Living Well as an Older Adult with Multiple Chronic Conditions: An Annotated Bibliography

Living Well as an Older Adult with Multiple Chronic Conditions: An Annotated Bibliography

Prepared by: Katherine Coatta & Andrew Wister

September 2013

Living Well as an Older Adult with Multiple Chronic Conditions

LiVWELL Research Group Research Mission: To foster innovative and interdisciplinary research and advance knowledge on living well with chronic disease across the life course.

Background: LiVWELL is an

The LiVWELL team members hold an

interdisciplinary chronic disease

integrated view of health research that

research group bridging Simon Fraser

emphasizes the interdependence of

University (SFU) researchers with

humans, health, and the physical,

diverse backgrounds and disciplinary

political, and social environment. Our

skill sets. This team was initiated as a

research program is designed to

way to develop and further chronic

cultivate a multi-level and mixed-

disease research at SFU, through

methods approach considering both

funding provided by SFU’s Community

the influences on and impacts of

Trust Endowment Fund.

chronic disease at individual, community, and policy levels.

About the authors: Katherine Coatta is a Master’s student in the Department of Gerontology at SFU. Her research interests include resilience in older adults and the creation of healthy communities.

Dr. Andrew Wister is an internationally recognized expert on aging research, issues, policies and training. He has been committed to research and training in the field of aging since the mid-1980s, and was the principal architect of Simon Fraser University’s graduate gerontology programs.

This document is distributed for purposes of comment, discussion, and research only. It may not be reproduced without permission of the authors. Information reported in this publication was supported by the LiVWELL Research Group and funded through the Community Trust Endowment Fund at Simon Fraser University. The opinions expressed in this document are those of the authors and do not necessarily reflect those of the LiVWELL Research Group.

More information on LiVWELL Research Group can be found at: www.livwellresearch.ca.

Contact us at liv_well@sfu.ca © LiVWELL Research Group, Simon Fraser University; ISBN: 978-0-86490-347-0 (Electronic Edition)

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Table of Contents LiVWELL Research Group ........................................................................................... 1 Report Summary .......................................................................................................... 3 Introduction .............................................................................................................................. 3 Method ..................................................................................................................................... 4 Defining and Quantifying Living Well & Multimorbidity .................................................... 5 Living Well: Older Adults’ Perspectives ............................................................................... 8 Fostering Living Well with Multiple Chronic Conditions ................................................. 10 Conclusion ............................................................................................................................ 14

Bibliography Contents ............................................................................................. 15 1. Defining and Quantifying Living Well and Multimorbidity ......................................... 23 a) Conceptual Development ................................................................................................... 23 b) Measurement Tools ............................................................................................................. 36 c) Quantifying Living Well and Multimorbidity ..................................................................... 47

2. Living Well: Older Adults’ Perspectives ........................................................................ 67 3. Fostering Living Well with Multiple Chronic Conditions ............................................ 82 a) Self-care and Self-management: The Informed, Activated Patient ............................... 82 b) Formal Care: Creating Prepared, Proactive Practice Teams .......................................... 99 c) Health Care System Reform ............................................................................................. 104 d) Community Support: A Socio-ecological Approach .................................................... 110

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Report Summary Introduction The purpose of this annotated bibliography is to create a database of studies that capture multidimensionality in the experiences of aging with multiple chronic conditions, and in particular, positive adaptation or what has been termed ‘positive deviance’. Our guiding question was: Why do some individuals with multiple chronic conditions manage and live with chronic illnesses better than others? Within this report, ‘living well’ is used as a broadly conceived term, aimed to include indications of well-being from physical, functional, psychological, social and emotional health domains. Underlying living well is the concept of wellness, which is considered to be an ever-changing process of realizing one’s potential as defined by the individual and based on a holistic view of human beings (McMahon & Fleury, 2012).

It is recognized here that health trajectories occur over a persons’ life, and therefore, must be understood within a life course perspective. However, a decision was made to focus on older adults, broadly defined as persons aged 50 and over, given the increased risk of chronic disease and multiple chronic conditions among persons at the latter stages of their life cycle, coupled with rapid population aging as the baby boomer generation transitions into their 50s, 60s, and beyond (Lochner & Cox, 2013). As such, this project is also guided by the concept of ‘healthy aging’ – a process of facing health challenges by optimizing function in all areas of one’s life (Hansen-Kyle, 2005).

The literature on chronic conditions has typically been focused on the burden of disease. On an individual level, chronic conditions have been associated with depression, decreased functional ability, decreased social interaction and lower life satisfaction (Hunger et al., 2011; Lee, Choi & Lee, 2001; Tinetti et al., 2011). From a societal perspective, chronic conditions have been correlated with longer hospital stays, increased use of health care resources, and decreased productivity (AGS Expert Panel, 2012). However, in spite of these disadvantages, many older adults living with multiple chronic conditions maintain a positive sense of well-being, and often rate themselves as ‘aging successfully’ (Strawbridge et al., 2002). This ‘well-being paradox’ (Windle, Woods & Markland, 2010), wherein life satisfaction is maintained in the face of objectively poor health, provides one impetus for the collection and review of diverse literature addressing ‘living well’ with multiple chronic illnesses.

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This review further takes into account the multiple terminologies used in relation to living with more than one chronic disease. In academic literature, there has recently been an increase in attention devoted to multiple chronic illnesses (multiple morbidity), given potential synergistic effects across diseases (De Groot et al., 2003).

Multiple chronic illnesses are defined as conditions where an individual has been diagnosed with more than one chronic disease – a condition that is slow in progression, long in duration, and typically limits function, productivity and quality of life (Institute of Medicine, 2012). This can be distinguished from comorbidity, which also includes multiple chronic illnesses, but is defined in terms of an index disease, such as persons with cardiovascular disease who also have diabetes.

The following annotated bibliography, containing reviews and commentary of almost 100 articles, assists the LiVWELL research group, as well as other researchers and organizations, in their goal of identifying multidisciplinary, solution based strategies to mitigate the negative impacts of aging with chronic conditions at all levels, including solutions for individuals, their families and communities, the health care system and the environment. The method for article selection, review, and classification continues below, followed by analysis and review of the emerging themes and future areas of research identified from reviewed articles. For ease of use, a separate table of bibliography contents is then further included, along with individual document summaries.

Method An environmental scan of the literature was conducted to obtain a broad representation of living well with multiple chronic conditions from a variety of perspectives and disciplines. Emphasis was placed in three areas of inquiry: •

Identifying how living well has been defined and quantified within the academic literature,

•

Understanding the perspectives of older adults, and;

•

Accumulating evidence on how living well may be fostered in the future.

The articles included in the annotated bibliography range from 1995 to 2013 and have been organized according to these three focus areas, and were reviewed with respect to article purpose, methodology, and findings. Additional commentary was

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also included for readers in order to better situate the paper alongside other reviewed articles as well as the larger academic field.

Defining and Quantifying Living Well & Multimorbidity The purpose of selecting this focus area was to ascertain how researchers and professionals have defined and measured living well, and how multiple chronic conditions have been examined in this diverse literature. Three types of research contributed to this understanding: conceptual developments, analyses of measurement tools, and quantitative studies.

A number of inter-related terms arose when searching for indicators of living well.

Common conceptualizations included healthy aging, defined above, (Hansen-Kyle, 2005; Depp et al., 2007; Peel et al., 2005) and successful aging (Baltes & Carstensen, 1996; Rowe & Kahn, 1997; Crowther et al., 2002; Dillaway & Byrnes, 2009; Kahana & Kahana, 2001; Strawbridge et al., 2002), though there has been little agreement over how these concepts should be operationalized. Rowe and Kahn (1997) identified three criteria for successful aging: avoidance of disease and disability, maintenance of physical and cognitive function, and engagement in social and productive activities.

However, these criteria have been met with criticism since they exclude the majority of older adults who are living with multiple chronic conditions. Furthermore, research reports that while 18%-28% of older adults meet the criteria for successful aging (Strawbridge et al., 2002; Hui Chan & Jones, 2012), 50%-92% of older adults rate themselves as aging successfully (Montross et al., 2006; Phelan, et al., 2004; Strawbridge et al., 2002). This is further evidence of the well-being paradox, and reflects a disconnect between older adults’ perspectives and researchers’ conceptualizations of successful aging. Furthermore, successful aging contains inherent biases in its meaning, since persons not aging ‘successfully’ may be blamed for not meeting this social expectation, a goal that is less attainable among individuals with fewer economic, social and psychological resources.

Alternative definitions of successful aging have included Baltes & Baltes’ (in Baltes & Carstensen, 1996) theory of selective optimization with compensation, which equates success with the individual attainment of goals. Similarly, Kahana & Kahana’s (2001) model of preventive-corrective proactivity defines outcomes of successful aging as positive affective states, meaning in life, and maintenance of meaningful activities and relationships. These concepts more closely align with the views of older SEPTEMBER 2013

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adults, and offer multiple pathways to wellness that acknowledge environmental influences and the adaptive capacity of older adults. In a concept analysis of healthy aging by Hansen-Kyle (2005), successful aging was classified as a consequence of healthy aging, further delineating the relationship between the two concepts.

Within the quantitative studies, living well was operationalized through measures of subjective and psychological well-being (Anaby et al., 2011, Boyle et al., 2009; Foottit & Anderson, 2011; Friedman & Ryff, 2012; Montross et al., 2006), life satisfaction (Anaby et al., 2011, Hui Chan & Jones, 2012, Windle), abilities in ADL/IADL (Erdal & Zautra, 1995; Hui Chan & Jones, 2012, Tinetti et al., 2011), resilience (Montross et al., 2006, Vahia et al., 2010), and self efficacy (Vahia et al., 2010). The only study to include all four domains identified as important indicators of health by older adults was Hui Chan & Jones (2012)1.

Although reports of wellness were maintained in many cases despite presence of chronic diagnoses, depression emerged as a consistent barrier to positive outcomes.

Research found that depressive symptoms were highly correlated with other chronic conditions (Lee, Choi & Lee, 2001; Fiest et al., 2011), and formed a synergistic relationship with multiple morbidities to lower self-rated health (Tinetti et al., 2011; Lee et al., 2001). This finding reflected the self-perpetuating and mutually reinforcing relationship between depression and multiple chronic conditions (Lee et al., 2001).

Furthermore, the correlation between lower well-being and depressive symptoms was maintained even for those with sub-threshold depression, indicating the importance of subclinical manifestations of depression (Vahia et al., 2010). A better understanding of this relationship and solutions to prevent and treat depression are warranted.

In addition to the methods by which living well was operationalized in the literature, the ways multiple chronic conditions were measured in the research were identified. Multimorbidity was defined either as the presence of two or more diagnosed chronic conditions, or as a measure of aggregate health burden, which

1

Physical, functional, psychological and social well being, from Phelan et al. (2004)

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included chronic conditions, subclinical symptoms, and functional impairments (Fried et al., 2004; Karlamangla et al., 2007). The literature search identified a number of studies that evaluated tools that measured aspects of multimorbidity. Two main types of tools were discussed, ordinal scales that offered a simple count of the number of conditions, and weighted measures that offered severity info that better reflected the impact of the conditions on a persons’ quality of life and functioning level (Lash et al., 2007). Tooth et al. (2008), for example, found that the weighted measure provided a better range and fit according to their data. Additionally, a variety of data sources have been used to amass data, including self report, medical reports, clinical judgment, and administrative data, each source with it’s own strengths, weaknesses, and appropriate application (Lash et al., 2007).

As Lash et al. (2007) noted, “all measures of [multi]morbidity are imperfect surrogates”, and confer some level of ambiguity. Suggestions to improve the measurement of multimorbidity were to include sensitivity measures, combine data from multiple sources, and to build an uncertainty measure into the tools to address the imperfections (Lash et al., 2007; Parekh et al., 2011). Furthermore, Karlamangla et al. (2007) suggest working from a nosology of chronic conditions based on the International Classification of Functioning (ICF), which would reflect the full range of functional capacity, including the positive factors or strengths of an individual. The inclusion of subclinical symptoms, such as sub-threshold depression (Vahia et al., 2010), is also recommended. These suggestions reflect the expanded conceptualization of multimorbidity, which attempts to account for the aggregate health burden faced by older adults (Chapman et al., 2007; Karlamangla et al., 2007; Peruccio et al., 2012).

Future research would be enhanced by a focus on factors identified by older adults as being important to their health. An improvement in measurement tools would improve the ability of researchers to target those with functionally relevant conditions, rather than dividing participants based on the number or type of conditions they present with. There is a need for more studies that explore gender differences. And lastly, a deeper understanding of the relationship between depression and other comorbid conditions, as well as other synergistic combinations of chronic conditions, should be a priority in the future.

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Living Well: Older Adults’ Perspectives The second section of this report consists of research on living well from the perspective of older adults themselves. This inquiry was driven by the acknowledgement that wellness is an individualized process (McMahon & Fleury, 2012), and as such it is essential to determine how older adults define and identify ‘living well’ within their own living contexts. The articles in this section were typically qualitative in nature, posing questions such as “How and why do some seniors live long and keep well?” (Bassett et al., 2007), “Tell me those things in your life that make you feel well?” (Easley & Scheller, 2003), and “What are the necessary components of managing your illness?” (Reichstadt et al., 2007).

Health tended to be described as the ability to “go and do meaningful activities” (Bryant, Corbet & Kutner, 2001; Easley & Scheller, 2003). References to the ability to engage in meaningful activities and relationships were more common than absence of illness or symptoms when older adults were asked to describe what being healthy and aging successfully meant to them (Basset et al., 2007; Hurd-Clarke & Griffin, 2008; Roberto & McCann, 2011). These findings create support for a model of health care that promotes a patient-centered approach and emphasizes achievement of individual goals rather than simply addressing clinical manifestations of disease (Institute of Medicine, 2012). Additionally, they reflect Kahana & Kahana’s (2001) components of successful aging more closely than Rowe and Kahn’s model of successful aging (1997).

An overarching theme of this section is that living well is multifaceted, characterized by influences from multiple domains as well as daily fluctuations and change (Roberto & McCann, 2011). For example, Basset et al. (2007) found 24 themes and Reichstadt et al. (2007) found 33 distinct themes when analyzing how older adults described successful aging. The various influences on health were grouped under three subheadings: personal, relational, and system-level dynamics.

Personal factors that were reported to contribute to healthy or successful aging commonly included having a positive attitude (Basset et al., 2007; Bryant et al., 2001; Easley & Scheller, 2003; Grundberg et al., 2012; Reichstadt et al., 2007), keeping active, specifically in meaningful activities (Basset et al., 2007, Bryant et al., 2001; Easley & Scheller, 2003; Grundberg et al., 2012; Knight & Ricciardelli, 2003; Osborne et al., 2012; Reichstadt et al., 2007), being independent (Basset et al., 2007, Charmaz, 1983; Osborne et al., 2012; Knight & Ricciardelli, 2003), and being able to adapt SEPTEMBER 2013

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(Bryant et al., 2001; Charmaz, 1983; Reichstadt et al., 2007; Romo et al., 2012).

Additionally, Phelan et al. (2004) found that the personal factors could be divided into domains of physical, functional and psychological well-being, which were complemented by social well-being.

Social and relational factors were also deemed essential for health, including the quality, quantity and composition of social relations (Basset et al., 2007, Easley & Scheller, 2003; Grundberg et al., 2012; Knight & Ricciardelli, 2003; Osborne et al., 2012; Reichstadt et al., 2007), as well as the ability to accept help and opportunity to offer support to others (Basset et al., 2007, Romo, et al., 2012; Sells et al., 2009).

System-level or external factors that were identified by older adults included financial resources (Basset et al., 2007), social services (Basset et al., 2007, Bryant et al., 2001), environmental factors (Fuller et al., 2010), and invitations to engage in the decision-making process (Fried et al., 2008).

Throughout the literature, references to personal influences on health were the most prominently discussed, followed by social or relational influences and thirdly system-level influences on health. The emphasis by older adults on personal factors highlights the individualized experience of wellness, as well as reflects the health promotion discourse that is centered on individual responsibility for health (Bryant et al., 2001; Pond, Stephens & Alpass, 2010).

An opportunity for further research into the perspective of older adults is to elicit how the themes that have emerged from the literature are inter-related. Are the components independent, additive or synergistic? Research indicates that many of these components build upon each other and do not exist in isolation (Lindsay, 2009).

Do the different components of “living well� fit into a hierarchy of needs? How could the identification of a hierarchy of needs be used to contribute to clinical decisionmaking and research, and how can it be customized to correspond with the nature of individual preferences to maintain a person-centered approach?

A gap in the knowledge base also exists as to how activities become imbued with meaning, and how meaningful activities are linked to wellness. A better understanding of meaningful activities would enhance the opportunities for solutionbased strategies aimed to attenuate the negative impacts of aging with chronic conditions. This also extends to how older adults value and acquire the roles that are available to them, and how this impacts their ability to live well.

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Future research in this area would also benefit from a greater representation of culturally diverse, very old, physically frail and/or disabled adults. Additionally, understanding living well would be enhanced by a lifespan approach, including studies that follow how the meanings of health change from onset of chronic disease throughout the lived experience of aging with multiple chronic conditions.

Fostering Living Well with Multiple Chronic Conditions The two previous sections addressed what older adults perceive to contribute to their health, as well as how living well has been manifested in the literature. The focus of this section is on fostering the ability of older adults to live well, and has been organized within the Expanded Chronic Care Model (Figure 1). This model has been applied as it identifies the various influences, and therefore intervention points, on health outcomes for individuals with chronic conditions.

FIGURE 1. Expanded Chronic Care Model (CCM)

Adapted from: Barr, V., Robsinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D. & Salivaras, S. (2003) The expanded chronic care model: An integration of concepts and strategies from population health promotion and the chronic care model. Hospital Quarterly, 7(1), 73-82

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1. Self-Care and Self-Management: The Informed, Activated Patient Within the literature, living well with multiple chronic conditions has been fostered by self-care and self-management initiatives, which correspond to the role of the informed and activated patient within the Expanded Chronic Care Model (1, Figure 1).

The purpose of self-care has been identified as a means to manage physical symptoms and functional loss, to compensate for the limits of formal care, and to adhere to social norms (Hurd-Clarke & Bennet, 2013). Additionally, Loeb et al. (2003) noted the motivation to engage in self-care was to “stay in control” and to “keep what I have”. Identification of the motivational patterns to engage in self-care provides an avenue for future research into facilitating best practices.

The ways in which older adults self-manage are multifaceted. Many studies reported behavioural coping strategies, such as changing one’s diet, exercising, taking medication, and smoking cessation (Leach & Schoenberg, 2008; Loeb et al., 2003; Loffler et al., 2012; Newson et al., 2012; Thorne et al., 2003). However, research from Canada suggested that there was little evidence of behaviour change after diagnosis of chronic conditions (Newson et al., 2012). Older adults also reported cognitive coping strategies, such as goal setting, social comparison, relying on faith or spirituality, dealing with a mix of emotions, prioritizing a main diagnosis, and living a life of meaning (Becker & Newsom, 2005; Hutchinson & Nimrod, 2012; Leach & Schoenberg, 2008; Lindsay, 2009; Loffler et al., 2012). Thirdly, self-care was accomplished by drawing on social resources and networks (Loeb et al., 2003, Loffler et al., 2012; Sells et al., 2009; Thorne et al., 2003; Vassilev et al., 2011; Zausniewski et al., 2001). Future research into the relationships between types of self-care, the cyclical relationship between self-care and wellness, availability and access to resources for self-care, and promising practices for self-management of multiple chronic conditions is recommended. Additionally, finding avenues for older adults to continue to give care to others, not only receive care, represents an opportunity to foster living well. This recommendation is supported by the finding that both giving and receiving social support were perceived to contribute to well-being (Sells et al., 2009).

Research on the barriers to self-care and self-management are an additional area of inquiry that will aid in the creation of practical solutions in the future. Importantly, studies indicated that higher disease totals and lower self-rated health scores were associated with greater overall barriers to self-care (Bayliss et al., 2007; Fuller et al.,

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2010). Commonly reported barriers included low functioning, poor knowledge of the conditions, higher depressive symptoms, financial constraints, poor patient-physician communication, lack of social support, pain, and lack of choices (Bayliss et al., 2007; Fuller et al., 2010; Jerant et al., 2005). Further research into barriers and facilitators to wellness at all levels of the Expanded CCM is advised.

2. Formal Care: Creating Prepared, Proactive Practice Teams Formal care was considered a factor in fostering living well with multiple chronic conditions, identified as the prepared, proactive practice team in the Expanded CCM (2, Figure 1). The perspectives captured here were often those of researchers with nursing backgrounds. The overarching theme within this research was the importance of incorporating patient preferences into the decision making process (AGS Expert Panel, 2012; Sevick et al., 2007; Tinetti et al., 2004). Suggestions for enhancing the support given by formal care professionals to older adults with chronic conditions were to recognize and support treatment options and decisions, improve the interpretation of the evidence, balance the desires of the physician with the capacity of the individual, engage patients in behaviour change, and reduce information processing burden (AGS Expert Panel, 2012; Sevick et al., 2007; Tinetti et al., 2004).

