Motivating Physical Activity Continuation in the Elderly

Sandra Cromwell, PhD, RN

Physical activity is known to benefit people of all ages. However, 70% of the elderly (>age 65) engage in no physical activity (PA); and most of those who do begin PA, stop again within 3-6 months.

Of special concern are members of ethnic minority groups, as statistics show that these elders are even more inactive than the general population. Women of all ethnic groups are more inactive than men, making minority women the least physically active group in the U.S. The consequences of this inactivity are premature decline in physiological functioning, early onset of disease, and premature dependency.

Prior PA research has focused primarily on PA initiation, not continuation. Two studies will focus on motivating elders to begin physical activity and continue physical activity long term. The first study addresses motivating Mexican American sedentary women to continue PA. Dr. Judith Berg, a Womans’ Health NP, and Dr. Mark Arnett, an exercise physiologist, are co-investigators on this study funded by the National Institute of Nursing Research. The second study will occur in Taiwan and Dr Cromwell will conduct this study in collaboration with faculty of a school of nursing in Taiwan.

For more information, or to become involved in either of these studies, please contact Sandra Cromwell at 626- 4036, or cromwell@nursing.arizona.edu.

Adolescents' Decision-Making about Drug Use

Caroline R. Ellermann, PhD, RN

Use of alcohol, tobacco and other addictive drugs (ATD) is a well-recognized public health concern and one of society’s greatest problems. Evidence indicates that some youth begin and end drug use during adolescence. A grounded theory methodology was used to explore adolescents’ views of their experience of beginning and ending ATD use. A Basic Social Psychological Process, Starting and Stopping, was identified from 12 interviews. Informants were age 14 to 18, had tried drugs at least 6 times and abstained for at least 6 months. Decision-making about drug use was described.

Three stages of use that led to decision points were found. If adolescents did not stop use during the beginning stage, Exploratory Use, the adolescents had the potential to progress through two additional stages of use, Purposeful Use and Intentional Use. The intensity of use increased with each stage. Each stage had identifiable triggers and barriers that had the potential to influence continued ATD use. Curiosity was a strong stimulus for beginning drug use and then exploring never-used-before drugs. An intervening dramatic event moved adolescents more quickly toward stopping. Future orientation was present as informants stopped drug use. Decisional points were characterized by the integration of what adolescents felt were benefits of use: friend relationships, liking the experience, learning about drugs, getting relief from perceived problems; and barriers to continued use: no continued interest, not liking the experience, goals obtained, effect on relationships, effect on future, dramatic event.

A Basic Social Structural Process was beginning to emerge. The structural process included drug availability, peer drug use and societal environment. The theory of adolescent decision-making about ATD use provides an opportunity for health professionals to better understand adolescent drug use.

A Multidisciplinary Model for Diabetes Disease Management

Donna Zazworsky, MS, FAAN; Estella Garcia, BSN, RN; Mary Stevens, LPN; Jim Dumbauld, DO; Robin Bleecker, RN; Linda Parker, BSN, RN; Daniel Casto, MD; Katherine Robinson, RD, CDE

St. Elizabeth of Hungary Clinic, a large primary and specialty care clinic for the uninsured, implemented a multidisciplinary disease management program to demonstrate the relationship between interventions and patient outcomes. Utilizing the FAST model (Lamb and Zazworsky, 2000), 114 patients were: 1) identified through ICD-9 codes for Type II diabetes, 2) risk assessed utilizing a risk assessment tool and a chart audit process, 3) stratified into Low, Moderate, Moderate-High and High groups and 4) provided care by a physician or nurse practitioner who followed the ADA clinical guidelines flow sheet and referred for 1:1 diabetes education provided by the nutritionist and nurses.

A Model for Enhancing Shared Decision-Making: SAVAHCS Pilot of Patient Appointment Guidebook

Connie S. Wilkinson, RN, PhD and
Marjory Williams RN

The purpose of this pilot study was to determine if providing patients with an educational guidebook designed to increase participation in the health care visit resulted in improved patient and system outcome measures. Two hypotheses where studied: first, that the mean item scores on an instrument to assess patient perception of effectiveness of a visit would be higher for the group receiving the guidebook prior to the visit than for the control group; and second, that the proportion of patients receiving recommended health promotion and disease prevention interventions would be higher in the group receiving the guidebook prior to the visit as compared to the control group.

A random sample of 280 patients scheduled for primary care team visits at the SAVAHCS Tucson facility, were assigned to one of two groups. The intervention group received the guidebook, while the second group was the control. The intervention group received a patient appointment guidebook with instructions in the mail prior to the scheduled routine visit with their primary care provider. Following the scheduled visit, patients in both groups were sent a short questionnaire with instructions and a postage-paid return envelope. Patients were informed in writing in the mailings that they had been selected to participate in a study designed to improve primary care services, that submission of the questionnaire constituted consent to participate, and that confidentiality of responses and comments would be maintained.

Approximately forty percent (40%) of the selected patients have returned completed post-visit questionnaires. The rate of return for the control group is 51%, compared to 28% for the group receiving the patient appointment guidebook. Patients in the group receiving the appointment guidebook report a higher level of satisfaction pertaining to involvement in the decision making process than do patients in the control group. This finding may indicate that providing patients with the appointment guidebook influenced their ability to participate in patient-provider interactions.
The results of the pilot investigation will be applied to the design of a larger research study to further investigate the impact of interventions to improve patient-provider relationships on patient and health care system outcomes.

Shu-Fen Wung, PhD, RN

Advanced practice nurses are assuming important responsibilities for early assessment and management of patients with an acute myocardial infarction (AMI). Standard 12-lead ECG is the standard of care for early assessment of AMI and is the major determinant of eligibility for reperfusion therapy. However, standard 12-lead ECG fails to detect ischemia in the posterior wall of the left ventricle so that patients with posterior wall AMI are often misdiagnosed and ineligible to receive early reperfusion therapy. Thus, a sensitive and specific ECG system is needed for early and accurate assessment of patients with posterior wall AMI.

Extensive literature search reveals that adding the posterior leads V7-9 only provides limited additional diagnostic information to the standard 12-lead ECG when the currently used ischemic criterion of 1 mm is applied to the posterior leads. Since the posterior leads are further away from the heart than the anterior precordial leads, the ECG recordings are often small in voltage. A study was designed to delineate ischemic criteria in the posterior ECG leads. In brief, in 53 patients undergoing non-emergent angioplasty via brief controlled occlusion of the left circumflex (LC) coronary artery (clinical model of posterior ischemia), continuous 15-lead ECGs (standard 12-lead plus V7-9) were recorded. The major finding of this study is that the currently used ischemic criterion of 1 mm for acute myocardial ischemia is inadequate to detect ST segment elevation in the posterior leads. Approximately half of the subjects had ST elevation ranging from 0.5mm to 1mm in the posterior ECG leads during LC coronary artery occlusion. Adjusting the ischemic criterion from 1 mm to 0.5 mm in V7-9 significantly improved the frequency to detect acute ischemia from 49% using the 12-lead ECG to 94% using the 15-lead ECG (p=0.000). Thus, an ischemic criterion of 0.5 mm in the posterior leads should be considered for acute posterior ischemia.

For a further indepth report of this study, see Wung SF, Drew BJ. New electrocardiographic criteria for posterior wall acute myocardial ischemia validated by a percutaneous transluminal coronary angioplasty model of acute myocardial infarction. Am J Cardiol 2001; 87, 970-4.