Social Determinants of Health: Considerations for Care of Older Veterans.

Social determinants of health (SDOH), the environments and circumstances in which people are born, grow, live, work and age, are potent drivers of health, health disparities, and health outcomes over the lifespan. Military service affords unique experiences, exposures, and social and health vulnerabilities which impact the life course and may alter health equity and health outcomes for older veterans. Identifying and addressing SDOH, inclusive of the military experience, allows person-centered, more equitable care to this vulnerable population. Nurses and other health professionals should be familiar with how to identify and address health-related social needs and implement interdiciplinary, team-based approaches to connect patients with resources and benefits specifically available to veterans.

Older Patients' Perspectives on Managing Complexity in CKD Self-Management.

BACKGROUND AND OBJECTIVES: Patients with CKD are asked to perform self-management tasks including dietary changes, adhering to medications, avoiding nephrotoxic drugs, and self-monitoring hypertension and diabetes. Given the effect of aging on functional capacity, self-management may be especially challenging for older patients. However, little is known about the specific challenges older adults face maintaining CKD self-management regimens. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted an exploratory qualitative study designed to understand the relationship among factors facilitating or impeding CKD self-management in older adults. Six focus groups (n=30) were held in August and September of 2014 with veterans≥70 years old with moderate-to-severe CKD receiving nephrology care at the Atlanta Veterans Affairs Medical Center. Grounded theory with a constant comparative method was used to collect, code, and analyze data. RESULTS: Participants had a mean age (range) of 75.1 (70.1-90.7) years, 60% were black, and 96.7% were men. The central organizing concept that emerged from these data were managing complexity. Participants typically did not have just one chronic condition, CKD, but a number of commonly co-occurring conditions. Recommendations for CKD self-management therefore occurred within a complex regimen of recommendations for managing other diseases. Participants identified overtly discordant treatment recommendations across chronic conditions (e.g., arthritis and CKD). Prioritization emerged as one effective strategy for managing complexity (e.g., focusing on BP control). Some patients arrived at the conclusion that they could group concordant recommendations to simplify their regimens (e.g., protein restriction for both gout and CKD). CONCLUSIONS: Among older veterans with moderate-to-severe CKD, multimorbidity presents a major challenge for CKD self-management. Because virtually all older adults with CKD have multimorbidity, an integrated treatment approach that supports self-management across commonly occurring conditions may be necessary to meet the needs of these patients.

Better learning through instructional science: a health literacy case study in "how to teach so learners can learn".

Health education and behavior change interventions typically pay little attention to the intervention's instructional foundation. Combining the fields of health literacy, cognitive psychology, and adult learning theory, this article provides an integrative scientific approach, called the BEAN (Better Education and iNnovation) model, to creating an instructional foundation based on how individuals acquire knowledge and skills. The article uses a case study example from an adult literacy center's health literacy class to explore how environmental factors and instructional strategies can be applied to health education and behavior change interventions. Data for this case study were derived through 20 hours of classroom observation and qualitative interviews with 21 adult education students and 3 instructors. Results provide practical examples of environmental factors and instructional strategies designed to facilitate learning, such as fostering autonomy, activating prior knowledge, and fostering perspective change. Results also describe the resulting health behavior changes of students attending the health literacy class, such as increased medication adherence and physical activity, improved nutritional habits, and increased question asking of health practitioners. This article serves as a first step to encouraging researchers and educators to consider the importance of drawing on cognitive psychology and theories of adult learning to create a scientifically based instructional foundation for health behavior change programs. Additionally, by drawing on the expertise of adult educators well versed in the science of instructional design, this article also demonstrates that the adult education classroom is an excellent setting for conducting health education and behavior change interventions.

An overview of dual sensory impairment in older adults: perspectives for rehabilitation.

Dual sensory impairment (DSI) refers to the presence of both hearing loss and vision loss. The occurrence of DSI is particularly prevalent among the aging population, with studies showing between 9% and 21% of adults older than 70 years having some degree of DSI. Despite this, there is little direction regarding recommended clinical practice and rehabilitation of individuals with DSI. It is assumed that the problems encountered by individuals with DSI are considerably greater than the effects of vision impairment or hearing impairment alone, because when these two sensory impairments are combined, the individual is seriously deprived of compensatory strategies that make use of the nonimpaired sense. In this article, the literature available regarding DSI is summarized, and research needs regarding rehabilitation strategies are outlined and discussed. Simple suggestions for addressing DSI are provided that use available tools and technology.

Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy.

BACKGROUND: The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence. OBJECTIVES: To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions. RESEARCH DESIGN: Prospective cohort study. SUBJECTS: New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549). MEASURES: Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG> or =20%. RESULTS: Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64). CONCLUSIONS: The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.