Although support groups exist for people trying to cope with similar health problems, the needs of the elderly may require modification of these groups. This article describes an information and support group modified specifically for the older adult. The characteristics of the older adult are described, case studies and themes illustrated, and the content of the modified community-based program is outlined.
Ninety-five percent of all older persons live in the community. Most of them live independently in their own homes or apartments. About one in six older persons lives in a household with relatives other than his or her spouse.' Increasingly, there is a need to structure interventions specifically designed to target this population.
The older person in the community may face many problems, some of them health related. There is a strong association between age and morbidity and disability from chronic diseases.2 One major chronic illness facing the elderly is diabetes mellitus. Approximately 8.6% of the population age 65 and older have noninsulin dependent diabetes (NIDDM). This compares to approximately 2.35% of the total population with a diagnosis of NIDDM.3 The resultant complications of diabetes can affect millions of elderly persons.4 An information and support group for the elderly with diabetes is an appropriate, effective, and economical approach designed to target the elderly in the community.
Although many healthcare agencies offer programs for coping with a chronic illness such as diabetes, these programs usually address the illness during its acute phases. Initial inpatient education focuses on learning the necessary skills and information to safely return home and manage the chronic illness. Little information may be given as to how to actually make the necessary lifestyle changes needed. Individuals may be unable to apply the knowledge they have acquired relative to the event or be without the support necessary to assist them in practicing new behaviors or skills. This deficiency may result in nonadherence to treatment regimens and poor adaptation to the new lifestyle.
Lifestyle modification necessitated by the onset of diabetes may be especially difficult to accomplish for the elderly. Lifelong habits and preferences are hard to change. Investigations have shown that assistance of supportive others is helpful in making lifestyle changes. Research on the concept of social support has centered around the role of social support in health and wellbeing5 and in adherence with the prescribed treatment regimen. Conceptually, social support is defined as input by family, friends, or support groups that furthers the person's goals or assists the person to develop and maintain physical and psychological well-being.6
Researchers and diabetes educators developed and tested a series of information and support groups for persons with diabetes.7 However, these groups did not take into consideration the specific needs of the older adult. The authors revised the sessions specifically for the older adult, then conducted the group sessions for elderly persons with diabetes from an outpatient geriatric clinic.
The potential group participants were selected from a sample that included all patients with NIDDM diabetes registered in the geriatric outpatient clinic of a large metropolitan hospital. Patients excluded from this sample were those who resided in a skilled care facility or who had a concurrent diagnosis of dementia. Physicians were informed of the purpose and goals of the group. Members of the group were mailed letters inviting them to participate.
Although small in number, the participants of the diabetic support group were representative of many elderly. All were single women who lived alone, either in their own home or apartment. They were also dependent on public or specialized transportation. The following are descriptions of the three members of the group.
Miss A is an 84-year-old single, retired, registered nurse. She is obese. Her NIDDM diabetes is moderately well-controlled by an oral hypoglycemic. It was diagnosed one year ago, while she was hospitalized for a cerebral vascular accident. Seven other medical conditions interfere with her functioning and require confinement to a wheelchair and specialized transportation now that she has left her apartment. She had recently returned to community living after post-hospital ization in a skilled facility.
Although Miss A was knowledgeable about health issues, she had not realized she was diabetic until she received the invitation to participate in the group. The group assisted her in accepting the diagnosis and its meaning. Her contributions to the group included some historical aspects of nursing, accounts of raising a niece (whom she remains close to) as a single parent, deciding to remain single despite the social stigma, and societal response to seeing a wheelchair-bound elderly lady alone in a shopping mall.
Mrs M is a 78-year-old widowed, retired clerical worker. She has outlived two husbands and has only one child with whom she shares holidays but little else. She has been diabetic for 16 years and is overweight. Control has been achieved with increasing dosages of an oral hypoglycemic. Her four other medical conditions do not impede her functional status. Mrs M maintains her independent lifestyle and shares her knowledge of community resources as well as information on low-salt, low-fat diets.
Mrs N is a 67-year-old divorced homemaker. She has been diabetic for eight years, starting with an oral hypoglycemic then switching to insulin with the need for increasing dosages. She is obese. She has five other health problems, but only one, her degenerative joint disease, affects her daily functioning. Her network of friends and her voluntary organizations substitute for her family who live out of town. Mrs N was the only member to bring a friend or family member to the group. She shared pamphlets on nutrition and community events for older adults, and also her experiences with a swimming class for people with arthritis.
Information & Support Content
The group method used was five weekly sessions of Wi hours. Each session had stated objectives, outline, and handouts. A statement about confidentiality was included in the initial session. The focus of the information that was given to all the groups in the study was not changed. However, specific content, examples and degree of complexity were revised from the original material to enhance its relevancy for an elderly population. In each session, discussion by participants as well as the inclusion of family and friends were encouraged. The following group goals were stated and emphasized:
1 . Expressing common problems
2. Sharing ways to cope with similar problems
3. Decreasing social isolation
4. Increasing adjustment to diabetes through adaptation of a healthy lifestyle.
The following is a brief description of the didactic content for each weekly session:
Identification and information concerning five components of a healthy lifestyle (diet, exercise, rest and relaxation, stress reduction, and utilization of resources) were presented in the first session. In addition, a historic viewpoint on wellness was presented. Diet information was adjusted for age-specific norms with emphasis placed on calcium intake. Acknowledgement was given for lifelong health decisions which helped participants attain their present age.
Included in session two were descriptions of change theory and helpfuí hints for maintaining change. In this session, emphasis was placed on the fact that older persons had indeed lived through many, and often rapid, changes. In addition, new strategies were taught to help participants cope with changes. Examples used in the group came from the participants' past. Prior individual coping strategies were discussed and shared. For example, Mrs N found that political involvement and becoming active in the tenants' union helped her to make friends and become less socially isolated.