Future research in this area would benefit from an expanded focus into the formal care structures embedded within communities, such as home care and personal support services available for people living in their own homes. This area of research would also include the identification of other “team players” in the community besides nurses and physicians who create, or could enhance, the prepared, proactive practice team.

3. Health Care System Reform Looking to the future, a number of researchers have identified health care reform as an opportunity to improve well-being in those with multiple chronic conditions.

Suggestions for health care reform were categorized under the umbrella of the health system in the Expanded CCM (3, Figure 1). When patients have been asked their opinions on processes of receiving care, they have highlighted the desire for convenient access to providers, continuity of care, clear communication, individualized care plans, and “to be heard” (Bayliss et al., 2008). These findings have been supported by the IOM’s 2012 report “Living Well with Chronic Illness”, which supports cooperative care initiatives among other priorities for research.

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Overall recommendations were to move away from a disease-focused model of care and towards a person-centered approach (AGS Expert Panel, 2012, IOM, 2012).

Some specific ideas were to improve the care system included introducing new nursing personnel (Boyd et al., 2007), enhancing self-management initiatives (Lorig et al., 1999), and accessing telehealth technologies (Barlow et al., 2007). Lastly, Parekh et al. (2011) recommended taking an action oriented approach, which included identifying evidence based models, redefining health outcomes, and developing payment reform.

4. Community Support: A Socio-ecological Approach The final and overarching component of the Expanded CCM is the community (4, Figure 1). In the model, the community has three roles: it directly supports the informed, activated patient, it supports the prepared, proactive practice team, and it refers to the grander social structure of the community with the responsibility for building healthy public policy, creating supportive environments, and strengthening community action (Barr et al., 2003). Research in this area reflects a broader, socioecological approach to fostering well-being, which can have an impact on all members of a community. Additionally, this perspective expands the focus of wellness from individual behaviours to societal change, and the possibilities of fostering health from the individual or health care system level to all available resources of a community (Barr et al., 2003).

Further research into assessing and accessing community resources (Koehn, Jarvis & Kobayashi, 2011) and creating supportive environments (Naaldenberg et al., 2012) will enhance our understanding of how communities can foster living well for older adults. Additionally, explorations of how ageism (Angus & Reeve, 2006) and the social construction of chronicity (Martin & Peterson, 2009) influence the experience of aging well with multiple chronic conditions indicate areas for future investigation.

Reflecting on the model, the outcomes defined currently include population health and clinical/functional outcomes. From a living well perspective, expanding the model to include wellness as an outcome would be valuable. The Expanded Chronic Care Model overall provided a useful framework to organize the various literature aimed to promote living well, as well as to help identify some of the gaps in this literature. Research on activated communities and prepared, proactive community partners was limited. Research on fostering living well became sparse the further one moved from the micro level influences like self-care up to the macro level influences

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on health, like social policy and access to care. This absence in the literature warrants future research.

Conclusion This annotated bibliography comprises an exploratory analysis of the literature on living well as an older adult with multiple chronic conditions or multiple morbidity.

Through a broad research strategy, a number of themes and areas for future research were identified.

Key themes tied to living well as an older adult with multiple chronic conditions included supporting an expanded concept of health which would include holistic goals of wellness, such as being able to “go and do� meaningful activities to become central to the care of older adults. This was also reflected in the consistent recommendations to enhance care that is person-centered, rather than disease focused, in an effort to address the complexity of multiple chronic conditions.

An associated theme was the multidimensionality and inter-relatedness of the domains and determinants of health, the intricacies of which require further research.

Using a model such as the Expanded Chronic Care Model and a socio-ecological approach will further enhance the opportunities to imagine and create solutions.

Lastly, evidence of the well-being paradox was manifest throughout the literature.

Disentangling this paradox requires an understanding of the ways in which individuals define their social worlds and maneuver through their life courses. There are indications that resilience and adaptive processes are embedded within multi-level spheres of influence that connect the individual to their social and physical environments. The implications of this are to continue to identify positive deviants who are managing to maintain wellness in the face of complex illness contexts, and to ascertain mechanisms through which this is possible.

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Bibliography Contents 1. Defining and Quantifying Living Well and Multimorbidity ............................. 23 a) Conceptual Development ................................................................................... 23 Baltes, M. & Carstensen, L. (1996) The process of successful ageing. Ageing and Society, 16(4), 397-422 ........................................................................................................ 23 Baltes, P. & Smith, J. (2003) New frontiers in the future of aging: From successful aging of the young old to the dilemmas of the fourth age. Gerontology, 49, 123-133 ................................................................................................................................................ 24 Crowther, M., Parker, M., Achenbaum, W., Larimore, W. & Koenig, H. (2002) Rowe and Kahn’s Model of Successful Aging revisited: Positive spirituality – The forgotten factor.

The Gerontologist, 42(5), 613-620 ......................................................................................25 Depp, C., Glatt, S. & Jeste, D. (2007) Recent advances in research on successful or healthy aging. Current Psychiatry Reports, 9, 7-13 .......................................................... 26 Dillaway, H. & Byrnes, M. (2009) Reconsidering successful aging: A call for renewed and expanded academic critiques and conceptualizations. Journal of Applied Gerontology, 28(6), 702-722 .............................................................................................. 27 Fried, L., Ferrucci, L., Darer, J., Williamson, J. & Anderson, G. (2004) Untangling the concepts of disability, frailty and comorbidity: Implications for improved and targeted care. Journal of Gerontology, Medical Sciences, 59(3), 255-263 .................................. 28 Hansen-Kyle, L. (2005) A concept analysis of healthy aging. Nursing Forum, 40(2), 4557 ............................................................................................................................................ 29 Kahana, E. & Kahana, B. (2001) Successful aging among people with HIV/AIDS. Journal of Clinical Epidemiology, 54, S53-S56 ................................................................ 30 McMahon, S. & Fleury, J. (2012) Wellness in older adults: A concept analysis. Nursing Forum, 47(1), 39-51.............................................................................................................. 31 Minkler, M. & Fadem, P. (2002) Successful Aging: A disability perspective. Journal of Disability Policy Studies, 12(4), 229-235 ........................................................................... 32 Paterson, B. (2001) The shifting perspectives model of chronic illness. Journal of Nursing Scholarship, 33(1), 21-26 ...................................................................................... 33 Rowe, J. & Kahn, R. (1997) Successful aging. The Gerontologist, 37(4), 433-440 ....... 34 Strawbridge, W., Wallhagen, M. & Cohen, R. (2002) Successful aging and well-being: Self rated compared with Rowe and Kahn. The Gerontologist, 42(6), 727-733 .......... 35

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b) Measurement Tools ............................................................................................ 36 Bayliss, E., Ellis, J. & Steiner, J. (2009) Seniors’ self-reported multimorbidity captured biopsychosocial factors not incorporated in two other data based morbidity measures. Journal of Clinical Epidemiology, 62(5), 550-557 ......................................... 36 Boyd, C., Weiss, C., Halter, J., Han, C., Erschler, W. & Fried, L. (2007) Framework for evaluating disease severity measures in older adults with comorbidity. Journal of Gerontology, Medical Sciences, 62A(3), 286-295 ........................................................... 37 De Groot, V., Beckerman, H., Lankhorst, G. & Bouter, L. (2003) How to measure comorbidity: A critical review of available methods. Journal of Clinical Epidemiology, 56, 221-229 ........................................................................................................................... 38 Glasgow, R., Stryker, L., Toobert, D. & Eakin, E. (2000) A socio-ecologic approach to assessing support for disease self-management: The chronic illness resources survey.

Journal of Behavioural Medicine, 23(6), 559-583 ............................................................ 39 Karlamangla, A., Tinetti, M., Guralnik, J., Studenski, S., Wetle, T. & Reuben, D. (2007) Comorbidity in older adults: Nosology of impairment, disease and conditions.

Journals of Gerontology, Medical Sciences, 62A(3), 296-300 ....................................... 40 Lamond, A., Depp, C., Allison, M., Langer, R., Reichstadt, J., Moore, D., Golshan, S., Ganiats, T. & Jeste, D. (2009) Measurement and predictors of resilience among community dwelling older women. Journal of Psychiatric Research, 43, 148-154 ..... 41 Lash, T., Mor, V., Wieland, D., Ferucci, L., Satariano, W. & Silliman, R. (2007) Methodology, design, and analytic techniques to address measurement of comorbid disease. Journal of Gerontology, Medical Sciences, 62A(3), 281-285 .......................... 42 Mukherjee, B., Ou, T., Wang, F. & Erickson, S. (2011) A new comorbidity index: The health related quality of life comorbidity index. Journal of Clinical Epidemiology, 64, 309-319.................................................................................................................................. 43 Parslow, R., Lewis, V. & Nay, R. (2011) Successful aging: Development and testing of a multidimensional model using data from a large sample of older Australians. Journal of the American Geriatric Society, 59, 2077-2083 ........................................................... 44 Resnick, B. & Inguito, P. (2011) The Resilience Scale: Psychometric properties and clinical applicability in older adults. Archives of Psychiatric Nursing, 25(1), 11-20 ..... 45 Tooth, L., Hockey, R., Byles, J. & Dobson, A. (2008) Weighted multimorbidity indexes predicted mortality, health service use and health related quality of life in older women. Journal of Clinical Epidemiology, 61, 151-159 ................................................. 46 c) Quantifying Living Well and Multimorbidity ...................................................... 47 Anaby, D., Miller, W., Eng, J., Jarus, T. & Noreau, L. (2011) Participation and wellbeing among older adults living with chronic conditions. Social Indicators Research, 100, 171-183 ......................................................................................................................... 47

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Baltes, P & Lang, F. (1997) Everyday functioning and successful aging: The impact of resources. Psychology and Aging, 12(3), 433-443 .......................................................... 48 Boyle, P., Barnes, L., Buchman, A. & Bennett, D. (2009) Purpose in life associated with mortality among community dwelling older adults. Psychosomatic Medicine, 71, 574579 ......................................................................................................................................... 49 Chapman, B., Lyness, J. & Duberstein, P. (2007) Personality and medical illness burden among older adults in primary care. Psychosomatic Medicine, 69, 277-282..50 Erdal, K. & Zautra, A. (1995) Psychological impact of illness downturns: A comparison of new and chronic conditions. Psychology & Aging, 10(4), 570-577........................... 51 Evert, J., Lawler, E., Bogan, H. & Perls, T. (2003) Morbidity profiles of centenarians: Survivors, delayers and escapers. Journal of Gerontology, Medical Sciences 58A(3), 232-237...................................................................................................................................52 Fiest, K., Currie, S., Williams, J. & Wang, J. (2011) Chronic conditions and major depression in community dwelling older adults. Journal of Affective Disorders, 131, 172-178.................................................................................................................................. 53 Foottit, J. & Anderson, D. (2011) Associations between perceptions of wellness and health related quality of life, comorbidities, modifiable lifestyle factors and demographics in older Australians. Australasian Journal on Ageing, 31(1), 22-27 .... 54 Friedman, E. & Ryff, C. (2012) Living Well With Medical Comorbidities: A Biopsychosocial Perspective. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 67(5), 535-544 ...................................................................55 Hui-Chaun, S. & Jones, B. (2012) Multiple trajectories of successful aging of older and younger cohorts. The Gerontologist, 52(6), 843-856 ...................................................... 56 Hunger, M., Thorand, B., Schunk, M., Doring, A., Menn, P., Peters, A. & Holle, R. (2011) Multimorbidity and health related quality of life in the older population: Results from the German KORA-Age study. Health and Quality of Life Outcomes, 9:53 ................. 57 Lee, Y., Choi, K. & Lee, Y. K. (2001) Association of comorbidity with depressive symptoms in community dwelling older persons. Gerontology, 47, 254-262 ............. 58 Lochner, K. & Cox, C. (2013) Prevalence of multiple chronic conditions among Medicare beneficiaries, United States, 2010. Preventing Chronic Disease, 10, 120137 ................................................................................................................................................ 59 Marengoni, A., Rizzuto, D., Wang, H., Winblad, B., Fratiglioni, L. (2009) Patterns of chronic multimorbidity in the elderly population. Journal of the American Geriatric Society, 57, 225-230 ............................................................................................................ 60 Montross, L., Depp, C., Daly, J., Reichstadt, J., Golshan, S., Moore, D., Sitzer, D. & Dilip, J. (2006) Correlates of self-rated successful aging. American Journal of Geriatric Psychiatry, 14(1), 43-51 ........................................................................................................ 61

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Perruccio, A., Katz, J. & Losina, E. (2012) Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. Journal of Clinical Epidemiology, 65, 100-106 .................................................... 62 Tinetti, M., McAvay, G., Chang, S., Newman, A., Fitzpatrick, A., Fried, T. & Peduzzi, P. (2011) Contributions of multiple chronic conditions to universal health outcomes.

Journal of the Geriatric Society, 59, 1686-1691 ............................................................... 63 Vahia, I., Meeks, T., Thompson, W., Depp, C., Zisook, S., Allison, M., Judd, L. & Jeste, D. (2010) Subthreshold depression and successful aging in older women. American Journal of Geriatric Psychiatry, 18, 212-220 ..................................................................... 64 Windle, G., Woods, R. & Markland, D. (2010) Living with ill-health in older age: The role of a resilient personality. Journal of Happiness Studies, 11, 763- 777 .................. 65 Yates, L., Djousse, L., Kurth, T., Buring J. & Gaziano, M. (2008) Exceptional longevity in men: Modifiable factors associated with survival and function to 90 years. Archives of Internal Medicine, 168(3), 284-290 .................................................................................... 66

2. Living Well: Older Adults’ Perspectives............................................................. 67 Bassett, R., Bourbonnais, V. & McDowell, I. (2007) Living long and keeping well: Elderly Canadians account for successful aging. Canadian Journal on Aging, 26(2), 113-126.................................................................................................................................. 67 Bryant, L., Corbett, K. & Kutner, J. (2001) In their own words: A model of healthy aging. Social Science and Medicine, 53, 927-941 ........................................................... 68 Charmaz, K. (1983) Loss of self: A fundamental form of suffering in the chronically ill.

Sociology of Health and Illness, 5(2), 168-197 ................................................................. 69 Easley, C. & Scheller, J. (2003) The experience of being old-old: Life after 85. Geriatric Nursing, 24(5), 273-277 ....................................................................................................... 70 Fried, T., McGraw, S., Agostina, J. & Tinetti, M. (2008) Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. Journal of the American Geriatric Society, 56, 1839-1844................................................................ 71 Grundberg, A., Ebbeskog, B., Abrandt Dahlgren, M. & Religa, D. (2012) How community-dwelling seniors with multimorbidity conceive the concept of mental health and factors that may influence it: A phenomenographic study. International Journal of the Qualitative Study of Health and Well-being, 7, 19716 ........................... 72 Hurd Clarke, L. & Griffin, M. (2008) Failing bodies: Body image and multiple chronic conditions in later life. Qualitative Health Research, 18(8), 1084-1095 ........................ 73 Knight, T. & Ricciardelli, L. (2003) Successful aging: Perceptions of adults aged between 70 and 101 years. International Journal of Aging and Human Development, 56(3), 223-245 ....................................................................................................................... 74 SEPTEMBER 2013

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Montbriand, M. (2004) Senior’s life histories and perceptions of illness’. Western Journal of Nursing Research, 26(2), 242-260 ................................................................... 75 Osborne, L., Bindermann, N., Noble, GJ. & Reed, P. (2012) Changes in key areas of quality of life associated with age and time since diagnosis of long-term conditions.

Chronic Illness, 8(2), 112-120 ............................................................................................. 76 Phelan, E., Anderson, L., Lacroix, A. & Larson, E. (2004) Older adults views of “successful aging”: How do they compare with researchers definitions? Journal of the American Geriatrics Society, 52, 211-216 ......................................................................... 77 Pond, R., Stephens, C. & Alpass, F. (2010) Virtuously watching ones health: Older adults regulation of self in the pursuit of health. Journal of Health Psychology, 15, 734-743.................................................................................................................................. 78 Reichstadt, J., Depp, C., Palinkas, L., Fulsom, D., Jeste, D. (2007) Building blocks of successful aging: A focus group study of older adults perceived contributors to successful aging. American Journal of Geriatric Psychiatry, 15(3), 194-201 ................ 79 Roberto, K. & McCann, B. (2011) Everyday health and identity management among older women with chronic health conditions. Journal of Aging Studies, 25, 94-100 . 80 Romo, R., Wallhagen, M., Yourman, L., Yeung, C., Eng, C., Micco, G., Perez-Stable, E. & Smith, A. (2012) Perceptions of successful aging among diverse elders with late life disability. The Gerontologist, Advance Access, doi:10.1093 /geront/gns160 ............ 81

3. Fostering Living Well with Multiple Chronic Conditions ................................. 82 a) Self-care and Self-management: The Informed, Activated Patient .................... 82 Bayliss, E., Ellis, J. & Steiner, J. (2007) Barriers to self-management and quality of life outcomes in seniors with multimorbidities. Annals of Family Medicine, 5(5), 395-402 ................................................................................................................................................ 82 Becker, G. & Newsom, E. (2005) Resilience in the face of serious illness among chronically ill African Americans in later life. Journal of Gerontology: Social Sciences, 60B(4), S214-S223 ................................................................................................................ 83 Chodosh, J., Morton, S., Mojica, W., Maglione, M., Suttorp, M., Hilton, L., Rhodes, S. & Shekelle, P. (2005) Meta-Analysis: Chronic disease self-management programs for older adults. Annals of Internal Medicine, 143, 427-438 ................................................ 84 Fuller, B., Stewart Williams, J. & Byles, J. (2010) Active living - The perception of older people with chronic conditions. Chronic Illness, 6, 294-305 .......................................... 85 Hitchcock Noel, P., Parchman, M., Williams, J., Cornell, J., Shuko, L., Zeber, J., Kazis, L., Lee, A. & Pugh, J. (2007) The challenges of multimorbidity from the patient perspective. Journal of General Internal Medicine, 22(Supp.3), 419-424 .................... 86

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Hurd Clarke, L. & Bennet, E. (2013) Constructing the moral body: self-care among older adults with multiple chronic conditions. Health, 17(3), 211-228 ......................... 87 Hutchinson, S. & Nimrod, G. (2012) Leisure as a resource for successful aging by older adults with chronic health conditions. International Journal of Aging and Human Development, 74(1), 41-65 ................................................................................................. 88 Jerant, A., von Freidrichs-Fitzwater, M. & Moore, M. (2005) Patients perceived barriers to active self-management of chronic conditions. Patient Education and Counseling, 57, 300-307 ........................................................................................................................... 89 Leach, C. & Shoenberg, N. (2008) Striving for control: Cognitive, self-care and faith strategies employed by vulnerable black and while older adults with multiple chronic conditions. Journal of Cross-Cultural Gerontology, 23, 377-399 .................................. 90 Lindsay, S. (2009) Prioritizing illness: Lessons in self-managing multiple chronic disease. Canadian Journal of Sociology, 34(4), 984-1002 ............................................. 91 Loeb, S., Penrod, J., Falkenstern, S., Gueldner, S. & Poon, L. (2003) Supporting older adults living with multiple chronic conditions. Western Journal of Nursing Research, 25(1), 8-29 ............................................................................................................................. 92 Lรถffler, C., Kaduszkiewicz, H., Stolzenbach, C., Streich, W., Fuchs, A., van den Bussche, H., Stolper, F. & Altiner, A. (2012) Coping with multimorbidity in old age: A qualitative study. BMC Family Practice, 13, 45-53 .............................................................................. 93 Newson, J., Huguet, N., Ramage-Morin, P., McCarthy, M., Bernier, J., Kaplan, M. & McFarland, B. (2012) Health behaviour changes after diagnosis of chronic illness among Canadians aged 50 and over. Statistics Canada, Catalogue #82-003-XPE, Health Reports, 23(4) ........................................................................................................... 94 Peel, M., McClure, R. & Bartlett, H. (2005) Behavioural determinants of healthy aging.

