Which factors enable older adults with multimorbidity to adapt and self-manage to increase health? A narrative literature review

Background: As ageing is accompanied by chronic illnesses, and chronic diseases account for most of the expenditures of the healthcare system, older people constitute an increasingly important population that is characterized by multiple medical conditions, cognitive and functional impairment and social problems. Multimorbidity leads to complex care through the use of different treatment strategies and the involvement of various health care professionals, which may lead to opposing advices or medications. Therefore patients with multimorbidity are at risk for suboptimal treatment, unsafe care, inefficient use of health care services, unnecessary costs and consequently higher risk for adverse events (van Oostrom, 2012). Challenges for current and future healthcare delivery are the growing group of older adults, the heterogeneity of this group, and the increasing healthcare costs for people with chronic conditions. As these people have to cope with physical, emotional, and social challenges of their chronic diseases and disabilities the question is which factors enable older adults with multimorbidity to adapt and self-manage.In this context the WHO definition formulated in 1948 can no longer be used. This definition describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 2003). Therefore in this research the new proposed concept of health as “the ability to adapt and to self-manage” is used (Huber, 2011).

Method: In this research the effect of multimorbidity on self-management and adaptation is explored by conducting a narrative literature review over the last fifteen years in English, German or Dutch on the key words older adults, coping, self-management, self-related health and multimorbidity. References lists from selected studies were evaluated to identify any additional relevant articles. Articles were excluded if they addressed one specific disease or health topic or if they did not address coping with multimorbidity in older adults.

Literature review: The literature shows several factors that influence health and the perception of health of older people with multimorbidity: social network, socio-economic status, cultural and personal attitudes to health and disease, prior experiences with the health care system, , living alone status, education level and patient’s coping strategies (Ament, 2012). Patients with multimorbidity and chronic diseases perceive their health differently, depending on somatic, social, mental and cognitive variables and patients adapt in multiple different ways(Strumberg, 2014 B).

There is a strong association between increasing medical comorbidity with reported worse self-related health (Perruccio, 2012; Berglund, 2014; Nützel, 2014). Self-rated health correlates with more urgent service use, hospitalization and mortality and reflects an individual’s health trajectory, and is predictive for the need for support for self-management activities (Martin, 2014; van Houtum, 2013). Medically complex patients and patients with increasing age tend to think their circumstances are controlled by outside factors (external locus of control). This highlights the importance of attending to psychological needs of individuals with multimorbidity, particularly as providers engage patients in decision-making processes and care plans (Henninger, 2012; Schnee, 2013).

Patients with multimorbidity want convenient access to health care, individualised care plans, support from one coordinator of care, and continuity of relationship with health professionals (Bayliss, 2008; Shadmi, 2006; McCormack, 2008). People with multimorbidity experience a poorer quality of life, yet they try to preserve their autonomy to the most possible extent and hold positive attitudes towards life (Loffler, 2012). They hope to find meaning and purpose, and desire to regain identity and sense of self-worth (Fortin, 2004; Duggleby, 2011;Holm, 2013). Therefore health care delivery systems should take patients potential for pro-active cooperation into account as they uniquely possess knowledge of their condition and circumstances (Edgren, 2012). Aim should be integrating patients’ needs and expectations in their care in order to result in higher self-related health (Strumberg, 2014A; Loffler, 2012).

Many current programs mention self-management interventions, but rarely define self-management and describe how the intervention is supposed to work (Ouwens, 2005; Boult, 2009; Wolff, 2009; de Bruin, 2012; Spoorenberg, 2013). This is relevant because there is often little association between disease complexity and level of self-management behaviors (Battersby, 2003).

Discussion: As health is the ability to adapt and self-manage health systems need to adopt these perspectives into in the development and evaluation of care trajectories for older adults with multimorbidity. The process of irreversible decline and the coping style of patients should also be addressed as well as the fact that many older adults with multimorbidity cope, not on their own, but with assistance from informal caregivers (Lanoix, 2013). To empower older adults in daily practice in maintaining balance, stability and adjusting a framework, like for instance the Neuman Systems Model, should be adopted by healthcare providers that takes physiological, psychological, sociocultural, developmental, and spiritual factors into account (Merks, 2012).