Making changes for a more healthy lifestyle was also discussed. Specifically, the benefits of weight loss and calcium intake were reviewed. Verbal encouragement, acceptance and group support were given to enable members to make targeted changes in their lifestyle.
Session three's content included the physiological effects of exercise on diabetes and methods to establish a personal exercise program. The content of this session was revised from the original. All of the participants had additional medical problems (eg, hypertension, obesity, arthritis) which prevented them from following through with content as originally written. Therefore, each member was assisted to develop a specific exercise program tailored to their functional status. Miss A's program consisted of upper-body wheelchair exercises scheduled at specific times during her typical day. Mrs N started a graded walking program in a shopping mall close to her home. Mrs M was given positive encouragement to continue her swimming program designed for people with arthritis.
The original content on stress management included a detailed description of the action of stress hormones on the body and on blood sugar. This information was greatly simplified. The members expressed difficulty distinguishing symptoms related to stress, to diabetes, and those that could be attributed to their other medical conditions. For example, dizziness, fatigue, and difficulty sleeping could have many etiologies. Sorting out possible causes and developing decision trees and action plans were well-received by the participants.
The last session was a summary and review. It also contained information about community resources. The group members shared information about resources found in their individual neighborhoods and communities. Time was also allotted for termination amongst the group members, including the facilitators.
Many themes recur when working with the elderly. For example, the focus of the group often strayed from the topic of diabetes to the management of other health problems. Physical ailments were many. Diabetes was far from a priority as a health concern; it was "just something else they had." Diabetes may not impact on daily functioning and mobility to the same extent as musculoskeletal conditions. Also, other illnesses may be more severe making demands on the elderly 's limited energy reserves. If the focus of a group is directed toward one disease entity, it may be necessary to choose persons who have been newly diagnosed with the disease or have had a change in the severity or management ofthat disease.
The information given on healthy lifestyle was related not only to the participants' diabetes but also to their other health conditions. Nutrition, weight control, exercise, and stress reduction, which were components of group content, are important aspects in the management of many other health conditions (eg, arthritis and heart disease).
The need for emotional support was another constant theme of the group. AU group members were either widowed, divorced, or single. All lived alone. Although family and friends were welcome, none attended due to physical illness or distance. Only one member had a relative who lived nearby. The group process met the emotional need for support as evidenced by very good attendance, despite the fact that all the group sessions were in winter. Some of the sessions were postponed due to severe weather or holidays. Frequent telephone calls were utilized to keep everyone informed.
All members of the group were very open in sharing their concerns on any topic. Although sessions were intended to last l'/2 hours, the discussion extended to two or more hours each time. Leaders were expected to share themselves,8 their opinions, and experiences as well.
Evaluation of Intervention
Two months post program, telephone interviews were conducted by an individual not associated with the original study. Example comments received in the evaluation included that it was "good to talk to someone in the same boat;" "everyone contributed to the group and made it interesting;" and "I would participate again in an information/support group."
In addition to the subjective positive feedback indicating that information had been imparted and support given, there were also some objective data which indicated that lifestyle changes had occurred. According to the outpatient clinic records, two out of three of the overweight or obese members showed a weight loss of greater than ten pounds six months after the group ended. Two participants no longer needed increases of diabetic medication. One member now takes calcium and exercises on a regular basis and another member uses a glucometer.
Some practical considerations need to be addressed when formulating a support group. Transportation can be a formidable problem. Many city-dwelling elderly rely on public transportation. However, it can become increasingly difficult to use public transportation if one uses a cane, walker, or has a musculoskeletal condition which can be so common among the elderly. Specialized transportation, eg, vans with ramps, may be the only means by which potential group members can leave their residences. A thorough knowledge of the communities' transportation resources, criteria for use, and geographic limitations is essential.
Assistance with arrangement of specialized transportation should be available. If any of the group members are able to drive, carpools could be arranged. Groups could also be arranged in communal meal sites and elderly housing adult day care centers to facilitate accessibility.
Another consideration when forming a support group is the climate of the area, time of year, and time of day. The elderly are at risk for hypo- and hyperthermia, and extremes of temperature and severity of climate may restrict attendance. It is also best to avoid groups that meet after dark because of the increased risk of crime and injury due to falls when out alone at night.
There may be other factors that need to be addressed when working with an elderly population, especially in a group format. There may be a need to provide an environment conducive to the hearing or visually impaired. An assistive listening device that selectively amplifies sound can be used by many individuals without a hearing evaluation. This device is very useful for the mildly impaired, especially in a group situation.
Use of large, serif-type printed material and contrasting colors may assist the visually impaired. Cognitive impairments are more difficult to address but not, of necessity, difficult to overcome. Maintaining group sessions on the same day in the same place and at the same time is helpful. Using a readability formula to simplify written material to a sixth- or eighth-grade level might also be useful.
Multiple medical conditions can also impede the participation of group members. The location and site must be handicapped-accessible including the restroom facilities, which should be close to the meeting area. Cushioned chairs with arms and footstools would be helpful in assisting those individuals with arthritis, congestive heart failure, etc, to participate. With nurses as group facilitators, medication assistance as well as individual tolerance assessment can be made.
The use of an information and support group as a nursing strategy is an effective tool to help promote adjustment to chronic illness. Although barriers to implementation do exist, they are not insurmountable. Utilization of the above-mentioned strategies may assist nurses to carry out this cost-effective intervention for the elderly with chronic illness as well as groups with other focuses.
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