American Journal of Preventative Medicine, 28(3), 298-304 ......................................... 95 Sells, D., Sledge, W., Wieland, M., Walden, D., Flanagan, E., Miller, R. & Davidson, L. (2009) Cascading crises, resilience and social support within the onset and development of multiple chronic conditions. Chronic Illness, 5, 92-102 ..................... 96 Thorne, S., Paterson, B. & Russell, C. (2003) The structure of every day self-care decision making in chronic illness. Qualitative Health Research, 13(10), 1337-1352 . 97 Zausniewski, J., Chaeweon, C. & Krafik, K. (2001) Social cognitive factors predicting the health of elders. Western Journal of Nursing Research, 23, 490-503 .................... 98 b) Formal Care: Creating Prepared, Proactive Practice Teams............................... 99 American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity (2012) Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of American Geriatrics Society, 60, E1-25 ...................................................................................................................................... 99

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Fried, T., Tinetti, M., Iannone, L., O’Leary, J., Towle, V. & Van Ness, P. (2011) Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Archives of Internal Medicine, 171(20), 1854-1856 ..... 100 Sevick, M., Trauth, J., Ling, B., Anderson, R., Platt, G., Kilbourne, A. & Goodman, R. (2007) Patients with complex chronic diseases: Perspectives on supporting selfmanagement. Journal of General Internal Medicine, 22(3), 438-444 ......................... 101 Tinetti, M., Bogardis, S. & Agostini, J. (2004) Potential pitfalls of disease-specific guidelines for patients with multiple conditions. The New England Journal of Medicine, 351(27), 2870-2874 ......................................................................................... 102 Vogeli, C., Shields, A., Lee, T., Gibson, T., Marder, W., Weiss, K. & Blumenthal, D. (2007) Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management and costs. Journal of General Internal Medicine, 22(3), 391-395 .................................................................................................. 103 c) Health Care System Reform .............................................................................. 104 Barlow, J., Singh, D., Bayer, S. & Curry, R. (2007) A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions. Journal of Telemedicine and Telecare, 13, 172-179 ....................................................................... 104 Bayliss, E., Edwards, A., Steiner, J. & Main, D. (2008) Processes of care desired by elderly patients with multimorbidities. Family Practice, 25, 287-293 .......................... 105 Boyd, C., Boult, C., Shadmi, E., Leff, B., Brager, R., Dunbar, L., Wolff, J. & Wegener, S. (2007) Guided Care for multimorbid older adults. The Gerontologist, 47(5), 697-704 .............................................................................................................................................. 106 Institute of Medicine (2012) Living well with chronic illness: A call for public health action. Washington, DC: The National Academies Press. ............................................ 107 Lorig, K., Sobel, D., Stewart, A., William Brown Jr., B., Bandura, A., Ritter, P., Gonzalez, V., Laurent, D. & Holman, H. (1999) Evidence suggesting that chronic disease selfmanagement programs can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37(1), 5-14 ................................................................... 108 Parekh, A., Goodman, R., Gordon, C. & Koh, H. (2011) Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life.

Public Health Reports, 126, 460-473 ............................................................................... 109 d) Community Support: A Socio-ecological Approach ......................................... 110 Angus, J. & Reeve, P. (2006) Ageism: A threat to aging well in the 21st century.

Journal of Applied Gerontology, 25, 137-152 ............................................................... 110 Barr, V., Robsinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D. & Salivaras, S. (2003) The expanded chronic care model: An integration of concepts and

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strategies from population health promotion and the chronic care model. Hospital Quarterly, 7(1), 73-82 ......................................................................................................... 111 Jang, Y., Mortimer, J., Haley, W. & Graves, A. (2004) The role of social engagement in life satisfaction: Its significance among older individuals with disease and disability.

The Journal of Applied Gerontology, 23(3), 266-278 ................................................... 112 Koehn, S., Jarvis, P. & Kobayashi, K. (2011) Taking care of chronic disease: An approach for Canada’s aging ethnic population: A workshop. Final Report, iCARE 113 Martin, C. & Peterson, C. (2009) The social construction of chronicity – A key to understanding chronic care transformations. Journal of Evaluation in Clinical Practice, 15, 578-585 ......................................................................................................................... 114 Naaldenberg, J., Vaandrager, L, Koelen, M. & Leeuwis, C. (2012) Aging populations everyday life perspectives on health aging: New insights for policy and strategies at the local level. Journal of Applied Gerontology, 31, 711-736 ..................................... 115 Vassilev, I., Rogers, A., Sanders, C., Kennedy, A., Blickem, C., Protheroe, J., Bower, P., Kirk, K., Chew-Graham, C. & Morris, R. (2011) Social networks, social capital and chronic illness self-management: A realist review. Chronic Illness, 7, 60 - 78 ........... 116

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1. Defining and Quantifying Living Well and Multimorbidity a) Conceptual Development Baltes, M. & Carstensen, L. (1996) The process of successful ageing. Ageing and Society, 16(4), 397-422 Purpose: To divert the focus from “What is successful aging” to “How do people age successfully according to his/her own definition?” This paper focused on the processes of selection, optimization and compensation.

Method: Reviewed the historical, societal and philosophical evidence for the process of successful aging.

Results: “We cannot predict what any individuals’ successful aging will look like until we know the domains of functioning and goals that the individual considers important, personally meaningful, and in which he/she feels competent.” The central argument of this paper was for a conceptualization of successful aging that was individualized and self-defined. “Success” was defined as the attainment of goals, which differ among individuals and have diverse outcomes and measures. The authors attempted to understand both the gains and losses that occur with age to create a holistic life course perspective. Three processes were identified that contribute to successful aging: Selection, optimization and compensation (SOC).

Selection refers to the restriction of life domains, either passively or actively, in anticipation of future changes in resources. It can also involve the incorporation of new domains, as long as they are fewer in number than those previously given up. It entails the readjustment of individual goals. Optimization refers to the enhancement of functioning and adaptive fitness due to enrichment or augmentation of resources and reserves. It may be used to reach existing goals, or in the pursuit of new ones. Optimization is dependent on possibilities and opportunities, and therefore societies play an essential role in creating environments that facilitate optimization. Lastly, compensation is the use of alternate means to reach the same goal. In this process goals are maintained, whereas in selection they are altered. It may be automatic or planned.

Commentary: This article added to the literature on aging well by providing a counterdefinition to Rowe and Kahn’s Model of Successful Aging. In terms of chronic illness, the authors contended that success cannot be defined as the absence of disease for all individuals, as they may define themselves to be aging successfully based on other criteria. Examples of alternative criteria may include psychological well being, personal meaning, social connectedness, and life satisfaction.

This model does not address the possibility that a person cannot attain their goals even with selection, optimization and/or compensation. If someone cannot reach their goals are they “unsuccessful”? Additionally, this metamodel attempted to include factors beyond the individual to facilitate successful aging; however, the onus tended to be placed on personal factors, such as behaviour modification to achieve one’s goals. Lastly, the model does not explain how an individual’s goals in one domain interfere or interact with SOC of another, and vice versa.

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Baltes, P. & Smith, J. (2003) New frontiers in the future of aging: From successful aging of the young old to the dilemmas of the fourth age.

Gerontology, 49, 123-133 Purpose: To provide an overview of research on successful aging with a focus on the differences between the young old (ages 60-70) and the oldest old (over age 80). To highlight the challenges of the fourth age, including living and dying with dignity.

Method: A review of the state of current knowledge, and recommendations for future research.

Results: This paper outlines the evidence that there are significant differences between the young old and the oldest old in regards to their ability to continue to live well. The young old (or third age) have been the subject of many recent studies that show the reality of wisdom, emotional intelligence, functional independence and other positive indications that aging can be a time of optimism and improvement. The fourth age, on the other hand, is a period of notable decline. This is where traditional views of the negative aspects of aging stem from, although it has been pushed to later years in the past decades. This extension of the lifespan is positive in that it creates opportunities for the third age, but it also requires new approaches to enhance the dignity and quality of life of those reaching the fourth age. The biocultural losses at this point in the lifespan require renewed research and conceptualization. A metatheoretical model was introduced highlighting these losses, which describes the fourth age as time in which biological plasticity decreases, need for culture increases, and the efficacy of culture decreases. Another conclusion that the authors reach is that a focus on health throughout the lifespan is the best way to improve the overall health of older adults, since health has a cumulative impact over the life course.

Commentary: This paper identified a dilemma in current gerontological research, namely that the tendency to focus on the positive results stemming from research, and political drive towards individualistic responsibility for health ignores the challenges of the fourth age. Many of the research findings have been based on the young old, who generally have the physical and cognitive ability to make changes and improvements. It neglects the challenges of the oldest old, which is where new research is required. Some ideas for future research outlined here include genetic restructuring and use of selective optimization with compensation (SOC) model (see Baltes & Carstensen, 1996). SOC is one way to conceptualize the adaptational capacity of older adults. With the high rates of dementia in the fourth age this theory is challenging, however at this stage in life perhaps the process could be initiated externally, instead of as an internal purposeful process.

This article is important in the study of living well with chronic conditions since it highlighted the delineation between the third and fourth age. It provided evidence for the importance of conducting research differently depending on which population (young-old or old-old) is being targeted.

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Crowther, M., Parker, M., Achenbaum, W., Larimore, W. & Koenig, H. (2002) Rowe and Kahn’s Model of Successful Aging revisited: Positive spirituality – The forgotten factor. The Gerontologist, 42(5), 613-620 Purpose: To expand the current model of “Successful Aging” proposed by Rowe and Kahn with an addition of the element of spirituality.

Method: A proposal to strengthen the Successful Aging model by adding positive spirituality.

Results: Positive spirituality has been described as the personal experience of the transcendent or sacred, encompassing both religion and spirituality. It was considered in this research to provide a buffering effect to the loss of control and helplessness associated with chronic disease. Furthermore, studies have shown positive associations between spirituality, religious coping and health outcomes such as speed of recovery from depression, immune function, and health behaviour adherence.

The basis for including religion into the successful aging dialogue comes from a health promotion perspective. The authors argue that the role of religious organizations has been overlooked as a resource for health promotion. In the conclusion it was emphasized that spiritual and religious-based interventions should elicit the permission and respect of participants, and be offered with sensitivity to beliefs, values and practices.

Commentary: It may be argued that the construct of positive spirituality fits into the existing model of successful aging under the “active engagement in life” section. Being engaged with a spiritual element is a life choice, which is not reflected in the way every older adult defines what is important to him/her. Therefore, the addition of spirituality as a fourth dimension may not be applicable to everyone and may already be captured in another domain.

The research cited was more concerned with formal, organized religion than with spirituality itself. Churches and other religious buildings can play a role in health promotion programs, both as a physical space to hold meetings and as a place to recruit older adults in the community.

This literature is consistent with the view that individuals have a moral imperative to engage in self-care and “age successfully”. Health promotion provides a path to deviate from traditional biomedical models of health care and towards the “ideal” of quality self-care.

Pairing religion and spirituality offers a community-level support system to reach and engage with older adults who participate in religious institutions. It may afford a beneficial avenue to improve the well-being of those who engage in formal religion.

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Depp, C., Glatt, S. & Jeste, D. (2007) Recent advances in research on successful or healthy aging. Current Psychiatry Reports, 9, 7-13 Purpose: To synthesize and compile recent research findings concerning successful or healthy aging.

Method: Articles were chosen for inclusion if they were published in 2005-2006, and were found using MEDLINE search for “successful aging” or “healthy aging”. This paper is a selective representation of important findings.

Results: Emerging areas of research identified included discovering the phenotype of successful aging, the predictors of successful aging, neurobiological mechanisms, and interventions to enhance healthy aging. A comprehensive definition of successful aging would ultimately be greater than just living a long life, include multidimensional phenotypes, bridge the gap between biomedical and older adults perspectives, and include resilience and cognitive ability.

Factors that were found to have significant affect on successful aging: age, nonsmoking, absence of disability, arthritis or diabetes. Factors that had moderate affect were greater physical activity, social contacts, better self-rated health, absence of depression and cognitive impairment.

Commentary: This paper gave a brief overview of a selected number of studies. There was a focus on neuroscience and cognitive issues that have not been addressed in social or psychological papers. Often, older adults with cognitive impairments have been excluded from studies on healthy aging, since it is more difficult to obtain data from this population.

Additionally, individuals with cognitive deficits are typically excluded from studies on aging successfully, as it is assumed that the impairment precludes them from living well. Future research into how those with cognitive impairments experience wellness is recommended, with examples becoming available in the field of dementia research.

A further exploration of how the processes of aging impact the brain is an important area of study. Linking these findings to older adults’ perceptions of healthy aging is also integral to broadening the scope of this research area.

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Dillaway, H. & Byrnes, M. (2009) Reconsidering successful aging: A call for renewed and expanded academic critiques and conceptualizations. Journal of Applied Gerontology, 28(6), 702-722 Purpose: To identify current literature on successful aging, to broaden critiques of successful aging to include complex sociopolitical and cultural origins, and to expand conceptualizations of successful aging as it is used within gerontology.

Method: A review of concepts and critiques relating to successful aging, and a call for an expansion of these understandings.

Results: Major Themes in Literature: The existing literature is anchored in the quest to measure success as an outcome of aging. There are a variety of constructs included to quantify success, however what they have in common is that they create “winners” and “losers”, and emphasize the individual responsibility, and therefore blame those who are not successful. Existing Critiques: One stream of critics use continuity theory to argue that successful aging cannot be measured compared to others but compared to one’s own history. A second faction criticize “successful aging” for being elitist, in that it is not an applicable term outside of privileged Western cultures, and is therefore exclusionary. Expanding the Political Commentary: A renewed analysis of the political impact that successful aging has had would look at how we view aging negatively, how successful aging terminology may support budget cuts, and how we discriminate against older adults. Who Developed the Paradigm? An important aspect to understanding successful aging is to look at the context within which it has grown. The paradigm is primarily attributed to work by Butler, Rowe and Kahn. Instead of broadening our understanding of aging, successful aging may have altered the definition. Political Climate: The authors provide a brief explanation as to how these ideas can affect policy decisions, for example the potential impact of successful aging on US Medicare reform. Toward a Broader Conceptualization: Human aging includes many more dimensions and contexts than are included in the narrow definition of successful aging as it is used today. To continue as it is risks contributing to ageism and discrimination of older adults.

Commentary: Support for the reconceptualization of successful aging can be found in numerous studies that contrast the perceptions of older adults with objectively rated successful aging (see Strawbridge et al., 2002). However, this field of research has been bound by the current understanding of what contributes to healthy aging. A recurring theme within this analysis was the emphasis placed on the individual to be responsible for one’s own health, and that chronic illness can be avoided if one works hard. This individualistic rhetoric is pervasive and will be very difficult to change. It is also popular with policy makers, as it decreases the responsibility of the state, and places it with individuals. The implication of this is to increase research into other determinants of health to create support for a socioecologic approach to health.

Future research into successful aging would benefit from expanding research on contextual factors, such as social, political, and family structures. These system-level factors impact an individuals’ capacity to live well and deserve research attention.

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Fried, L., Ferrucci, L., Darer, J., Williamson, J. & Anderson, G. (2004) Untangling the concepts of disability, frailty and comorbidity: Implications for improved and targeted care. Journal of Gerontology, Medical Sciences, 59(3), 255-263 Purpose: To differentiate between the terms frailty, disability, and comorbidity to improve research and care of older adults with these intersecting conditions.

Method: A narrative review was employed to discuss the different definitions, and implications, of the three related concepts.

Results: Disability was defined as difficulty or dependency in carrying out activities of daily living, including roles, self-care, and activities deemed important to ones quality of life. Frailty was defined as the physiologic state of increased vulnerability resulting from decreased reserves of multiple physiologic systems. The core entities included weakness, poor endurance, weight loss, low physical activity and slow gait. Comorbidity was defined here as aggregate of clinically manifest diseases present in an individual, within which the inclusion of subclinical manifestations were recommended. There are causal relationships between these terms, which explains their frequent co-occurrence.

Clinically, comorbidity has been deemed important in that it helps identify the different diseases that require treatment and highlights the complexity of multiple chronic conditions.

Medical care for disability on the other hand was noted to be concerned with therapeutic interventions to minimize functional impairments, while medical care for frailty has been focused on improving strength and nourishment to enhance overall capacity.

Commentary: From research on the perspectives of older adults, it would appear that disability is most closely associated with how older adults define their own health (see Bryant et al., 2001). Therefore, to enhance research on improving the health and well being of older adults it will be essential to better understand the relationships between these subjects, including the causal pathways linking each condition. Living well with multiple chronic conditions may be the ability to minimize disability and functional interruptions to ones daily activities.

Future research has been recommended to further distinguish between these conditions, refine their definitions and criteria, develop standardized approaches for screening and assessment, and enhance the knowledge of interventions that are unique to each condition.

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Hansen-Kyle, L. (2005) A concept analysis of healthy aging. Nursing Forum, 40(2), 45-57 Purpose: To define healthy aging as a distinct conceptualization, enhancing its applicability in research, planning, promotion and delivery of health care programs for older adults.

Method: Conceptual analysis as outlined by Walker & Avant (1995). First, all definitions and uses of the term were identified. Second, the attributes of healthy aging were delineated.

Third, cases which fit the concept were identified, along with those that do not fit but are similar. Fourth, the concept analysis required the detailing of antecedents and consequences of healthy aging, and lastly the empirical referents were defined.

Results: The concept of healthy aging was found to be defined within four domains: a dictionary definition, medical/gerontological, psychological/social, and nursing. The attributes of healthy aging were found to be a process of adaptation and change, self defined and individualistic, slowing down of bodily processes, acceptance and movement towards death, desire to participate, ability to function physically, cognitively and socially, and continued modification. Antecedents of healthy aging were noted to fall into three broad categories: physical, cognitive, and social or supportive factors. Compensation and adaptation lead to resilience, which is the ultimate antecedent to healthy aging. Consequences of healthy aging are successful aging, independence and autonomy, however it is noted that these are culturally defined concepts and not universally applicable. A new definition of healthy aging is thus: the process of slowing down physically and cognitively, while resiliently adapting and compensating in order to optimally function in all areas of one’s life. The empirical referents identified were physical function, emotional stability, and community interaction, for which tools have been developed, while adaptation and compensation remain undeveloped.

Commentary: This concept analysis provided a necessary review and practical implementation of healthy aging within a nursing domain, and therefore influences future work on caring for older adults to promote healthy aging. The delineation and sequencing of healthy aging as a distinct construct from successful aging and resilience were particularly useful.

Future research would be strengthened by the application of the model of healthy aging to studies on older adults with multiple chronic conditions. Research on the antecedents of healthy aging could include new measures of adaptation and compensation, the process of resilience, and intervention strategies to enhance healthy aging. Research on the consequences may include cultural analyses of successful aging, independence and autonomy. It may also include refined measures of healthy aging, such that the researcher definitions align with older adults perceptions of the concept.

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Kahana, E. & Kahana, B. (2001) Successful aging among people with HIV/AIDS. Journal of Clinical Epidemiology, 54, S53-S56 Purpose: To outline a model of successful aging that provides alternatives and opportunities for those aging with chronic illness.

Method: The example of aging with HIV/AIDS was used to illustrate an alternative model of successful aging, termed the model of preventive-corrective proactivity.

Results: This model of successful aging provides an alternative understanding of successful aging that is inclusive of those aging with chronic disease. In this model, the stressors include normative aging experiences, including illness, loss, and person-environment incongruence.

The outcome of the model includes measures of quality of life such as affective states, meaning in life, and maintenance of valued activities and relationships. Any of these three outcomes may be present as indicators of success. To reach these goals, a variety of resources have been identified. These include internal psychological resources, termed dispositions of successful aging: hopefulness, altruism, self esteem, coping, and life satisfaction. Personal behaviours also influence the outcomes, which have been subdivided into preventive or corrective adaptations. Thirdly, external resources may be engaged to meet successful aging outcomes, including financial and social support. The final component recognized in the model is the influence of sociodemographic variables, which can impact any and all of the pathways to successful outcomes.

Commentary: This model more closely reflected the descriptions of healthy/successful aging depicted by older adults with multiple chronic conditions. It allowed for a broad range of influences to be captured, including social determinants of health that have generally been ignored. It also created more inclusive, subjective outcomes of success that will resonate with a larger audience of older adults. Additionally, it recognized that a person could be successful in one domain, while facing struggles in another. However, the name (Prevention-Correction Proactivity) implies that the path to wellness still involves individual behaviour change, and an emphasis on self-responsibility to engage resources.

Further research is recommended to test this model in populations of older adults with multiple chronic conditions. Understanding how the system can become more responsive to the needs of older adults will enhance the ability of external resources to act as a support rather than a barrier to successful outcomes.

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McMahon, S. & Fleury, J. (2012) Wellness in older adults: A concept analysis.

Nursing Forum, 47(1), 39-51 Purpose: To provide an historical, evolutionary analysis of the concept of wellness, with examples for nursing intervention.

Method: A concept analysis was conducted, using articles published within the last 60 years relating to wellness and older adults. A total of 53 articles were included in the analysis. Data analysis was enabled by the creation of a historical timeline of the articles, and subsequently organizing the data into the defining attributes, antecedents and consequences of wellness.

Results: The modern use of the term wellness arose in the 1950’s as an alternative to medicine’s focus on absence of disease, disability and death. Today, it is understood to be an element that contributes across all states of health and illness, and as an ever-changing process defined by the individual within a holistic view of humanity.

The attributes of wellness are that it is multidimensional, as well as ever-changing and unique. It also includes becoming, integrating and relating. The antecedents of wellness are connecting with others, imagining opportunities, recognizing strengths and seeking meaning.

The consequences of wellness are being well and living values.

Related concepts that were identified were well-being and health promotion. Well-being is differentiated as being a product of life coherence, including happiness and self-actualization.

