Criteria The criteria chosen for the selected concept were autonomy, management/maintenance as it relates to disease comorbidities, holistic, prevention/change, positive connections/attitude, and self-determination. Autonomy was chosen rather than independence because one can be autonomous and make decisions without being independent of others. In fact, a prevailing subject in the literature review was the need to not only have a positive attitude, but also to have meaningful support from one’s environment and social circle. It is important in any discussion of health promotion to state disease management and health maintenance as important criteria, but so is prevention and willingness to change unhealthy behaviors. These terms were more encompassing than the term of injury prevention, which was dropped from the final list and replaced with holistic, because health promotion is more than just prevention of physical ailments. Finally, selfdetermination was added along with autonomy because, although one needs to be able to have the freedom to make decisions, it is also important to follow through and act on those choices.
Consequences The final area is consequences, or what occurs as a result of the chosen concept of health promotion in the elderly with CAD.
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The final chosen terms were dignity, wellness, value, growth, health enhancement, and life satisfaction. The terms that were replaced in the final list, such as energy, were replaced with more board terms, such as health enhancement and wellness, because health promotion may be different for every individual, and especially the elderly, depending on his or her current health state. In addition, the reviewed literature showed that elderly patients who felt in control saw more value and dignity in their lives, and thereby reported greater satisfaction with life.12
Theoretical definition The concept of health promotion in the elderly with CAD is a holistic technique that focuses on disease management and prevention, comorbidity maintenance, and lifestyle change to help the older patient maintain positive connections, attitude, autonomy, and self-determination.
Operational definition Health promotion in the elderly with CAD is directed toward helping older adults achieve wellness and increased life satisfaction in light of their current health status. The Dartmouth Primary Care Cooperative Information Project scale is an example of a tool that encompasses health promotion in the elderly with CAD by looking at activity level, smoking status, and health perception.
CONCLUSION Health promotion is a key concept in improving wellness, not just in the elderly, but in all populations. No longer is the focus of being healthy just on the absence of disease; health care providers must see the patient as a whole person, addressing physical, mental, emotional, and spiritual health. This was an issue encountered when performing the medical discipline literature review. Because the increased longevity of the population, physicians and third-party payers, such as Medicare, need to acknowledge the value of health promotion in the elderly, not just as a means for better life satisfaction, but also as a moneysaving strategy.20 Ultimately a happier, more valued population will lead to a healthier future for America.
REFERENCES 1. World Health Organization. Health promotion. http://www.who. int/topics/health_promotion/en/. Accessed April 18, 2014. 2. US Census. Population. Federal interagency forum on aging related statistics. 2010; http://www.agingstats.gov/aging statsdotnet/Main_Site/Data/2012_Documents/Population.aspx. Accessed May 8, 2014. 3. American Heart Association. Statistical fact sheet 2013 update older Americans & cardiovascular diseases. 2013; http://www. heart.org/idc/groups/heart-public/@wcm/@sop/@smd/docum ents/downloadable/ucm_319574.pdf. Accessed May 8, 2014. 4. Pender N. Health promotion model. 1982; http://deepblue.lib. umich.edu/bitstream/handle/2027.42/85350/HEALTH_PRO MOTIONMANUAL_Rev_5-2011.pdf?sequence=1. Accessed April 18, 2014. 5. McEwen M, Wills EM. Theoretical basis for nursing. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins; 2011.
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6. Miller JW. Wellness: the history and development of a concept. Spektrum Freiziet 2005;27:84-106; http://www.fh-joanneum.at/ global/show_document.asp?id=aaaaaaaaaabdjus&. Accessed April 18, 2014. 7. Dunn HL. Points of attack for raising the levels of wellness. J Natl Med Assoc 1957;49(4):225-35; http://www.ncbi. nlm.nih.gov/pmc/articles/PMC2641304/pdf/jnma007160025.pdf. Accessed April 18, 2014. 8. Dunn HL. High level wellness for man and society. Am J Public Health 1959;49(6):766-92; http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1372807/pdf/amjphnation00322-0058.pdf. Retrieved April 18, 2014. 9. McMahon S, Fleury J. Wellness in older adults: a concept analysis. Nursing Forum 2012;47(1):39-51. http://dx.doi.org/10.1111/j.1744-6198.2011.00254.x. 10. Raingruber B. Contemporary health promotion in nursing practice. Burlington (VT): Jones & Bartlett; 2013. 11. Parissopoulos S, Kotzabassaki S. Orem’s Self-Care Theory, Transactional Analysis and the Management of Elderly Rehabilitation. ICUS NURS WEB J 2004;(17); JAN-MAR. Retrieved from http://www.researchgate.net/publication/ 253650815_Orem%27s_Self-Care_Theory_transactional_ analysis_and_the_management_of_elderly_rehabilitation_ %28citations_32%29. 12. Wilhelmson K, Eklund K. Positive effects on life satisfaction following health- promoting interventions for frail older adults: a randomized controlled study. Health Psychol Res 2013;1(12):44-50; http://dx.doi.org/10.4081/hpr.2013.e12. 13. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982;17(1):37-49.
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14. Lach HW, Everard KM, Highstein G, et al. Application of the transtheoretical model to health education for older adults. Health Promot Pract 2004;5(1):88-93. http://dx.doi.org/10. 1177/1524839903257305. 15. Richardson J. Considerations for health promotion and disease prevention in older adults. Perspectives in Prevention from the American College of Preventive Medicine, http:// www.medscape.com/viewarticle/531942; 2006; Accessed April 18, 2014. 16. Twain M. Pudd’nhead Wilson’s new calendar. Following the equator, Vol. II. New York: Harper & Brothers; 1907:137. 17. Haywood K, Garratt AM, Schmidt LJ, et al. Health status and quality of life in older people: a review. Patient-Reported Health Instruments Group. 2004; http://phi.uhce.ox.ac.uk/ pdf/phig_older_people_report.pdf. Accessed April 19, 2014 18. Badertscher N, Rossi PO, Rieder A, et al. Attitudes, barriers and facilitators for health promotion in the elderly in primary care: a qualitative focus group study. Swiss Med Wkly 2012;142:w13606. http://dx.doi.org/10.4414/ smw.2012.13606. 19. Brown University Institute for Community Health Promotion. Rate your plate. 2005; from http://brown.edu/academics/ public-health/centers/community-health-promotion/sites/brown .edu.academics.public-health.centers.community-health-promo tion/files/uploads/Rate%20Your%20Plate.pdf. Accessed April 20, 2014. 20. American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac rehabilitation: low cost, low technology, great medicine! 2013; https://www.aacvpr.org/Portals/0/ resources/professionals/CRPresentationforPhysiciansAHA_ Jan2013.pdf. Accessed April 23, 2014.
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