Health promotion is similar to wellness, although the goal of health promotion is health whereas the goal of wellness is better quality of life.

Commentary: This concept analysis reinforced the centrality of the individuals’ goals and values in determining their health. It also promoted research into understanding and promoting unique strengths and the use of a strengths based perspective. Furthermore, it contextualized wellness as a factor that may be present at any point along the illness to health continuum. For those with multiple chronic conditions, this means that wellness can be achieved regardless of illness status. As a result, wellness is more closely aligned with the prevention-correction proactivity model (Kahana & Kahana, 2001) rather than the successful aging model (Rowe & Kahn, 1997).

Further research is needed to create a better distinction between wellness and well-being, and to understand the multilevel determinants, influences and supports for wellness.

Additionally, creating tools to identify individual strengths and wellness goals would enhance care for older adults with multiple chronic conditions.

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Minkler, M. & Fadem, P. (2002) Successful Aging: A disability perspective.

Journal of Disability Policy Studies, 12(4), 229-235

Purpose: To draw attention to the problems that the term “successful aging” and its narrow dimensions pose to individuals aging with disability.

Method: This paper provides a conceptual review of successful aging as well as a critique of the term as applied to individuals with disability.

Results: Successful aging is comprised of three components: avoidance of disease and disability, maintenance of mental and physical function, and active engagement in life.

However, these components have been framed as outcomes of individual choices, not as factors influenced by extrinsic circumstances and events. It is argued therefore that definitions of success may be different between people according to their own biography. The authors advocated for an increased awareness of the gains and losses that characterize the aging process, to more fully appreciate the value of those with disabilities.

Commentary: This article contributed to the argument that chronicity and disability are socially constructed phenomenon, which are shaped by cultural norms and socioeconomic status in combination with physiological decline (see Martin & Peterson, 2009).

The implications of this research were that we should adapt the environment to the needs of older adults with disabilities to enhance functional abilities, political policy should support social participation by those with disability, and funding to enhance accessibility of communities.

Further research in the area of successful aging must consider a broader ecological approach that draws upon extrinsic resources and the environment. Research is also needed to broaden definitions of aging away from dichotomies such as “successful/unsuccessful”.

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Paterson, B. (2001) The shifting perspectives model of chronic illness. Journal of Nursing Scholarship, 33(1), 21-26 Purpose: To create a model of chronic illness using previous qualitative research.

Method: A metastudy of 292 qualitative research studies was conducted with a vigilant analysis of data, method and theory. The criteria for inclusion limited studies to those published between January 1980- 1998, wherein the researchers investigated the perspective of a person with chronic illness where the data trail was evident, and demographic profiles of the participants were available. Relevant reports were found using computer searches, reference reviews, citation indexes, reviews of research, as well as professional and journalbased networks.

Results: From the studies analyzed, the researchers proposed an alternative model of living with chronic illness called the shifting perspectives model. This contrasted with the previously accepted “chronic disease trajectory�. Where the trajectory posits that individuals move along a course of experiences based partially on length of time with the diagnosis, the shifting perspectives model was explained as the experience of chronic illness continuously shifting between having illness as the foreground and wellness as the foreground. It is a complex process guided by individual beliefs, values, attitudes, expectations and perceptions. The illness as foreground was characterized by the chronic illness being a main focal point for the individual, including sickness, suffering, loss and burden. Having wellness as the foreground occurred when the individual attempted to find meaning and reconstruct their self-identity within their new situation. In this state, people were more likely to rate their health as good or excellent despite functional impairments. Shifts from wellness to illness in the foreground were described to be precipitated by a threat to control. Conversely, shifting to wellness was described to be considerably more complex, and require individuals to disengage from the illness, implement changes and locate resources to maintain their wellness perspective.

Commentary: Both perspectives are thought to have a place within the experience of chronic illness, and both may be experienced to different degrees by individuals throughout their lifetimes. Having wellness at the foreground was posited to be the preferred state for individuals to live well with chronic illness in the long term. Further research should examine these shifts in focus, and how clinicians and caregivers can best help individuals depending on their current perspective. Research into how our health and social policies reinforce an illness as foreground perspective should also be initiated.

This paper detailed the components of a thorough meta-study, including meta-data-analysis, meta-method and meta-theory. These components are useful to keep in mind when reading and evaluating research.

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Rowe, J. & Kahn, R. (1997) Successful aging. The Gerontologist, 37(4), 433-440 Purpose: To review the body of work related to successful aging and consider some pathways to success.

Method: A review of previous research on successful aging. The authors gathered evidence within the three domains that define successful aging, which are the avoidance of disease and disability, maintenance of physical and cognitive function, and engagement in social and productive activities.

Results: Since the original paper on the criteria of successful aging was published (Rowe & Kahn, 1987), there have been a number of studies supporting the concept. The first criterion of successful aging is the avoidance of disease and disability. It has been noted that “usual aging” is associated with chronic disease risk. However, biological studies have revealed that intrinsic factors alone do not determine the risk of chronic illness later in life, the relative contribution of genetic factors decreases over the lifespan, and environmental and behavioural factors play important roles in health outcome determination for older adults. Plus, intraindividual variability in biosociopsych measures may be more predictive of health than mean measures and interindividual comparisons.

Maximizing cognitive and physical function is the second criterion of successful aging.

Cognitive function has been predicted by higher education, peak pulmonary flow rates, physical activity around the home, and self efficacy. Physical function has shown to be maintained by those with good socioeconomic and health status variables, as well as moderate to strenuous physical activity, and emotional support from family and friends.

Engagement with life, the third component of successful aging, is determined by social relations, including being part of a social network and the availability of socio-emotional and instrumental support. However, it is noted that no single type of social support is the most effective: it depends on the fit between the requirements and offers. Lastly, engagement with life is evaluated as productive work, which may include paid and unpaid work, and is predicted by functional capacity, education and self-efficacy.

In the conclusion, it is noted that individuals may move “in and out” of criteria for success.

The mechanism for returning to successful aging is described as resilience.

Commentary: The concept of successful aging has produced a large body of work and is contentious from the point of view of those aging with multiple chronic conditions. The exclusive criteria of “low risk of disease and disability” creates a barrier for those aging with multiple chronic conditions, when in fact many of these individuals are able to transcend their challenges and remain actively engaged and perceived themselves to be aging with success.

“Living well” may offer an alternative term for those who do not meet these narrow, prescriptive criteria. However, the value of the categorization of those who manage to age without chronic conditions are a signal of “positive deviance” and are an area for future research (see Evert et al., 2003).

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Strawbridge, W., Wallhagen, M. & Cohen, R. (2002) Successful aging and wellbeing: Self rated compared with Rowe and Kahn. The Gerontologist, 42(6), 727733 Purpose: To compare older adults’ self-rated successful aging to Rowe and Kahn’s definition of successful aging. Then, to predict well-being from the two measures.

Method: Participants were drawn from the Alameda County Study, a longitudinal study that began in 1965. The sample consisted of data from 867 participants at the 1999 follow-up, 65+ years old. Self-rated successful aging was based on agreement with the following statement: I am aging successfully/aging well. Criteria based on Rowe & Kahn’s definition included absence from disease, ability to perform ADL/IADL activities, absence of risk factors, physical and mental function self-reports, connections with people and being productive. These two measurements were then used to predict well-being.

Results: Half of the respondents rated themselves as aging successfully, compared to only 18.8% who fit the Rowe & Kahn criteria. Further, 36.8% of individuals classified as successful by Rowe & Kahn did not rate themselves as successful. For the dichotomous variables of wellbeing, 10 out of 11 variables were associated more strongly with self-rated successful aging.

For the continuous variables, older adults who were rated successful by either definition had greater well-being scores.

Commentary: This article articulated the difficulties in labeling older adults as aging “successfully”, since this implies that those not meeting these criteria are “unsuccessful”. This article exemplified the discrepancy between older adults’ perceptions of successful aging and how the concept is defined in research. Especially interesting is that not all of the participants who were classified as aging successfully by the Rowe & Kahn criteria considered themselves to be aging successfully. Older adults with inconsistent results between the two definitions represent an opportunity for future research to understand this gap (see Bryant et al., 2001).

This research indicated that the presence of a chronic condition has the ability to influence well-being and measures of successful aging. However, presence of a chronic condition does not preclude an individual from experiencing successful aging.

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b) Measurement Tools Bayliss, E., Ellis, J. & Steiner, J. (2009) Seniors’ self-reported multimorbidity captured biopsychosocial factors not incorporated in two other data based morbidity measures. Journal of Clinical Epidemiology, 62(5), 550-557 Purpose: To explore whether self-report measures of multimorbidity provide greater biopsychosocial feedback for researchers to use.

Method: The self-report measure was administered as part of a larger study on barriers to selfcare in multimorbidity. The cross-sectional survey included 352 older adults, minimum age 65 years, who were diagnosed with diabetes, depression, and osteoarthritis. Respondents provided a full list of chronic conditions, as well as a rating of how much that condition interfered with activities of daily living. This self-reported measure was then compared to the Quan comorbidity index (based on ICD-9 codes) and Chronic Disease Score (pharmacy data that includes age, gender and a disease severity weighting). Statistical analyses were used to compare these three forms of morbidity measurement.

Results: The self-report model had several components that were statistically significantly associated with disease burden above and beyond either of the data based measures. These factors were physical function, financial constraints, self-efficacy and compound effects of chronic illnesses.

Commentary: This research indicated that the disease burden experienced by older adults in this sample living with chronic conditions was impacted by factors that have not been accounted for in typical comorbidity measures. This has implications for choosing which measure to use in a research study, and also varies based on the outcomes one is looking for.

Furthermore, it was indicated that future studies would benefit from using a combination of measures.

It is not surprising that compound effects of conditions remained a salient factor above and beyond mere disease counts for the impact of disease burden. This reinforces the complexity in studying and managing chronic conditions in the face of multimorbidity. This finding may have been especially noticeable in this sample as the authors purposefully chose individuals with discordant diagnoses.

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Boyd, C., Weiss, C., Halter, J., Han, C., Erschler, W. & Fried, L. (2007) Framework for evaluating disease severity measures in older adults with comorbidity. Journal of Gerontology, Medical Sciences, 62A(3), 286-295 Purpose: To examine disease-specific severity measures using a comparison framework, and to evaluate their use in comorbid older adults.

Method: The Medline data-base was searched for all severity classification systems pertaining to single chronic disease diagnoses. Experts within each disease domain were also contacted to elicit any additional severity measures used in practice. Disease severity measures were defined as categorization approaches that distinguish between a minimum of two levels of disease (ie. greater or lesser disease). Each approach was reviewed based on the following framework: a) purpose of obtaining severity rating, b) level of information used, and c) feasibility.

Results: The framework was able to identify goals, levels of information and feasibility that were different within and between different diseases, as hypothesized. Additional components that did not fit into the framework but were found in some measures included presence of other diseases, behaviours, level of treatment required, and sociodemographic variables.

Commentary: The challenges of using disease-specific severity measures in patients with comorbid diseases were highlighted in this research. One example is that measures such as “Degree of shortness of breath� may be capturing the severity of connected diseases, not just the index disease. However, the authors caution against using generic measures of global severity, as these decrease the ability to pick out complexities and subtleties that are disease specific. Therefore, a unified system of severity classification is recommended, that is comprised of disease specific scales coordinated by the goal/purpose of measurement and level of information (ie. collection point along continuum from pathology through symptoms to quality of life). The purpose of this framework was to guide researchers and clinicians to question underlying goals and outcomes measured by each instrument and whether comorbid diseases are influencing the results. However, the framework was not well articulated within the text and would benefit from a schematic representation to guide future use.

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De Groot, V., Beckerman, H., Lankhorst, G. & Bouter, L. (2003) How to measure comorbidity: A critical review of available methods. Journal of Clinical Epidemiology, 56, 221-229 Purpose: To assess the validity and reliability of currently available methods for measuring comorbidity for use in clinical research through a systematic review of the literature.

Method: This study involved a database search for articles that used comorbidity indices as a prognostic variable. The search was performed in Medline and Embase, up until September 2000. The comorbidity indices from each study were assessed for their content, criterion, predictive and construct validity, as well as test-retest, inter- and intra-rater reliability.

Results: A total of twelve comorbidity indices were found in the literature, plus one disease count measure. Data on content and predictive validity were available for all measures. The Charlson Index, Cumulative Illness Rating Scale (CIRS), Index of Coexistent Disease (ICED), and Kaplan Index were deemed reliable and valid measures for use in clinical research. The other 9 indices did not have enough data to be appropriately assessed.

Commentary: The CIRS has been the index most valued for it’s application to clinical research, due to it’s high validity, reliability, and use of clinically relevant body systems to detail comorbidity. The ICED measures both pathophysiological disease severity and disability, and was therefore recommended as a useful tool in disability research. The Charlson Index was deemed most appropriate for mortality research, while the Kaplan was most applicable to diabetes research.

Comorbidity indices require an index disease to be labeled and all other diagnoses become secondary. Previous research (see Thorne et al., 2003) showed that older adults often select an index disease that affects them the most, and direct their time and resources to a primary target. Therefore comorbidity may be more useful clinically than multimorbidity.

This research is relevant to the study of living well with chronic conditions since disease severity is linked to functional and quality of life outcomes for older adults with multiple chronic conditions (see Ferrucci et al., 2000).

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Glasgow, R., Stryker, L., Toobert, D. & Eakin, E. (2000) A socio-ecologic approach to assessing support for disease self-management: The chronic illness resources survey. Journal of Behavioural Medicine, 23(6), 559-583 Purpose: To report the development and assessment of the Chronic Illness Resources Survey (CIRS), a tool for measuring support and resources for self-management.

Method: Participants were screened by telephone and included if they had a diagnosis of arthritis, COPD, diabetes, heart disease, or a combination of these diseases. A total of 123 participants were recruited, between 40-88 years old. Participants completed the CIRS and a number of other validated instruments to test for the convergent, content, and criterion validity of the CIRS. Demographic and medical histories were collected to assess the construct and predictive validity. To control for response bias, the participants also completed the Balanced Inventory of Desirable Responding.

Results: Age was moderately and significantly correlated with support in the CIRS, with older adults reporting higher levels of support (r=0.35, p<0.01). The total CIRS scores were internally consistent, and test-retest reliability was consistent. Significant correlations were found between the CIRS and similar established scales. A Brief CIRS was also developed based on these results for use in clinical settings, which was fairly internally consistent and moderate testretest reliability. Overall the CIRS was a stronger predictor than single-channel support scales (ie. Social Support for Eating Habits and Exercise Survey).

Commentary: The development of this scale represented a significant addition to multi-level support research for older adults. The scale was demonstrated to be concise, easily scored, and applicable across a number of chronic diseases. The scale also included an identification of the importance that the user ties to each type of social support. This feature would be useful in clinical settings as it would allow health care providers to tailor interventions based on areas of low perceived support and high perceived importance.

Areas identified for future research included replicating the analysis with a more diverse sample, over a longer period of time, and with a greater variety of chronic diseases. Research on whether the CIRS can motivate individuals to improve their health behaviours is also warranted.

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Karlamangla, A., Tinetti, M., Guralnik, J., Studenski, S., Wetle, T. & Reuben, D. (2007) Comorbidity in older adults: Nosology of impairment, disease and conditions. Journals of Gerontology, Medical Sciences, 62A(3), 296-300 Purpose: To propose an assessment of comorbidity (or multimorbidity) by measuring physiological and psychological functioning.

Method: A conceptual outline of potential comorbidity nosology based on the International Classification of Functioning, Disability and Health (ICF) used by the World Health Organization.

Results: The nosology proposed in this study is based on the ICF, which divides functioning among various domains. These include mental, sensory, voice and speech, cardiovascular, hematological, immunological, respiratory, digestive, metabolic, endocrine, genitourinary, neuromuscular, and skin. The goal of this nosology is to facilitate the creation of comorbidity indicies that reflect the full range of possible function and the interactions between domains.

Commentary: Comorbidity was defined in this article as the total burden of biological dysfunction, making it synonymous in this case with multimorbidity. The benefits reported of this nosology were that it recognizes the full spectrum of performance in each system, including positive or protective factors as well as the negative aspects. It also accounts for decrements in health before the outright diagnosis of disease, therefore it does not rely on clinically diagnosed diseases alone. The importance of subclinical impacts of disease have also been recognized in other research (see Vahia et al., 2010) Limitations of this nosology are that it doesnâ&#x20AC;&#x2122;t account for social or other support systems, lifestyle, socioeconomic factors or health care access, which may also impact the burden of chronic conditions. Nor does it assess how these system-level functions are impacting real world quality of life and functional abilities.

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Lamond, A., Depp, C., Allison, M., Langer, R., Reichstadt, J., Moore, D., Golshan, S., Ganiats, T. & Jeste, D. (2009) Measurement and predictors of resilience among community dwelling older women. Journal of Psychiatric Research, 43, 148-154 Purpose: To examine the validity and factor structure of the Connor-Davidson Resilience Scale (CD-RISC) in a sample of older women. Further, to compare the relationship of resilience to other factors of successful aging found in the literature, such as physical function, cognitive function, social engagement, well being, self-rated successful aging, and positive attitude.

Method: The sample was drawn from the Womenâ&#x20AC;&#x2122;s Health Initiative in San Diego, and included 1,395 participants over age 60. Data was collected via a questionnaire, which included demographic information, the CD-RISC to measure resilience, and various scales to measure the successful aging factors listed above. In the statistical analyses, an exploratory principal components analysis was conducted on the CD-RISC to examine the factor structure.

Pearson correlates were then run to compare resilience to successful aging components.

Results: The level of resilience and internal consistency of the CD-RISC found in this study was similar to that found by the original research on younger adults. However, the construct analysis revealed a different factor grouping, which may indicate that older adults engage in an alternate process of resilience. The four factors revealed in the research were personal control and goal orientation, adaptation and tolerance for negative affect, leadership and trust in instincts, and spiritual coping.

When comparing resilience to successful aging components, resilience was strongly correlated to optimism, emotional well-being and self rated successful aging, as well as somewhat correlated with days spent with family and friends per week, and physical functioning.

Commentary: This research revealed differences in the factor analysis when comparing the results from older women to a sample of younger adults. The main difference was that older women appeared to have greater tolerance for negative affect and adaptability compared to younger participants in the original research by Connor & Davidson (2003). This may indicate that as we age our coping styles change to a more passive approach. This finding could be particularly true for older adults faced with chronic illness, and is an important avenue to explore to understand if and how resilience changes throughout our lives.

Resilience was defined in this article as the ability to adapt positively to adversity. For older adults aging with chronic disease, the construct of resilience may be a key factor in defining those individuals who are living well.

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Lash, T., Mor, V., Wieland, D., Ferucci, L., Satariano, W. & Silliman, R. (2007) Methodology, design, and analytic techniques to address measurement of comorbid disease. Journal of Gerontology, Medical Sciences, 62A(3), 281-285 Purpose: To describe the ways in which comorbidity is measured in recent research on older adults, to point out the limitations of such measurements, and to raise awareness for how this impacts research findings.

Method: A review of the analytic strategies, data sources, and placement of the comorbidity variable within comorbidity measures, and how these effect the resulting research.

Results: The three analytic strategies used for dividing participants into comorbidity categories in research are ordinal, weighting, and categorization. Ordinal is a simple counting method, and is therefore conceptually easy to apply, however, it assumes there is a linear relationship between number of conditions and outcomes. Weighted measures address the severity and differential impact, however this method runs the risk of overcustomization. Third, categorization addresses the nonlinear nature of the relationship, but may lose information the other measures can provide.

The data sources for obtaining morbidity status come from medical records, self-report, clinical judgment and administrative data. Medical records are beneficial in that they are generally detailed and reflect clinical opinion, however they may be difficult to obtain and of variable quality. Self report has shown validity compared with medical records, is easy to obtain, but is subject to recall bias. Clinical judgment may be simple, but possibly incomplete.

Lastly, administrative data may be useful when available, but also may be incomplete and of variable quality.

Also important in the study of comorbidity is the placement of the variable within equation modeling. If comorbidity is assumed to be a confounding variable in research, misclassification of participants as comorbid may significantly change the adjusted estimates. When comorbidity is the modifier, misclassification may result in modification, interaction or interdependence to be found when there is none. Misclassification of comorbidty as the exposure variable has unpredictable consequences on the effect found. Lastly, when comorbidity is the dependent variable, misclassification biases findings to the null hypothesis.

It is evident from these scenarios that the placement of comorbidity has implications for the validity of research findings.

Commentary: Measuring comorbidity was found to be difficult. This sentiment was captured in the phrase â&#x20AC;&#x153;all measures of comorbidity are imperfect surrogatesâ&#x20AC;? since they are trying to measure a conceptual entity, the onset and the outcomes of comorbidity are difficult to clarify, and data is often incomplete. This research outlined the potential hazards to research if better measurements of comorbidity are not created and implemented, especially in the study of older adults where comorbidity is present. Recommendations for future development of highquality comorbidity and multimorbidity measurement tools are to use sensitivity analyses, obtain data from multiple sources, and to build in a measure of uncertainty to address the imperfection of available measures.

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Mukherjee, B., Ou, T., Wang, F. & Erickson, S. (2011) A new comorbidity index: The health related quality of life comorbidity index. Journal of Clinical Epidemiology, 64, 309-319 Purpose: To derive and validate the health-related quality of life comorbidity index (HRQL-CI) Method: The study used data from the 2003 and 2005 Medical Expenditure Panel Survey (MEPS) in the US. The data from the 2003 version were used to develop the index, while the 2005 data were used to validate the measure. A total of 44 clinical classification codes (CCCs) were identified, and those having the greatest impact on HRQL were selected using the LASSO method. Two models were created, one that was based on the absolute values found and one weighted by the strength of regression coefficient of the CCC. Prediction error, external validation, and predictive ability for single item HRQL, mental and physical health were computed. All results were compared to the Charlson-CI as the benchmark.

Results: This model helped explain the variation in health-related quality of life outcomes by controlling for the impact of comorbidities in a research sample. Furthermore, it significantly outperformed the commonly used Charlson-CI. Commentary: This index appeared to be applicable in studies that aim to control for comorbidity on health-related quality of life outcomes. Further research is needed to compare it to other indices in addition to the Charlson-CI. The instrument development included a wide range of CCCs; however, some were excluded on the basis that they did not appear in the 2003 sample. Furthermore, this was not developed on/for older adults specifically, and the impact chronic conditions have on their health-related quality of life may differ.

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Parslow, R., Lewis, V. & Nay, R. (2011) Successful aging: Development and testing of a multidimensional model using data from a large sample of older Australians. Journal of the American Geriatric Society, 59, 2077-2083 Purpose: To create a model of successful aging that encompasses physical and mental health, social support and cognition. To use structural equation modeling to assess the relationships between predictor variables as well as their relative strengths.

Method: From a larger study sample, 2,286 participants were selected, ages 60-85 years.

Successful aging was ascertained via self-assessed mental and physical health, quality of life and cognition. The predictors of successful aging were past and current mental and physical health, health behaviours and social measures. Structural equation modeling was used to assess the contribution of the past and present factors to the latent variable, successful aging.

Results: In the final model, physical and mental health, life satisfaction, and cognition were statistically significant and independently related to successful aging. Those in the highest quartile of â&#x20AC;&#x153;aging wellâ&#x20AC;? had an average 2 chronic illnesses.

Commentary: This research contributed to the conceptualization of aging well with chronic conditions by creating a multidimensional structural model. Further, it showed that older adults can age well with chronic conditions. The contributions made to the model come in part from modifiable factors, which can therefore be the target for future interventions for aging well. In particular, physical activity was a primary health-promoting factor that can be improved. Future studies that employ an experimental design should explore whether increasing physical activity can result in an improvement in successful aging, according to the model outcomes.

Limitations of the study include incomplete variables used to create the model, for example measures of resilience or financial security were excluded. Also, the study did not include participants over age 85, and therefore may be missing factors that are salient for the oldest old and their rating of successful aging. See Baltes and Smith (2003) for more on the differences between young old and old old adults.

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Resnick, B. & Inguito, P. (2011) The Resilience Scale: Psychometric properties and clinical applicability in older adults. Archives of Psychiatric Nursing, 25(1), 11-20 Purpose: To provide support for the psychometric properties of the Resilience Scale, to assess the ability of the scale to identify older adults with low resilience.

Method: The study sample was drawn from two settings, a continuing care home with 163 participants and a hip fracture exercise program accounting for 101 participants. The 25-item Resilience Scale was completed, along with measures of self-efficacy, expectations for exercise, mini-mental state exam (MMSE), and the Yale Physical Activity survey. The Resilience Scale was tested for unidimensionality using the principal components analysis of the standardized residuals. Model fit was tested using Root Mean Square Error of Approximation, Rasch analysis, and INFIT/OUTFIT tests.

Results: The results provided support for the use of the Resilience scale with older, white women between the ages of 80-90. The Rasch analysis and model fit tests were mostly positive, along with sufficient evidence of internal consistency. Furthermore, there was a significant correlation between the Resilience Scale and self-efficacy, outcome expectations and exercise adherence.

Commentary: This scale highlighted the one of the many facets of resilience. It focused on dispositional resilience, which may be more tied to personality characteristics than emotional, physical, or mental resilience. Therefore it created a limited picture of resilience. Another issue is that many of the participants had high tested levels of resilience, and could not be sufficiently differentiated based on the results. Adding questions that probe varied approaches to resilience and providing a more heterogenous sample may offer greater insight into resilience among older adults. The authors also recommended rewording some of the questions and changing to a dichotomous scale to improve the ease of use in research and clinical settings. This scale needs to be tested with different populations including males to ensure that it is generalizable.

This scale was able to identify older adults with low levels of dispositional resilience.

However, it needs to be improved upon before being recommended as an overall scale of resilience, or as a useful tool to differentiate those with high levels of resilience.

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Tooth, L., Hockey, R., Byles, J. & Dobson, A. (2008) Weighted multimorbidity indexes predicted mortality, health service use and health related quality of life in older women. Journal of Clinical Epidemiology, 61, 151-159 Purpose: To develop and test multimorbidity indices for use with community dwelling older women, using self-reported data.

Method: This research was developed based on an expansion of Byles et al.. (2005) and to complement work done on males by Fan et al.. (2002). Participants were recruited Australian Longitudinal Study on Women’s Health. They were divided into two groups, the development Sample A (n=5217) and the validation Sample B (n=5217), which allowed the indexes to be tested a second time to ensure validity. First, the researchers developed two multimorbidity indexes based on a regression analysis of self-reported chronic conditions from Sample A. The unweighted index treated each morbidity equally, which created a summation of morbidities.

The weighted index used the regression coefficients to produce integer values for each morbidity, which were subsequently summed. The outcomes tested were mortality, use of health services, health related quality of life, and assistance with activities of daily living. The weighted and unweighted scales were then used to predict the outcomes in both Sample A and Sample B. Results: Overall, the weighted index had a better fit and a greater range of possible values than the unweighted version, and was therefore deemed most useful. In the regression analysis it was found that mortality was predicted by stroke, heart disease, emphysema/bronchitis, Alzheimer’s disease, cancer, iron deficiency and diabetes. All health service use variables were predicted by stroke, cancer, heart disease and low iron. Activities of daily living were most strongly predicted by Alzheimer’s disease, falls causing fracture, stroke and cancer. Chest pain, urinary incontinence, low iron, arthritis, diabetes cancer, depression and anxiety were associated with all domains of HRQOL, and Alzheimer’s disease was associated with 4 domains of HRQOL. Commentary: The weighted scales were developed using only women, and therefore are not generalizable to the male population, who may have different coefficients related to their chronic disease profiles. More research needs to be done to evaluate weighted indices of comorbidity to determine if it is possible or even recommended to employ a single index, or if each index should be tailored to gender, race, living situation and socioeconomic status.

Validity testing of this index should be performed in a wider range of older adults.

Another important finding was that iron deficiency and Alzheimer’s disease were significant predictors for many of the outcomes variables, ranging from quality of life to mortality. These conditions are not frequently included in multimorbidity research, but from the strength of these findings it is recommended that they be included in the future.

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c) Quantifying Living Well and Multimorbidity Anaby, D., Miller, W., Eng, J., Jarus, T. & Noreau, L. (2011) Participation and well-being among older adults living with chronic conditions. Social Indicators Research, 100, 171-183 Purpose: To assess whether the accomplishment of participation or satisfaction with participation was more important to the well-being of participants, as well as to assess the unique contribution of participation to well-being.

Method: 200 participants were recruited into the study, aged 65+ with a minimum of 2 chronic conditions. Data was collected by self-report and physical testing. The measurements included participation (both amount and type of participation and satisfaction with participation), perception of social support, demographic factors, and subjective well-being (measured with Satisfaction with Life Scale).

Results: The model showed a slight (3%) contribution to well-being from satisfaction with participation. No effect was found from accomplishment of participation. However, the model did find that chronic conditions, social support and satisfaction with participation did explain 31% of the variance in life satisfaction.

Commentary: The study participants had a high level of participation and mobility, and therefore the results are not representative of more restricted older adults. The authors predicted that as ability decreases, satisfaction with participation will have a greater impact on well-being. Future studies should include a greater range of disability and participation levels.

An experimental, mixed methods design may better elicit the relationship between participation and well-being.

In this study, well-being was measured as a single construct, accounting only for life satisfaction. Well-being is a multi-dimensional concept, and perhaps by adding more measures of well-being into the study there will be a greater chance that satisfaction with participation will have a detectable effect. It may also be interesting to control for degree of functional ability or impairments in ADL/IADL tasks, as these have shown to be important to older adultsâ&#x20AC;&#x2122; concepts of aging well.

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Baltes, P & Lang, F. (1997) Everyday functioning and successful aging: The impact of resources. Psychology and Aging, 12(3), 433-443

Purpose: To identify differences in daily activities between people classified as resource rich and those classified as resource poor. It is hypothesized that negative aging effects will be minimized for those with greater resources.

Method: The study data came from the larger BASE research, and included 516 adults age 70103 years old. Resource richness was identified via eleven measures that rated participants in four categories: sensorimotor, cognitive, personality, and social resources. A Yesterday Interview was conducted to elicit the daily functional pattern of the older adults in the study.

Specifically, the sequence, duration, frequency, geographical and social context were of interest to the researchers. The daily activities were divided into eight categories: self-care (ADL), housekeeping (IADL), physical leisure, intellectual/cognitive leisure, television watching, social engagement, resting, and sleeping. Due to exploratory factor analysis the four resource types were grouped into sensorimotor-cognitive and personality-social. These were then dichotomized, and using a median split the participants were classified as resource rich if they scored high in both domains and resource poor if they scored low in both.

Results: When the participants were split into their resource groups, there were 95 participants classified as high-resource, 104 as low-resource and the rest were high in one domain and low in the other. Age was most strongly negatively associated with sensorimotorcognitive resources. When the resource rich and resource poor groups were contrasted, the former had a greater variety of activities, and fewer resting periods. These two groups did not differ in sleep or ADLs. Commentary: The finding that resource rich older adults were more active throughout their daily activities is hypothesized to be evidence of selection, optimization and compensation (see Baltes & Carstenson, 1996). Exploring the differences in these processes between resource rich and resource poor individuals is an avenue for further study. Further exploring the meaningfulness of these activities would be important in future research.

It was expected that older adults who reported low social resources would also have low social interaction throughout the day. The question remains whether there is a causal effect occurring between these variables, which could not be elicited from the current cross-sectional study.

Future research would benefit from longitudinal analysis as well as the addition of chronic condition variables to determine whether these resource factors have a buffering effect on the well being of older adults in the face of chronic illness.

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Boyle, P., Barnes, L., Buchman, A. & Bennett, D. (2009) Purpose in life associated with mortality among community dwelling older adults.

Psychosomatic Medicine, 71, 574-579 Purpose: To determine whether there is a relationship between purpose in life and all-cause mortality in older adults.

Method: Data were used from two longitudinal studies based in Chicago. The sample consisted of 1,238 participants. Follow up testing occurred at an average of 2.7 years. Purpose in life was assessed using a modified 10-item measure from Ryff and Keyes scales of Psychological Well Being. The results were reported as hazard ratios based on purpose in life scores, while controlling for: age, race, gender, and education, as well as depressive symptoms, disability, neuroticism, number of chronic conditions and income.

Results: The study found that individuals with a greater purpose in life score had less chance th of all-cause mortality. The cumulative hazard for mortality in individuals within the top 90 th percentile of reported purpose in life was 57% of that found for 10 percentile, even after controlling for the above variables.

Commentary: These results were significant because even after the models were statistically controlled using number of chronic conditions, there was a greater survival rate recorded for those with higher purpose in life. This study, however, did not address whether those who survived were in fact “living well”. Future studies should investigate whether purpose in life impacts older adults’ perceptions of well-being and life satisfaction, and whether it is a modifiable factor.

A key concept in this paper was purpose in life, which was defined in this study as a “complex multi-dimensional construct that reflects the tendency to derive meaning from life’s experiences and possess a sense of intentionality and goal directionality that guides behaviour”. It stems from humanistic psychology, the writings of Victor Frankl and is considered a key component of human flourishing, and therefore useful to study as related to aging well.

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Chapman, B., Lyness, J. & Duberstein, P. (2007) Personality and medical illness burden among older adults in primary care. Psychosomatic Medicine, 69, 277282 Purpose: To use the five-factor model (FFM) of personality to determine whether these personality traits are associated with morbidity in older adults.

Method: Data collection began with an interview and was followed up with a mail-in package consisting of the personality questionnaire (NEO-FFI), the Cumulative Illness Rating Scale, Hamilton Depression Rating Scale, and lifestyle behaviour questions. A total of 449 participants had complete data. The five personality traits tested for in the NEO-FFI are Neuroticism, Extraversion, Conscientiousness, Openness, and Agreeableness. The statistical analyses tested for associations between the personality traits and chronic illness variables.

Results: Overall, the study found that older, less educated, more depressed, more neurotic, less extraverted, less conscientious, less open, and less agreeable individuals had higher Cumulative Illness Rating Scale (CIRS) scores. Once all variables had been added into the model, conscientiousness was the only personality trait found to be statistically significantly associated with aggregate disease burden. A comparison between the variables of conscientiousness and age revealed that a 10-year age gap had less of an impact on CIRS than highest versus lowest levels of conscientiousness. Those with the highest levels of conscientiousness had 87% less overall health burden. Within conscientiousness, a linear combination of orderliness and goal-striving was found to be significantly associated with morbidity, while dependability and other combinations were not.

Commentary: This research contributed to the chronic illness literature by delineating whether certain personality traits may contribute to chronic illness in later life. This was a novel method to understand chronic conditions, and is part of a broader life span development approach to the cumulative hazards of chronic illness.

Future research would benefit from a deeper exploration of why and how conscientious personality traits offer a protective effect on disease burden in older adults. It is also important to note that personality traits may not be stable over the life course. It is possible that individuals with lower health burden maintained a greater sense of conscientiousness. As this was a cross sectional study, it was not possible to draw causal conclusions.

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Erdal, K. & Zautra, A. (1995) Psychological impact of illness downturns: A comparison of new and chronic conditions. Psychology & Aging, 10(4), 570-577 Purpose: To compare the impact of new versus chronic health downturns on psychological health. To provide support for either the additivity theory or the anticipatory coping theory of adaptation to chronic illness.

Method: The sample, which was obtained from the Life Events and Aging Project in Arizona, included 269 non-institutionalized older adults. Participants were followed for one year to illicit illness downturns and outcomes on measures including the mental health inventory, PERI demoralization composite, Bradburn positive affect scale, performance of IADLs, and pain scale. Participants were subsequently categorized based on their illness downturns in the previous year: chronic illness downturn, new illness downturn and no illness downturn. The hypotheses were tested in a 2x3 factorial design.

Results: the findings revealed that predictable (chronic) illness downturns had a greater negative effect on well-being than new downturns. Chronic health events appeared to be more distressing than acute stressors, which supports the additivity theory. Furthermore, pain was found as a covariate of distress but not well-being.

Commentary: This research has highlighted the importance of continued support for older adults with chronic conditions. It is not fair to assume that since someone has dealt with a similar problem that they are better equipped to handle it in the future. This research is further supported by the cascading crises theory (see Sells et al., 2009), which also found that chronic conditions contribute to declining health and diminished resources. It may also reflect some of the tenets of the shifting perspective paradigm (see Paterson, 2001), with a new diagnosis causing a shift to illness-in-foreground perspective. Research in the future should focus on how to bring wellness back to the foreground.

A strength of this study was the prospective design that allowed the researchers to follow their participants for a year, and to assess their psychological status at various intervals.

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Evert, J., Lawler, E., Bogan, H. & Perls, T. (2003) Morbidity profiles of centenarians: Survivors, delayers and escapers. Journal of Gerontology, Medical Sciences 58A(3), 232-237 Purpose: To determine the relative timing of the onset of diseases among centenarians.

Method: Using a retrospective cohort design, the researchers obtained health history questionnaires from 424 individuals ages 97-119. The questionnaire included the age of onset of 11 major diseases, as well as cognitive impairment and alcohol or tobacco use. The study excluded age of onset of cognitive impairment due to the difficulty in assessing onset.

Results: Centenarians were found to fit into three morbidity profiles, termed survivors, delayers and escapers. Survivors were those with a diagnosis of an age-related illness prior to the age of 80; 24% males and 43% females fit into this category. Delayers were diagnosed after the age of 80; 44% male, 42% female were classified as delayers. Lastly, Escapers were th those who attained their 100 year without the diagnosis of any major age related illness; 32% of males and 15% females.

Commentary: This study provided support for the compression of morbidity hypothesis. The majority of centenarians either delayed or escaped a chronic illness diagnosis, which aided them in achieving exceptional longevity. Differences between men and women were th interesting to compare, since males were significantly more likely to have reached their 100 year without chronic illness, however they were less likely to reach 100 at all. Comparatively, women were more likely to reach 100 years of age, while surviving with a chronic illness, often for over 20 years since diagnosis. These gender differences highlight new research paths to understand why these differences exist.

Categorizing older adults as survivors, delayers and escapers is a more positive labeling scheme than successful vs. unsuccessful aging. Whether an individual has escaped chronic illness diagnosis may not make him or her a more successful ager, and vice versa. Indeed, this research shows that 85% of women and 66% of men reached 100 years of age with a chronic condition. It would be interesting to investigate the experiences of these centenarians and whether or not they felt they have successfully aged.

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Fiest, K., Currie, S., Williams, J. & Wang, J. (2011) Chronic conditions and major depression in community dwelling older adults. Journal of Affective Disorders, 131, 172-178 Purpose: To assess the prevalence of major depression alongside comorbid chronic conditions in a Canadian sample of 50+ and 65+ year olds.

Method: Data were collected from the Canadian Community Health Survey 1.2 â&#x20AC;&#x201C; Mental Health and Wellbeing, 15,591 over age 50. In the survey, episodes of major depression in the past 12 months were considered, along with 36 chronic conditions. Control variables included gender, age, marital status, education, and household income. Logistic regression modeling was performed to determine the correlation between specific conditions and major depression.

Results: For individuals over 65 years, major depression was most commonly associated with chronic fatigue syndrome, fibromyalgia, and migraine. These top three were consistent across the age ranges, although the affects appeared to be greater for those in the younger cohorts (greater percentage of comorbid depression). Depression was also associated with the top three most common conditions for older adults (heart disease, arthritis, and back problems) but to a lesser extent.

Commentary: Major depression was highly correlated with other chronic conditions for older adults. Since this was a cross-sectional analysis, it was not possible to determine the direction of this relationship: whether the conditions cause depression or vice versa. Research that contributes to a deeper understanding of this correlation may lead to improvements in quality of life for older adults. The high prevalence rates of comorbid depression in the top three conditions alert researchers of future study avenues.

Given the negative effect that depression has on quality of life it is essential to further explore these relationships.

An interesting difference that was not explored in this paper was the finding that proportionately more individuals in the younger cohorts experienced depression when diagnosed with the same illnesses. For example, 26% of 18+ year olds experienced major depression with chronic fatigue syndrome compared with 19% of 65+ year olds (Table 4). It is not clear if this is statistically significant difference; however, this finding may imply that older adults have better coping resources or resilience to deal with life altering chronic conditions.

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Foottit, J. & Anderson, D. (2011) Associations between perceptions of wellness and health related quality of life, comorbidities, modifiable lifestyle factors and demographics in older Australians. Australasian Journal on Ageing, 31(1), 22-27 Purpose: To explore the associations between perceived wellness and health related quality of life, comorbidities and modifiable lifestyle factors.

Method: The study employed a cross-sectional design, using a questionnaire to elicit perceived wellness from 257 older adults over the age of 65 years living in the community.

Additional measurements included Medical Outcomes Survey short form version two (SF36vs2), modifiable lifestyle questions, comorbidity and sociodemographic information. The results were analyzed using hierarchical regression to determine the influence of the variables on perceived wellness.

Results: Perceived wellness was positively correlated with all eight of the components of health related quality of life, with general health being the strongest correlate. Disease and disability contributed 20% of the variance in perceived wellness scores, while age was a significant variable for women and demographic factors contributed 6% total variance. The regression model indicated that hearing deficits, mobility, chronic disease, memory, regular exercise, being single and gambling below hazardous levels were contributed to perceived wellness.

Commentary: The association between quality of life variables and perceived wellness indicated that the physical and mental abilities had a stronger association with perceived wellness than did social functioning or pain. This suggests that it was the ability to function and manage negative feelings that drove perception of wellness in this population. In comparison, the correlation with social functioning may be an indirect pathway to perceived wellness, which is influenced by functional ability. Similarly, pain may only impact perceived wellness if it impairs oneâ&#x20AC;&#x2122;s ability to do what they want.

The two chronic condition variables that were independently associated with perceived wellness were hearing impairment and memory. This indicated that impairments in these areas were influencing individualâ&#x20AC;&#x2122;s ability to function, therefore decreasing perceived wellness.

The findings of this study support research indicating that it is not multimorbidity per se that influences well being, but the ability to cope and maintain a level of functioning that reflects what the older adult wants to be able to do (see Bryant et al., 2001). Further research may identify methods to determine how to help older adults cope with functional changes so that they can still participate in meaningful activities.

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Friedman, E. & Ryff, C. (2012) Living Well With Medical Comorbidities: A Biopsychosocial Perspective. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 67(5), 535-544 Purpose: To determine whether positive psychological functioning can moderate the relationship between number of chronic conditions and inflammatory factors.

Method: This study used data from the national survey of Midlife in the United States (MIDUS).

Participants from the original study who had clinical assessments completed were invited into the study the sample size was 998 participants, ages 35-86. Number of chronic conditions (from a list of 12), eudaimonic and hedonic well-being were assessed and inflammatory markers were obtained from fasting levels of interleukin-6 and c-reactive protein.

Results: The study found that when comparing individuals with similar numbers of multiple chronic diseases, those with higher positive affect, purpose in life and positive relations with others had lower levels of inflammation. Additionally, high levels of multiple morbidities did not preclude high levels of life satisfaction.

Commentary: This article provided evidence that biological factors may be influenced by psychological status in individuals with chronic conditions. However, the study was unable to clarify the direction of this relationship. It is possible that there is an alternate cause of increased inflammation, which in turn leads to a decrease in psychological status. Previous studies have shown that positive psychological function can improve overall health and wellbeing (see Boyle et al., 2009). The present study attempted to expand the understanding of this relationship by examining the biological processes occurring. Furthermore, this article contributed to the argument that aging successfully should not be considered unattainable for those living with multiple chronic conditions.

Since this study included adults under the age of 65, it would be useful to repeat using only older adults, including those over 85 years old. The effect sizes found were small (1-2% of variance explained), and the inflammatory markers were only collected once, creating the possibility that the samples were not representative of usual circulating levels of IL-6 and CRP.

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Hui-Chaun, S. & Jones, B. (2012) Multiple trajectories of successful aging of older and younger cohorts. The Gerontologist, 52(6), 843-856 Purpose: To use trajectory analysis on two cohorts to determine the health status of older adults and related successful aging over time. Additionally, to explain patterns of successful aging over time using longitudinal data.

Method: The Taiwan Longitudinal Survey on Aging began in 1989, with interviews conducted every few years. Participants with at least 3 data sets were included. The total sample included the older cohort of 2,584 participants born prior to 1930, and the younger cohort of 2,233 participants born between 1931-1946. Measures of successful aging were number of chronic conditions, physical function difficulties, depressive symptoms, and emotional support and social interaction. The trajectories created were used to predict self-rated health and life satisfaction.

Results: Each cohort was found to have four health trajectories, and as hypothesized they were slightly different between the older and younger cohorts. The older cohort was separated into successful aging (29.1%), usual aging (36.3%), declining health (23.2%) and care demanding (11.4%). The younger cohort was categorized into insecure aging (9.8%), successful aging (54.2%), declining health (28.3%) and care demanding (7.7%). The trajectories were able to explain 11.9% of variance in life satisfaction and 22.7% of variance in self-rated health for the older adults. The trajectories explained even greater variance in the younger cohort, with 15.6% variance explained for life satisfaction and 26.9% explained for self-rated health.

Commentary: Using trajectory analysis to further categorize and define successful aging was a unique contribution to the literature. The differences between older and younger cohorts is important to consider in future studies, since it indicates that there may be an age or cohort effect impacting successful aging outcomes (see Baltes & Smith, 2003). The insecure aging trajectory for the younger cohort was especially concerning, as financial struggles are causing strain on health resources. Replication of this study in Canada would be beneficial.

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Hunger, M., Thorand, B., Schunk, M., Doring, A., Menn, P., Peters, A. & Holle, R. (2011) Multimorbidity and health related quality of life in the older population: Results from the German KORA-Age study. Health and Quality of Life Outcomes, 9:53 Purpose: To test the impact of 6 major chronic conditions on health related quality of life (HRQoL) as measured by the EQ-5D. Also included were analyses of combinations or chronic conditions.

Method: The data source for this research was the German KORA-Age Study. In total, 4,565 questionnaires were obtained that were relevant for the present study. Information collected included self-report of chronic conditions, height and weight for BMI calculations, and EQ-5D self-reported health state description. The chronic conditions included stroke, diabetes, chronic bronchitis, hypertension, coronary event and cancer. Multiple regression analyses were performed to identify the simultaneous effects of chronic conditions and sociodemographic variables.

Results: The analyses showed that each of the chronic conditions had a significant impact on HRQoL independently and in combination with other conditions. The most severe independent agents were history of stroke and coronary events. The most powerful synergistic combinations were diabetes + coronary problems, and stroke + coronary problems. Another finding was that BMI had an inverted U-shaped effect on HRQoL, indicating that maximum HRQoL was found at a BMI around 24.8 kg/m2 and decreased for both higher and lower BMIs. Commentary: One contribution of this study to the literature was computation of BMI in comparison to HRQoL. The results afforded a clearer understanding of the risks to HRQoL from both high and low BMI, indicating that the relationship in non-linear.

The analysis of synergistic relationships among chronic conditions also added to the body of literature that aims to ascertain the effects of multimorbidity on living well. It is becoming clearer that listing out the various conditions with which a person is diagnosed does not provide enough information. It is also important to examine the complexity of these relationships and how they interact within individuals.

In further research it would be beneficial to include a greater number of comorbidities, a broader conceptualization of multimorbidity, (see Perruccio et al., 2012), and severity of the diagnosed conditions.

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Lee, Y., Choi, K. & Lee, Y. K. (2001) Association of comorbidity with depressive symptoms in community dwelling older persons. Gerontology, 47, 254-262 Purpose: To examine the independent and synergistic effects of comorbid diseases on depressive outcomes in older adults living in the community in South Korea.

Method: Data from a national survey of 2,058 community dwelling older adults age 60+ were used to complete this analysis. Depression levels were measured on an 11 item scale based on the Centre for Epidemiological Studies for Depression Scale, and comorbidity was indicated by the number of diseases an individual indicated, along with the combinations of disease pairs. Covariates included sociodemographic characteristics, self-rated health, physical function, history of hospital admission in the past year, contact with friends and neighbours and emotional support.

Results: Those with a medical condition had higher rates of depressive symptoms compared to those without. Additionally, there was a linear relationship found between number of chronic conditions and depressive symptoms. For older men, the pairs of hypertension + heart disease and hypertension + stroke had a synergistic effect on depressive symptoms. For women, the pairs of arthritis + stroke, arthritis + fracture and hypertension + respiratory disease had synergistic effects.

Commentary: This study highlighted the relationship between depressive symptoms and comorbidity. The finding that depressive symptoms increase with number of chronic conditions is especially concerning as it is known that number of conditions increases with age.

It is therefore important to consider an individuals mental health when discussing physical manifestations of disease. An important avenue for future study will be to verify the cause-andeffect of depression and chronic conditions. There are indications that the two are selfperpetuating and mutually reinforcing, which therefore makes intervention even more crucial.

Another area for future research is the identification of synergistic pairs that increase the likelihood of depressive symptoms above and beyond the individual diseases themselves. It was also interesting to note that there were significant gender differences in the synergistic pairs, which requires further study. Lastly, it would be beneficial to repeat this study in Canada, as there may be cultural differences in the expression of depression.

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Lochner, K. & Cox, C. (2013) Prevalence of multiple chronic conditions among Medicare beneficiaries, United States, 2010. Preventing Chronic Disease, 10, 120137 Purpose: To use the US Department of Health and Human Services Strategic Framework to determine the prevalence of multimorbidity among Medicare beneficiaries.

Method: The Centres for Medicare and Medicaid Services (CMS) database was used to obtain fee-for-service claims made in 2010 by Medicare beneficiaries. The beneficiaries were considered to have a chronic condition if they were treated for any of the following 15 diseases in the past year: Alzheimers and dementia, arthritis, asthma, arterial fibrillation, cancer, chronic kidney disease, COPD, depression, diabetes, heart failure, hyperlipidemia, hypertension, ischemic heart disease, osteoporosis, and stroke. Subjects were classified as having multiple chronic conditions if they had two or more conditions. Common dyads and triads were also identified.

Results: Among beneficiaries 65 years and older, 69.1% of males and 73.4% of females had 2 or more chronic conditions. Prevalence of chronic conditions increased with age, and was higher for women than men in all age groups. Prevalence was highest for non-Hispanic blacks for women (79.6%), and non-Hispanic whites for men (69.6%). Prevalence of multiple chronic conditions also increased for dual-eligible beneficiaries, who tended to have low incomes and be 85+ years old. The most prevalent diseases appearing in dyads were hypertension, hyperlipidemia, diabetes and ischemic heart disease. The most common triad was ischemic heart disease, hyperlipidemia and hypertension, which affected 46.2% of men and 29.4% of women with 3 or more chronic conditions.

Commentary: This research indicated that there is a pressing need for continued research into the epidemiology, prevention and effective treatment of multiple chronic conditions.

Importantly, it identified four common conditions that are most prevalent in combination with other diseases. These four (hyperlipidemia, hypertension, diabetes, and ischemic heart disease) may represent early warning signs for future multimorbidity, and therefore require more research. They may also indicate a site for secondary intervention and prevention for at risk individuals.

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Marengoni, A., Rizzuto, D., Wang, H., Winblad, B., Fratiglioni, L. (2009) Patterns of chronic multimorbidity in the elderly population. Journal of the American Geriatric Society, 57, 225-230 Purpose: To identify patterns of comorbidity and multimorbidity common in older adults. Of particular interest was the co-occurrence of diseases beyond chance.

Method: The study sample of 1,099 participants with a minimum age at recruitment 75 years was derived from the Kungsholmen Project in Sweden. Data was first collected in 1987-1989, and follow-up was 1991-1993. The standardized protocol for data collection included a social interview, regarding living conditions and social status; neuropsychological battery using criteria from the DSM-IV; and a clinical exam conducted by a physician. The criteria for a chronic illness diagnosis were met if one or more of the following were present: the condition was permanent, was caused by non-reversible pathological alteration, or required rehab/ long period of care. Statistical analysis included prevalence, conditional count, logistic regression and cluster analyses.

Results: All chronic illnesses were more likely to occur with comorbid conditions than alone.

Visual impairment, heart failure, and deafness were the most likely to be found with a cooccurring chronic condition. The strongest association was found between hypertension and heart failure, and this was supported in the cluster analysis, which linked heart failure, hypertension, cerebrovascular disease and atrial fibrillation in one group. Five clusters were found in total.

Commentary: A strength of this study was that it used four different ways to account for multimorbidities in the sample, which reinforced the findings. The results of the prevalence estimates and cluster analysis are a valuable starting point for future research into synergistic relationships among chronic illnesses. Of interest would be the clusters/pairs that do not appear to have a common pathology. A further understanding of disease clusters may also alert clinicians to risks a patient may face when diagnosed with a particular chronic condition.

The results of this study were influenced by the number of chronic diseases included (15 diseases total), which allowed for more comorbidities to be found than a study that included fewer diseases. However, the study did not include arthritis or osteoporosis, which have a typically high prevalence among older adults.

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Montross, L., Depp, C., Daly, J., Reichstadt, J., Golshan, S., Moore, D., Sitzer, D. & Dilip, J. (2006) Correlates of self-rated successful aging. American Journal of Geriatric Psychiatry, 14(1), 43-51 Purpose: To determine the correlates of self-rated successful aging, and to compare these findings to major definitions used in aging research.

Method: Participants were recruited from local retirement communities, a total of 205 individuals, with a minimum age of 60 years. Using a take home survey, the following areas were assessed: demographic characteristics, activities, health related quality of life (SF-36), everyday functioning, subjective rating of successful aging, resilience (CD-RISC), and rates of illness. Successful aging was operationalized according to Phelan and Larson (2002). Statistical analyses were performed to compare self-rated successful aging to the research-based definition.

Results: 92% of respondents rated themselves as aging successfully. Compared to researcherdefined criteria, the majority of participants met the criteria for independent living, mastery/growth, positive adaptation, life satisfaction/emotional well-being and active engagement with life. However, the results did not correlate with absence of physical illness or with absence of limitations in activities.

Commentary: The impetus for this research came from the disparity found between researcher-defined definitions of successful aging and older adultsâ&#x20AC;&#x2122; self-classification. Research has shown that self-rated successful aging does not correlate with the absence of disease. This study built upon previous research (see Strawbridge et al., 2002). Clearly the disconnect between self rated and researcher defined aging warrants further investigation to create a definition of successful aging that reflects older adultsâ&#x20AC;&#x2122; perspectives and should accomodate the presence of chronic conditions. The researchers also pointed out the need to compare self-rated health to self-rated successful aging for degree of overlap in the two constructs.

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Perruccio, A., Katz, J. & Losina, E. (2012) Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. Journal of Clinical Epidemiology, 65, 100-106 Purpose: To examine the relationships between domains of multimorbidity (including medical comorbidity, musculoskeletal, physical and social function, mental health and geriatric issues) and self rated health. To determine whether these domains have independent effects on self rated health.

Method: Three years after hip surgery, 958 patients completed a questionnaire regarding self rated health, medical comorbidity, musculoskeletal function, physical and social function, mental health and geriatric problems, as well as education, income, race, height and weight as control variables. Regression analyses and path analyses were conducted to determine the independent and mediator effects of the various domains of multimorbidity.

Results: Each health domain was significantly related to self-rated health. Medical comorbidity was able to explain 11% of SRH, and this effect was a 78% direct effect. All the other domains combined explained 27% of SRH. Medical comorbidity was able to explain a minimal amount of variance in other domains of mulitmorbidity.

Commentary: Multimorbidity was described in this study as the aggregate effect of health burdens, which included but was not limited to medical comorbidity. This definition extended the scope of multimorbidity, creating a more holistic approach, which may make it more applicable to research on older adults. However, comorbidity maintained the largest independent effect on self rated health. This research supported the introduction of a nosology of chronic illness that would include a range of function from positive to negative and therefore create a more complete picture of health (see Karlamangla et al., 2007) These results provided a new perspective on why some older adults have poor functional status yet retain a high level of perceived health status. The effects from other domains of multimorbidity may be supporting their positive perception, such as high mental health, or lack of geriatric issues. Since multimorbidity is a complex construct its effect on self-rated health will be varied in each individual and it is important to understand how individuals define and prioritize their health.

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Tinetti, M., McAvay, G., Chang, S., Newman, A., Fitzpatrick, A., Fried, T. & Peduzzi, P. (2011) Contributions of multiple chronic conditions to universal health outcomes. Journal of the Geriatric Society, 59, 1686-1691 Purpose: To examine the effect of five different chronic conditions on self-rated health, ADL/IADL activity, symptom burden and death.

Method: The researchers used data from the Cardiovascular Health Study, including 5,298 individuals, aged at least 65 years old. The five chronic conditions selected for the study were heart failure, COPD, osteoarthritis, depression, and cognitive impairment. They were chosen due to their high prevalence and morbidity in older adults. The health outcomes were selfrated health, ADL/IADL activity, symptom burden and death. Multiple linear regressions were used to examine the effects of the chronic illnesses on the first three outcomes. Cox models were used to examine the relationship between the illnesses and death.

Results: All five chronic conditions studied had a negative association with self-rated health and ADL/IADL activity. All conditions except cognitive impairment had an adverse association with symptom burden. Heart failure had the greatest association with death. Synergistically, participants with heart failure + depression, cognitive impairment + depression and osteoarthritis + depression had lower functional outcomes (ADL/IADL scores) than the expected result of each condition added together.

Commentary: The main focus of this paper addressed how individual chronic conditions affect health outcomes. Comparing synergistic pairs improved the understanding of the detrimental impacts of comorbidity that were greater than the sum of their parts. Interestingly, all of the synergistic pairs that were found include depression as half the pair. Depression also had the largest affect on symptom burden. This signifies the importance of including depression in chronic condition research, and for finding better ways to treat older individuals with depression. Further research should also look at the impact on universal health outcomes of disease treatments, and how these treatments may adversely affect concurrent conditions.

This research also extended the current interest in defining “successful aging”. It acknowledged that freedom from disease is not necessarily the benchmark for positive health.

Instead, patients may define one’s own goals in the context of universal health outcomes (see Knight & Riciardelli, 2003). Improving or maintaining functional status may be most important for one individual, whereas symptom management may be the priority for another.

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Vahia, I., Meeks, T., Thompson, W., Depp, C., Zisook, S., Allison, M., Judd, L. & Jeste, D. (2010) Subthreshold depression and successful aging in older women. American Journal of Geriatric Psychiatry, 18, 212-220 Purpose: To compare the results of non-depressed women to sub-threshold depressed (StD) women on multiple measures of successful aging. The hypothesis was that women who are not clinically depressed would still have worse outcomes compared to non-depressed individuals.

Method: A total of 1,979 participants were recruited from the larger Women’s Health Initiative study in San Diego. Data was collected by self-report forms, and included the Center for Epidemiological Studies Depression scale (CES-D) to measure depression. Subthreshold depression was considered a score between 8-15, non-depressed scored less than 8, and clinically depressed scored 16+. Measures of successful aging were self-rated success, physical and mental functioning, attitude towards aging, mastery, self-efficacy, optimism, cognitive performance, anxiety, hostility and resilience. Data were also obtained for history of mental health problems.

Results: In the sample, 20.3% of the participants met criteria for StD. As predicted, women with StD had lower self-rated successful aging, lower physical and mental function, less positive attitude towards aging, less resilience, self efficacy, mastery, optimism, and higher anxiety and hostility. However, their scores were better than those with clinical depression.

Commentary: Since depression has such a broad, negative impact on older adults’ ability to live well, it is important to study those who don’t fit into a clinical category but who are also experiencing the negative effects of depressive symptoms. This research highlighted the relevance of StD as a barrier to living well, and as a possible avenue for intervention. Further, this research supported the idea that depression exists on a continuum, and is not a dichotomous variable.

The implication of these findings for research on living well is that even subclinical depressive symptoms should be included in research. Additionally, other research has found that depression has synergistic relationships with other chronic conditions to negatively impact ability to complete ADL and IADL tasks (Tinetti et al., 2011). This threat to functional ability requires further research and potential intervention.

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Windle, G., Woods, R. & Markland, D. (2010) Living with ill-health in older age: The role of a resilient personality. Journal of Happiness Studies, 11, 763- 777 Purpose: To evaluate whether a resilient personality can moderate the effect of ill health on subjective well-being in older adults. The hypothesis is that a resilient self will provide compensation to allow for the maintenance of subjective well-being in the face of ill health.

Method: Data were collected from 1853 individuals aged 50-90 years old in the United Kingdom. The measures obtained from questionnaires included demographic info, chronic conditions (OARS 26 item), life satisfaction index, and 19-item resilience scale. The moderation hypothesis was tested using analysis of variance, wherein the interaction effect of resilience x ill health had a greater explained variance compared to the main effects while controlling for sociodemographic variables. For comparison, the participants were divided into four age groupings, 50-59, 60-69, 70-79 and 80-90 years old.

Results: A significant increase in variance explained was found when the interaction variable ill health x resilience was entered for three out of the four age groups (60-69, 70-79, and 80-90).

The 60-69 age group was characterized by “protective stabilizing” effect, in which increased resilience provided stable scores in well-being despite increasing ill health. A “protective reactive” effect was described in the 70-79 age group, as resilience provided some stability until one reached the more extreme end of ill-health. And in the 80-90 year age group resilience was also characterized as “protective reactive”, and another finding was that when resilience was low, well-being was also low regardless of the ill health measure.

Commentary: This research provided insight into the moderating potential of resilience on well-being for older adults with chronic conditions. The finding that low resilience leads to low well being in the face of positive health indicators also represents an important area to further investigate, as it highlighted the potential pervasiveness of resilience for self-rated successful aging.

A key concept that was identified in this research was the well-being paradox. With the decreasing health of older adults, there is an expectation to see a comparable decrease in subjective well-being, yet some older adults escape the subjective decline. Theories that may explain this phenomenon include top-down theory, stress process model, selective optimization with compensation, and continuity theory.

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Yates, L., Djousse, L., Kurth, T., Buring J. & Gaziano, M. (2008) Exceptional longevity in men: Modifiable factors associated with survival and function to 90 years. Archives of Internal Medicine, 168(3), 284-290 Purpose: To use prospective data to identify modifiable risk factors in men over 90 years old, and to look at late life function in older males.

Method: The study sample of 2,357 individuals included men who were originally recruited as part of the Physician Health Study, which began in 1981. Participants were born on or before December 31, 1915, and were classified as having the potential to reach 90 years of age. Data collection consisted of self-reported demographic and health variables collected at baseline, as well as yearly questionnaires regarding changes in health or lifestyle factors, including onset of chronic disease. Statistical analyses compared survivors to non-survivors on baseline and follow up data.

Results: 41% of the men in this study lived to 90 years of age. These men were statistically significantly more likely to exercise, less likely to smoke or be obese, and have less hypertension, diabetes and angina than non-survivors. These adverse factors reduced the likelihood of exceptional longevity, wherein having 1, 2, 3 or 4 of the above factors was associated with a 33%, 49%, 75%, or 88% lower odds ratio of reaching 90 years compared to individuals with none.

Modifiable risk factors that were linked to higher physical function in survivors were exercise (24 x/week), non-smoking, and not being obese.

Commentary: A strength of this research was that it employed a longitudinal prospective design that covered 25 years and over 2000 participants. It also went beyond building survival curves to identify the ways modifiable lifestyle factors can help one live well into older age.

Living well was quantified in part as higher physical functioning to cope with chronic illness.

Incidence of cancer and cardiovascular disease was lower in survivors, and when it did occur it was 3-5 years later compared to non-survivors. This finding supports the compression of morbidity hypothesis, and reflects the â&#x20AC;&#x153;delayerâ&#x20AC;? category found in other research (see Evert et al., 2003).

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2. Living Well: Older Adults’ Perspectives Bassett, R., Bourbonnais, V. & McDowell, I. (2007) Living long and keeping well: Elderly Canadians account for successful aging. Canadian Journal on Aging, 26(2), 113-126 Purpose: To gain a deeper understanding of what older Canadians believe keeps them healthy and aging well.

Method: Qualitative interviews with older Canadians with the primary question: “How and why do some seniors live long and keep well?” A representative sample of 2,783 Canadian older adults aged 75+ were included. Responses were recorded verbatim, and an inductive approach was used to analyze the responses. Independent variables recorded included age, marital status, living arrangement, English or French as language of interview, and health status (defined as no ADL difficulty, continent, and 3MS of 85+).

Results: A total of 24 themes emerged from the interview process. The first category was defined as personal factors, and themes under this heading included positive attitude, autonomy, sense of self, self-care, responsible living, nutrition, keeping active, work ethic, disciplined approach to health, longevity, being an informed consumer, and acknowledging factors beyond one’s control. English speakers were more likely to bring up self-factors, such as sense of self and self-care as important aspects of aging well. The second theme heading was relationships with others, divided into quality and quantity of relationships with family, friends, spouse, marriage, children, grandchildren and reciprocity. In this section females were more likely to cite quality relationships with family and friends as important whereas men tended to focus on their spousal relationship. The third category was system influences, and this included mentions of financial resources and support from social services.

Commentary: This study offered insight into how older Canadians understand and define their lives in the context of growing old. A limited number of respondents described their health or illness, indicating that an objective measure of this outcome may not be relevant in their conceptualization of living well. Furthermore, there was little contrast in responses between those who were frail or healthy.

Future studies would benefit from incorporating a greater number of individuals in the “frail” category, to get a better picture of how one defines living well in the context of ill health.

It would also be beneficial to compare the responses of those who considered themselves as “aging successfully” and how they believe they have achieved this status themselves. A deeper probe into the perceived individual and system level interactions would also reveal important policy considerations for older adults.

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Bryant, L., Corbett, K. & Kutner, J. (2001) In their own words: A model of healthy aging. Social Science and Medicine, 53, 927-941 Purpose: To enhance quantitative research in the area of healthy aging by soliciting older adults perspectives on the subject.

Method: This study represents the qualitative arm of a larger, mixed methods study. For this research, interviews were conducted with 22 “deviant” participants, selected due to large differences between self-rated health and the results predicted by a regression model. They were categorized as extreme under-raters, moderate under-raters, moderate over-raters, and extreme over-raters. The interviews were at least 45 minutes long, and included semistructured and open-ended questions regarding participants perceptions of health. The transcripts were analyzed and parsed for themes and common phrases.

Results: The participants defined health as “going and doing meaningful things”. The criteria for this were having something meaningful to do, achieving balance between abilities and challenges, having appropriate external resources, and having the necessary personal attitudinal characteristics.

There were differences in responses between the over-raters and under-raters. The over-raters tended to be more assertive and active, and understand the importance of their role and responsibility as a patient. They tended to have a more holistic approach to health, including doing things and being with people. Under-raters, on the other hand had limited participation with their health care providers, and tended to follow orders, rather than engage in the dialogue. They were more likely to describe their health in terms of their physical condition.

Commentary: Qualitative, investigative research is essential to create definitions of healthy aging that reflect the perspectives of older adults. This study presented a novel approach by targeting the over and under-raters specifically, since their variance from a traditional predictive model will help explain the deviation from widely used research variables.

Furthermore, a focus on the extreme over-raters identified those classified as “positive deviants”, who provide indications of what it means to live well.

Interestingly, the participants defined health as “going and doing”, which is in contrast to the biomedical model of health, wherein going and doing may be an outcome of having good health. The authors described this discrepancy and recommended the need for future research.

A further avenue for future research is to explore the connection between well-being and patient-physician communication. The extreme under-raters had notably limited participation with their physicians, which may represent an area for intervention.

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Charmaz, K. (1983) Loss of self: A fundamental form of suffering in the chronically ill. Sociology of Health and Illness, 5(2), 168-197 Purpose: To explore the how chronically ill individuals cope with changing self-identities as a result of their chronic conditions. To further understand sources that lead to suffering a â&#x20AC;&#x153;loss of selfâ&#x20AC;?.

Method: The data for this paper comes from qualitative interviews with 57 chronically diagnosed adults, age range 20-89 years old. The transcripts were analyzed using a symbolic interactionist perspective and grounded theory.

Results: Suffering loss of self was considered to happen through several main mechanisms.

First, living a restricted life led chronically ill individuals to feel as though their independence had been taken from them, and they struggled with their new limitations. The author noted that the lives of chronically ill are sometimes more restricted than they need to be, since the world is designed for healthy and able-bodied individuals. Living a restricted life also led to an increased focus on the disease itself. The second feature of loss of self was social isolation experienced by those with chronic conditions. This was caused by a) the experience of the illness setting one apart from others, b) treatment taking place within the home, c) the focus of the ill person upon oneself. Third, chronically ill persons experienced discrediting definitions of the self, which developed through interactions with others, and by not meeting their own expectations. Lastly, becoming a burden increased the perception of loss of self, as independence and perceived control are decreased.

Commentary: This paper described self-identity as typically constructed of control and action.

It exemplified the ways in which the limitations created by chronic conditions create a loss of sense of self. However, more recent work that included only older adults (see Roberto & McCann, 2011) suggested that older women do not characterize their lives with chronic conditions as a loss of self, but rather through changes in embodied, aging and social selves.

Future research may focus on the challenge of living well with chronic illness while facing the suffering caused by changing self-identities. Older adults that can create new, valued identities in the face of changing health needs are hypothesized to have a more positive aging experience. As a society, valuing the roles of older adults, including the chronically ill, may enhance their definitions of self. Further research into how older adults best adapt to changing self-identities, and how they can be supported, is needed.

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Easley, C. & Scheller, J. (2003) The experience of being old-old: Life after 85.

Geriatric Nursing, 24(5), 273-277 Purpose: To employ a qualitative approach to understanding what facilitates well-being in the oldest-old (85+) of the population.

Method: A phenomenologic qualitative design was used to elicit experiences and interpretations of being old from 15 women over the age of 85. The interviews were guided by the following questions: Can you tell me what it is like for you to be (your age)? Can you tell me things in your life that you enjoy now? What are some things that cause trouble for you? Can you tell me those things in your life that make you feel well? Can you tell me about your health now? Can you tell me about those things in your life that do not make you feel well? Major themes were pulled from the data by 2 researchers, and their results were compared to ensure validity.

Results: Three major themes were revealed in the analysis of the transcripts. These included engagement, family connection, and attitudes. Engagement was the process of participating, being productive and being involved. Feelings of dependence in this area affected their wellbeing, and mobility was a greater predictor of decreased well-being than chronic illness alone.

Close family connections were also regarded as important to well-being, with all of the participants mentioning family in a positive way. Lastly, attitudes of acceptance, positivity, feeling secure/cared for, having a laugh, and being able to integrate the past and present were associated with well-being.

Commentary: This research reflected findings from other studies which identify being able to â&#x20AC;&#x153;go and doâ&#x20AC;? to be essential to the perceived well-being of older adults (see Bryant et al., 2001).

It also suggested that mobility is a more important factor than positive attitude, as mobility challenges may be associated with depression and negative affect. Further research into this connection and into possible interventions is warranted. Additionally, a wider range of participants would enhance the generalizability of these findings.

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Fried, T., McGraw, S., Agostina, J. & Tinetti, M. (2008) Views of older persons with multiple morbidities on competing outcomes and clinical decisionmaking. Journal of the American Geriatric Society, 56, 1839-1844 Purpose: To elicit the thoughts of older adults with multiple chronic conditions and multiple medications on competing outcomes and decision making.

Method: A total of thirteen focus groups were conducted, with a total of 66 participants who were 65+ and had at least 5 medications. The focus groups were led by a research facilitator, who guided the questions to understand the participantsâ&#x20AC;&#x2122; goals of treatment, any adverse affects of treatment, and whether they had ever changed or stopped a treatment. The focus groups evolved based on early findings that this sample readily understood the concept of adverse medication effects.

Results: The participants readily understood the concept of adverse medication effects. A first, in the discussions, the participants discussed the disease specific goals that have been made by their physicians, but as the meetings progressed there was a greater emphasis on the broader goals and quality of life indicators. Participants tended to conceptualize risk reduction in absolute terms only, comparing the detriments of taking a medication to the outcome of death. Lastly, the decision making process was heterogeneous and appeared to occur on a continuum. People differed in the number or degree of adverse effects they would be willing to withstand in order to live.

Commentary: This study was highly focused on medication effects and decision making. The results are therefore pertinent for doctors who are prescribing medication and to engage older adults with multiple chronic conditions in discussions regarding their health goals and therefore decide the best course of treatment. This has been a common theme within the literature, which urges care to become less disease focused and more person centered.

Furthermore, the education around medication management and clinical decision making needs to be strengthened such that a dialogue between patient and doctor can happen regarding the desired outcomes.

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Grundberg, A., Ebbeskog, B., Abrandt Dahlgren, M. & Religa, D. (2012) How community-dwelling seniors with multimorbidity conceive the concept of mental health and factors that may influence it: A phenomenographic study.

International Journal of the Qualitative Study of Health and Well-being, 7, 19716 Purpose: to describe the variation in how older adults with multimorbidity understand mental health and the factors that influence it.

Method: A qualitative design was employed to interview 13 community-dwelling older adults.

Semi structured interviews included two main questions: How do you perceive the concept of mental health, and what do you consider might influence mental health? The results were analyzed using a phenomenographic approach, including the processes of familiarization and condensation.

Results: Six different ways to conceptualize mental health and the factors that influence it were evident in the analysis. The three positive factors were that mental health was dependent on desirable feelings and social contacts, power of the mind and ability to control thoughts, active behaviour and healthy lifestyle. The three contrasting negative factors were dependent on undesirable feelings and social isolation, powerlessness of the mind and inability to control thoughts, and passive behaviour and physical inactivity. The first in each category were considered to be associated with emotions, the second with thoughts and the third with actions. Each of the categories was described to be interacting with one another to either improve or worsen mental health.

Commentary: This research contributed to the evidence of lay understandings of mental health. Important for older adults with multiple chronic conditions was the finding that participants felt that social connectedness was important for the mental health, while also feeling isolated from participation due to their various chronic conditions. This indicates that mental health of older adults with multiple chronic conditions can be improved with a targeted intervention to increase social participation.

In future research, these concepts may be used to understand what older adults do to improve their health, based on the factors they believe are influencing their mental state. Another area of opportunity that this research identified was to promote individual health promotion dialogues to address individual understandings of mental health.

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Hurd Clarke, L. & Griffin, M. (2008) Failing bodies: Body image and multiple chronic conditions in later life. Qualitative Health Research, 18(8), 1084-1095 Purpose: To explore the changing body image of older adults with multiple chronic conditions, within the context of gender, ageism and illness.

Method: 10 women and 10 men were given qualitative interviews that focused on their body image and how it has changed given their chronic diagnoses. The participants were 68-89 years old, and had 5-18 chronic illnesses each. They were drawn from a larger study. Symbolic interactionist perspective was used, with an added lens of gendered and ageist world views.

Results: Four recurring themes were found in the analysis. The first was failing appearance, which included dissatisfaction with weight, and physical disfiguration. These changes had implications for their self-esteem and self-confidence. Secondly, older adults reported that failing physical abilities contributed to their body image, notably that decreased functional ability led to increased dependence. It was noted that both men and women often felt like their younger self was trapped within an aging body. Third, feelings about being old impacted body image, as a striking realization that they are in fact “old”. The participants were split as to whether this had a negative or positive impact. Lastly, the inevitability of aging was a common theme. About half of the participants commented on needing to accept or resign oneself to the inevitability of getting old.

Commentary: This research contributed to the literature by including a broad range of chronic conditions. It examined the experience of aging within a sociocultural context, which is essential to further understand how our norms and values can positively or negatively influence the experience of aging, especially with chronic disease. A recurring theme in the study was that many older adults do not “feel” old, but that their younger self was trapped within an aging body. This finding of continuity of self gives insight into stability of our identity over time.

Differences between men and women were examined in this research. Although there was crossover, nearly all women mentioned failing appearance contributing to their body image, which highlights the pervasiveness of appearance in our culture, as well as the objectification of female bodies. Men, on the other hand, were more likely to describe their physical limitations as impacting their body image, exemplifying the notion of the “body as a tool”, rather than as an object. Similar to other findings (see Roberto & McCann, 2011), both male and female participants tended to minimize their health difficulties to onlookers, and thereby manage their body image.

The implications of this research to living well are that aging is experienced in a social and gendered environment, which should be taken into consideration in future research. How body image contributes to quality of life is a further avenue of exploration.

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Knight, T. & Ricciardelli, L. (2003) Successful aging: Perceptions of adults aged between 70 and 101 years. International Journal of Aging and Human Development, 56(3), 223-245 Purpose: To explore the perceptions of older adults regarding successful aging, and see if there are differences between old (70-84) and older (85+) adults. To ask older adults how they feel about their age. And thirdly, to gauge how older adults rate the criteria of successful aging and how the criteria interrelate.

Method: Interviews were conducted with 60 older adults (42 female, 18 male) individually in their own residential setting. The transcripts were coded using content analysis to analyze the data.

Results: The participants first responded on what they felt were the components of successful aging. In descending order of percentage of the responses, these were: being healthy, being active, happiness, independence, relationships, appreciation of life, and longevity. 36% of participants said they were happy with their age, while another 41% said they accepted their age. When rating the importance of themes emerging from the literature, the three most important components were health, happiness and mental capacity. No significant differences were found in the responses between the two age groups (70-84 vs. 85+ years).

Commentary: This research acknowledged that focusing on specific success outcomes ignores the heterogeneity of older adults. Therefore this study related to other research that has advocated for personally defining goals and success for oneself (see Fried et al., 2011).

This research critiqued a broad range of topics and questions. It would have benefited from being reorganized into three separate focused papers that included more of a critical analysis of their findings. It is important to ask older adults their perceptions of aging; however, this paper failed to explore the meanings that older adults attach to these perceptions, and how it affects them on a daily basis. Furthermore, while this study was qualitative, it had 42 questions, which limited the depth and probing of responses, therefore it was reported in a more typically quantitative fashion.

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Montbriand, M. (2004) Senior’s life histories and perceptions of illness’.

Western Journal of Nursing Research, 26(2), 242-260 Purpose: To elicit the life histories of older adults, and determine whether they attribute their current health status to past behaviours and life events.

Method: The life stories of 190 older adults, aged at least 60 years were collected. Of these 107 were used for the report. A rigorous procedure was used to elicit themes from the life stories, and phone calls were made to participants to clarify details. Eventually, the stories were divided into optimistic, which included romance (n=25) and quest (n=14) narratives, and pessimistic, which encompassed chaos (n=42) and tragedy (n=26).

Results: Overall, members of the pessimistic group were more likely to equate past events with current disease states. Of the control variables, the only significant difference between groups was that the optimistic group achieved a higher level of education on average. Gender differences were noted in each of the themes. In chaos, women were more likely to tell of abuse and men of missed opportunities. Chaos-defined lives were more likely to have cancer, and less likely than the tragedy group but more likely than the optimistic groups to have orthopedic, cardiac or chronic pain complaints. For those with tragic stories, men were more likely to cite negative epiphanies at retirement, whereas women’s tragedies involved poverty and unhappy marriages. In quest stories, older adults found meaning in life through adventures and seeking independence. On the negative side, these older adults were more likely to have orthopedic and cardiac problems, but on the positive side they were likely to have happy marriages. The romance group was distinct in that they had found their true loves.

These individuals were least likely to have cancer, cardiac or orthopedic conditions, or complain about daily pain.

Commentary: In this research, illness was defined as the experience of symptoms and suffering, whereas disease was the clinical assessment (Kleinman, 1986). This is a useful distinction that is not often applied in research, as the terms disease and illness are often used interchangeably but may be conceptually distinct.

This research gave insight into the lifespan perspective of health, and how previous life experiences are related to later life disease. An interesting point that the author made was that the objective life stories between pessimistic and optimistic older adults were not significantly different: both underwent great challenges and adversity, but dealt with them differently.

Additionally, their findings have implications for quantitative research, as it suggests that controlling for “happy marriages” may be a more salient determinant of health than mere dichotomies of married vs. single. Those who are unhappily married may have worse health than their single counterparts.

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Osborne, L., Bindermann, N., Noble, GJ. & Reed, P. (2012) Changes in key areas of quality of life associated with age and time since diagnosis of longterm conditions. Chronic Illness, 8(2), 112-120 Purpose: To determine whether key areas of quality of life change as a function of age and/or length of time with a chronic condition.

Method: A qualitative analysis was conducted, comparing the descriptions of quality of life between older and younger adults who were either recently diagnosed (<1 year) or had been living with a chronic condition for 10-20 years. Therefore, there were four categories: young + newly diagnosed; young + had condition long term; old + new diagnosis; and old + had condition long term. The study included a total of 71 participants, and data was collected using an online survey tool with open-ended questions.

Results: A total of six themes were produced from the analysis: independence and normality, involvement, social and emotional well-being, psychological well-being, physical well-being, and financial security. All of the groups had significant discussion around independence and normality. The young-newly diagnosed were most concerned with involvement, whereas the older newly diagnosed were concerned with social and emotional well-being. The younger, long term diagnosed participants expressed psychological well-being as a priority, whereas the older, long term diagnosed participants had concerns about their physical well-being.

None of the groups was highly concerned with financial security.

Commentary: The findings from this study are important when critically examining tools used to evaluate quality of life for chronically ill individuals. These tools (ie. EQ-5D, SF-36) do not focus on independence or normality, but rather on physical and psychological outcomes.

Since this study found independence and normality to be consistently ranked as important to quality of life it would be valuable to have QoL assessment tools that include these constructs.

The age range was 31-50 years old. It would be beneficial to repeat this study with older adults to see how quality of life may change at even older ranges of the lifespan. Assessing the differences between individuals with a new diagnosis and those who have been living and coping with a condition over many years also has potential benefits. Another avenue for future research would be to follow individuals after diagnosis to see how quality of life measures change within one person, and whether these patterns of change are similar when dealing with other life events, such as grieving. Coping with chronic disease is especially interesting because there are both chronic, long term aspects as well as daily manifestations and variable acute symptoms of the disease.

A key concept found in this study was the maturation and adaptation hypothesis, which posits that as people age (mature) and adapt to life with chronic conditions, different aspects of quality of life become more or less important. Future research is recommended to further understand the differential impacts of these two phenomena.

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Phelan, E., Anderson, L., Lacroix, A. & Larson, E. (2004) Older adults views of “successful aging”: How do they compare with researchers definitions? Journal of the American Geriatrics Society, 52, 211-216 Purpose: To determine whether older adults have thought about aging and aging successfully. To compare their perceptions of aging well to definitions published in the literature.

Method: Two samples were mailed a questionnaire that elicited whether or not the participants had thought about aging, whether these thoughts had changed over the past 20 years, and what components they believed contributed to successful aging. The first sample included 1,985 Japanese Americans aged 65y+, and the other 2,581 white older adults, aged 65y+.

Results: Overall, 90% of the respondents had thought about aging successfully, and 60% of these had experienced changes in these thoughts over the past 20 years. Over 75% of the participants rated thirteen of the aspects of aging successfully as important. These included remaining in good health until close to death, feeling satisfied with my life the majority of the time, having friends and family who are there for me, staying involved with the world and people around me, being able to make choices, being able to meet al.l needs and some wants, not feeling lonely or isolated, adjusting to changes, being able to care for myself, feeling good about myself, feeling able to cope with challenges, being able to act according to my inner standards and values. The white sample also included learning something new as a criterion for successful aging. These aspects were subdivided into four broader categories of health: physical, functional, psychological and social. The inclusion of all four of these domains does not appear in the available research, which often focuses on one or two domains.

Commentary: The findings from this research supported the notion that successful aging is a multifaceted, complex process. The results indicated that older adults include broad definitions of health into their understanding of aging, and begs the inclusion of all domains of health when considering successful aging.

This research could have benefited from soliciting whether there were any additional aspects of aging well that were NOT included in the researcher definitions to date.

Additionally, it is recommended to examine whether “successful aging” overlaps with other concepts around aging well, healthy aging, and quality of life.

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Pond, R., Stephens, C. & Alpass, F. (2010) Virtuously watching ones health: Older adults regulation of self in the pursuit of health. Journal of Health Psychology, 15, 734-743 Purpose: To examine the impact of individual responsibility for health on health promotion programs for older adults. To further understand how older adults take up, negotiate, and resist health promotion and aging bodies.

Method: Qualitative interviews were conducted with 60 older New Zealand adults. Eighteen months later, 50 participants were interviewed a second time to gain greater insight into changes in health and health-related choices. Detailed accounts of personal health, aging, and meaning were collected. Foucauldian discourse analysis was used to frame the uptake, resistance, and moral management of health promotion.

Results: Three health promotion discourses were detected in the interviews: biomedical, which dealt with doctors and diagnosis influencing view of health; successful aging, which aligns with Rowe and Kahnâ&#x20AC;&#x2122;s model; and aging as biological decline, which were the anticipated changes in their bodies. Moral duty appeared within the health promotion discourse as either being virtuous and practicing healthy behaviour or lazy and neglecting your health. The resistant discourses identified were aging as inevitable, which entailed the acceptance of ill health and that it is somewhat beyond our control, and health as capricious, which meant experiencing health as subject to external forces. The resistant discourses can be experienced simultaneously with health promotion discourse.

Commentary: This article highlighted a shortcoming of health promotion discourse: that it has led people to believe that if one is virtuous and follows regimented behaviours one will remain healthy, whereas deviants will be punished with poor health. In reality, our behaviours shape our health trajectories, but are not the only factor impacting our health. This article articulated the ways in which older adults have been positioned within health promotion discourse and how social policies may work to influence responsibility and moral virtuousity. The implications for living well are to focus on factors beyond health behaviour as means to facilitate wellness in older adults with multiple chronic conditions.

The participants in this study were a young group of older adults. Replicating this study in a variety of countries and with older age groups will enhance the understanding of health discourse in later life and how older adults define health to better meet their unique needs.

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Reichstadt, J., Depp, C., Palinkas, L., Fulsom, D., Jeste, D. (2007) Building blocks of successful aging: A focus group study of older adults perceived contributors to successful aging. American Journal of Geriatric Psychiatry, 15(3), 194-201

Purpose: To elicit older adults definitions of successful aging.

Method: The sample was recruited from retirement communities in San Diego, 72 participants in total with an age range of 60-99 years. A total of 12 focus groups were conducted, with two main questions consistent throughout. These were: 1) How would you define successful aging?

2) What are the necessary components of successful aging? The data was analyzed using grounded theory and the â&#x20AC;&#x153;Coding Consensus, Co-occurrence and Comparisonâ&#x20AC;? strategy.

Results: The analysis revealed a total of 33 categories that defined successful aging. These were then further broken down into 4 themes: positive attitude and adaptability, environmental and social support system, good health, and engagement in stimulating and meaningful activities. The themes were also integrated with each other, with some components serving as foundations for the success of other components, while others acted in a compensatory fashion.

Commentary: This study found many sub-categories of successful aging, which supported the concept that successful aging is a multivariate, complex term. It also used the perspective of older adults to broaden the understanding of the experience of aging. Compared to quantitative studies on aging well, this study gave more importance to positive attitude and the ability to adapt, versus the absence of disease. Previous research (Bryant et al., 2001) also found similar themes when building a model of healthy aging based on qualitative interviews.

The similarity of these results helps build generalizability of the findings across populations.

The interrelationships identified among the themes that have emerged from this study represent an avenue for future research. Especially interesting among the interrelationships were how some components, such as financial stability and social support, acted as foundational needs upon which other aspects of successful aging were built. This indicated a potential hierarchy of needs within the model of successful aging. Additional research should also investigate how/whether these themes change as a function of chronic conditions. Future research should also continue to investigate the psychological constructs associated with chronic conditions, such as resilience, since positive attitude and adaptability were considered integral to successful aging in this study.

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Roberto, K. & McCann, B. (2011) Everyday health and identity management among older women with chronic health conditions. Journal of Aging Studies, 25, 94-100 Purpose: To explore the health perceptions of older women regarding how they interpret their health on a daily basis, and how they talk about their health with others.

Method: The study employed a longitudinal, qualitative design including 36 women ages 6989 years, with multiple chronic conditions. Using symbolic interactionist and grounded theory approach, the results from the interviews were coded, and the themes “Descriptions of Health” and “Talking to Others about Health” were chosen as the focus of this paper.

Results: From a symbolic interaction perspective, it was found that the intersection of selves (particularly the aging, social and embodied selves) were used to a greater extent to discuss everyday heath than actual disease status.

Descriptions of health: The women in the study tended to talk about their health in a holistic manner, not confining it to their diagnosis. They depended on signs and symptoms from their body to interpret their everyday health. Further, most of the participants reported that their limitations influenced how they felt about their health. The impact on function was more important than the disease itself.

Talking to others about health: These findings were classified as part of the older women’s “social selves”. As expected, the participants reported regulating how much and with whom they spoke about their health. This management contributed to their continuity of self in their social roles.

Commentary: This study enhanced the literature around living well with chronic conditions because it reinforced the idea that older adults do not separate their conditions from their overall experience of health. Rather, in this study it depended more on how these conditions limited the participants and affected their ability to do meaningful activities. This reflected a similar finding in Bryant et al. (2001), wherein older adults’ defined their health as the ability to “go and do” meaningful things. This limitation was attributed by some women to old age in general.

Results from this study support other research developments in this field. For example, using feedback from the body and viewing health as a holistic concept beyond individual diagnosis is a finding that reflects Thorne et al. (2003) in their exploration of everyday decision making in the chronically ill. Also, the concept of self within chronic illness is explored in Charmaz (1983), although the perspectives outlined here were not as bleak as Charmaz’s “loss of self” description.

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Romo, R., Wallhagen, M., Yourman, L., Yeung, C., Eng, C., Micco, G., PerezStable, E. & Smith, A. (2012) Perceptions of successful aging among diverse elders with late life disability. The Gerontologist, Advance Access, doi:10.1093 /geront/gns160 Purpose: To gain insight into older adults’ perceptions of successful aging in the face of disability. In particular, to elicit the opinions of ethnic minority older adults.

Method: Fifty-six participants were recruited from the On Lok Lifeways community program.

The participants were a minimum of 59 years old, and lived in the community while being eligible to live in a nursing home, thus capturing the disability requirement. One on one interviews were conducted in the participant’s native language. Grounded theory methodology was used to analyze the data, and positional maps were used to explore differences between cultural groups.

Results: The overarching theme drawn from the interviews was that aging required “living in a new reality”. Participants were represented either as acknowledging the new reality, or rejecting the new reality. Acknowledging the new reality was characterized by accepting limitations and adapting, accepting help, trusting in God, and shifting priorities. This group was described to be aging successfully. Rejecting the new reality was characterized by denying the effects of disability, wherein people still felt they were aging successfully, or of not being able to reconcile themselves with their disability, and therefore felt like they have not aged successfully.

Commentary: This study added to recent literature by asking for older adults’ views of successful aging without imposing objective criteria. This method has been understood to be a positive approach to patient-centered health care. The inclusion of a diverse sample in this study was also a strength, since we live in an ethnically diverse country and cannot assume that perceptions of successful aging are the same across cultures. However, the sample was too small to draw definitive culture-based generalizations. This sample was also drawn from a community program that may have greatly influenced the participants’ views of successfully aging.

A new perspective that this research identified was that individuals can reject their reality of living with a chronic condition, and still see themselves as aging successfully. Future research may determine whether their perception of aging successfully will persist if they acknowledge their illness. Lastly, the theory of selective optimization with compensation, a commonly used theory in successful aging literature, was drawn upon to explain some of the findings.

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3. Fostering Living Well with Multiple Chronic Conditions a) Self-care and Self-management: The Informed, Activated Patient Bayliss, E., Ellis, J. & Steiner, J. (2007) Barriers to self-management and quality of life outcomes in seniors with multimorbidities. Annals of Family Medicine, 5(5), 395-402 Purpose: To examine the effect that potential self-management barriers have on health outcomes such as low reported health status and physical functioning in older adults with multimorbidity.

Method: Telephone interviews were conducted with 352 participants, aged 65+ years, who had coexisting diagnoses of depression, osteoarthritis and diabetes. Guided by previous research on barriers to self-management, data was collected regarding level of depression, physical functioning, self-efficacy and health literacy. Sociodemographic information, disease count, disease burden, financial constraints, social activity, patient-clinician communication, medication knowledge and adherence, and knowledge of conditions were also obtained, and computed into the linear regression model.

Results: In the linear regression, higher disease count, lower physical function, less knowledge of conditions, less social activity, greater depressive symptoms financial constraints and being male were all statistically significantly related to low perceived health status. When physical functioning was examined as the dependent variable, financial constraints, income, patient clinician communication, compound effects of conditions, and persistent depressive symptoms were all statistically significant.

Commentary: This research advanced previous work on barriers to self-management programs to further understand how these barriers influence health outcomes commonly used in clinical research. However, the researchers did not relate whether these potential barriers were acting as barriers for the respondents. Presence of these factors was instead directly related to the health outcomes. It would be prudent to conduct a study in which the barriers experienced by the individual were studied in relation to oneâ&#x20AC;&#x2122;s own health status. This type of analysis would be more valuable than the present study because not all barriers identified by a researcher may be acting as a barrier to the participant. These results were restricted to the population represented by the participants, which was a group that had access to an HMO, and were predominantly white, middle class older adults. In future research it would be pertinent to include a larger sample of older adults from a variety of backgrounds.

A final interesting point, physical functioning was used both as a barrier to self-management and as a health outcome. This highlights the cyclical nature of either improving or worsening health. If physical functioning is improved, barriers to self-care will be lessened and functional outcomes will also improve.

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Becker, G. & Newsom, E. (2005) Resilience in the face of serious illness among chronically ill African Americans in later life. Journal of Gerontology: Social Sciences, 60B(4), S214-S223 Purpose: To understand how older African American’s live with their chronic illnesses on a daily basis, and how their interpretations impact how they manage their chronic conditions. To gain a deeper understanding of how a different culture may interpret the experience of chronic illness.

Method: This paper is based on multiple, in-depth, qualitative interviews with 38 African American participants who were at least 65 years old, and had at least one chronic condition.

Respondents were interviewed 4-5 times over the course of several years. Interviews lasted 1-2 hours and contained open-ended questions regarding health, experience with illness, health practices, and access to health care. Qualitative analysis were performed to elicit codes and subsequent themes.

Results: The overarching theme of the research was that the participants relied on their resilience to cope with chronic conditions. Key descriptors were determination, perseverance, and tenacity. Other themes that strongly influenced older African American’s philosophy of illness were racism (including inequality and prejudice), religiosity, and independence. All four themes – resilience, racism, religiosity, and independence - were found within all 38 participants’ transcripts.

Commentary: The cultural background of African American’s is characterized by themes of survival and overcoming adversity, which may contribute to their philosophy regarding living with a chronic condition. This research highlighted the importance of cultural values to the development of individual resilience. Further research would benefit from comparing the different philosophies of resilience between cultural groups.

The finding that older African American adults turned to religion as a form of coping with chronic conditions was supported by research Leach & Schoenberg (2008). Including a dimension of spirituality to the model of successful aging has been advocated by Crowther et al. (2002).

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Chodosh, J., Morton, S., Mojica, W., Maglione, M., Suttorp, M., Hilton, L., Rhodes, S. & Shekelle, P. (2005) Meta-Analysis: Chronic disease selfmanagement programs for older adults. Annals of Internal Medicine, 143, 427438

Purpose: To assess the effectiveness of self-management programs for arthritis, diabetes mellitus and hypertension.

Method: A search was conducted to gather studies that used randomized controlled trials involving arthritis, hypertension or diabetes mellitus and assessed decrease in pain and/or improvement in function. Of 780 studies screened, 53 fit the criteria. The outcomes of interest included clinical measures, such as blood glucose levels and blood pressure, as well as intermediate outcomes such as knowledge, self-efficacy and health behaviours.

Results: The diabetes programs were found to have a statistically significant effect on hemoglobin levels (pooled effect size -0.36), and some of the studies found a decrease in blood glucose levels. The studies focusing on diet and education had the largest pooled effect size. Hypertension research found positive intervention effects for both systolic and diastolic blood pressure. For osteoarthritis there were negligible effects for functioning, and a small effect for pain reduction. The results did not indicate what specific areas of the programs were producing benefits to participants.

Commentary: Possible causes for the positive results found in the literature reviewed may be due to publication bias, as only studies that had positive results were submitted or accepted for publication. Although these studies examined three different chronic diseases, it was still limited to single disease management, and did not increase information regarding managing multiple diseases at once. Furthermore, it was unclear as to which aspects of the program were most beneficial to the participants. This study is therefore of limited relevance to the study of self-management for multimorbidity.

The paper made use of a conceptual model developed out of clinical literature and discussion to describe the components perceived to be essential to self-management program. These included the following characteristics: tailoring, group setting, feedback, psychological emphasis, and medical care. Future research has the task to discover whether and how these factors lead to positive outcomes for self-management participants.

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Fuller, B., Stewart Williams, J. & Byles, J. (2010) Active living - The perception of older people with chronic conditions. Chronic Illness, 6, 294-305 Purpose: To identify barriers and motivators for physical activity participation for older adults with chronic conditions, and to create a framework of health behaviours for ‘active living’.

Method: Two focus groups were held to elicit older adults’ perceptions regarding general health beliefs, benefits of physical activity, and how physical activity fits into their specific situation. One focus group, titled ‘Never Too Late’ was comprised of healthy older adults, and the second, ‘Active Living’ was drawn from local chronic illness support groups. A comparative group framework was used to identify differences between these two groups.

Results: The ‘Never too Late’ group reported fewer functional impairments and higher selfrated health compared to the ‘Active Living’ group. The results from the focus groups identified barriers to physical activity broken down into four domains: health, family, environment & choices, and lack of interest. The focus groups revealed that the ‘Active Living’ (less healthy) group of older adults cited more overall barriers to physical activity than their healthier counterparts. Between the two groups the common barriers were all focused on the environmental barriers. Furthermore, both groups acknowledged the importance of physical activity to health. In the end, the authors produced a model for active living, which is based on personal, community and system level influences, and is filtered through behaviour change theories.

Commentary: This research was well situated in theory (Transtheoretical, Health Belief Model and Social Cognitive Theory), which provided a basis for the thematic analysis of the qualitative data. Lack of theory is often a criticism of gerontological research, so this study adds valuable discussions of theoretical ideas. The results provided older adults’ perceptions of barriers to physical activity, many of which were framed within the context of environmental factors, regardless of physical impairments.

The proposed model had many similar components to the expanded chronic care model (Barr et al., 2003), but was presented in a less elegant manner. However, the addition of behaviour change theories may be an important area to explore with the expanded chronic care model.

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Hitchcock Noel, P., Parchman, M., Williams, J., Cornell, J., Shuko, L., Zeber, J., Kazis, L., Lee, A. & Pugh, J. (2007) The challenges of multimorbidity from the patient perspective. Journal of General Internal Medicine, 22(Supp.3), 419424 Purpose: To identify the needs and challenges of patients with multiple chronic conditions compared to their single condition counterparts.

Method: This study used a cross sectional design, with a randomly selected sample of 720 patients. Participants were grouped according to their ICD-9 disease classification. The measurements used were demographic variables, functional status, number of contacts with health care providers, components of primary care, self-management learning needs, and willingness to see non-physician providers.

Results: The multiple condition patients were statistically significantly more likely to report being willing to learn the 22 self-management skills compared to the single condition patients.

The 5 skills they listed most often were use medications correctly, monitor important symptoms, improve sleep, manage pain, and identify or use hospital resources. Multiple condition patients were more likely to report being willing to see an alternative care provider, such as physicians assistant, social worker, psychologist, nutritionist, or pharmacist.

Commentary: This study showed that there were some differences between the willingness of individuals with multiple chronic conditions compared to those with a single disease diagnosis to learn about self-management techniques and access alternative care. This may have been due to the greater demand that multimorbidity presents to an individual. This research supports the development of individual treatment plans that account for the complexity of patients with multimorbidity, and that there cannot be a one size fits all approach to care.

Research in this area that expands how people choose which self-management skills are relevant to them, how they can be supported in making positive behaviour changes to manage chronic disease, and with a focus on older adults is recommended.

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Hurd Clarke, L. & Bennet, E. (2013) Constructing the moral body: self-care among older adults with multiple chronic conditions. Health, 17(3), 211-228

Purpose: To qualitatively explore how older adults with multiple chronic conditions manage their health. Of particular interest were how social norms around health promotion and gender shaped their experience.

Method: A total of 35 participants completed two in depth interviews. The participants were recruited through newspapers and posters, and were included if they were at least 70 years old, had a minimum of three chronic conditions, and had at least one of the following: arthritis, back pain, cataracts/glaucoma, or heart disease. The interviews were recorded and transcribed verbatim. The initial codebook included types of self-care and reasons for self-care.

Results: There were three overarching themes in participantsâ&#x20AC;&#x2122; explanations for their use of selfcare. These included the management of physical symptoms and functional losses, compensation for limits of physician directed care, and adherence to social norms regarding health. Gender differences surfaced regarding the reasons for self-care. For men, control over their bodies and maintaining healthy lifestyle were emphasized, whereas the women were concerned with not becoming dependent because it would interfere with their ability to help others. Approximately one third of the participants felt they were not doing enough self-care and expressed feelings of guilt.

Commentary: This study articulated the reasons why older adults engage in self-care practices, and highlighted the gender differences that motivate individuals to engage in selfcare. Future research into these motivational factors may prove beneficial to interventions for older adults with multiple chronic conditions.

Other opportunities for future research identified in this article include drawing on a more diverse group of adults, exploring the sources of messaging that are influencing older adults self-care behaviour, including the media. Additionally, an analysis of the barriers and facilitators older adults face in managing their health would be beneficial.

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Hutchinson, S. & Nimrod, G. (2012) Leisure as a resource for successful aging by older adults with chronic health conditions. International Journal of Aging and Human Development, 74(1), 41-65 Purpose: To examine the leisure-related goals of older adults, and how they contribute to older adults living well with chronic conditions. The model of Selective Optimization with Compensation (SOC) (Baltes & Baltes, 1990) was used to frame the results.

Method: The eighteen respondents represented a convenience sample of older adults who began a new activity subsequent to the diagnosis of a chronic condition. Semi-structured interviews were audio taped, and lasted an average 90 minutes. Questions elicited how participation changed since the onset of the most recent condition, what caused the changes, and how the participant felt about it. They were asked to rate their well-being as well as evaluate their coping strategies. Qualitative techniques were used to analyze the data.

Results: Three themes relating to how individuals met their needs and stayed involved were identified in the interviews: drawing on existing resources, setting leisure based goals, and using strategies to get more out of life. A fourth theme, more than managing - living a life of meaning, highlighted the way in which leisure based activity may influence well-being for the chronically ill. Personal and social resources played a role in whether or not an individual would engage in leisure activity to manage their health and well-being.

Commentary: Leisure time participation is theorized to help older adults manage illness and live well with their chronic conditions in the following three ways: by providing a positive distraction, maintaining physical and mental health, and contributing to finding meaning in life.

A strength of this article was that it drew upon the selection, optimization and compensation (SOC) model to understand the choices older adults were making. One difference that was found in comparison to the original model was that people with chronic conditions often did not feel as though they had a choice in the selection component and rather used substitution of one activity for another. There was also acknowledgement that all of the categories were interrelated through goals and resources. There was also a negative case provided, showing that these techniques and attitudes are not universal.

Future research should tune into a broader spectrum of older adults living with chronic conditions to see if these themes are applicable in a wider range of participants. More attention should be paid as well to the non-participants, and those who are not aging well as in the case of the negative subject in this study. Longitudinal data may also reveal how SOC changes with chronic disease trajectories and subsequent morbidities. Lastly, other aspects of managing chronic conditions were not included, such as financial security and access to health care.

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Jerant, A., von Freidrichs-Fitzwater, M. & Moore, M. (2005) Patients perceived barriers to active self-management of chronic conditions. Patient Education and Counseling, 57, 300-307 Purpose: To elicit the barriers that older adults face when self-managing chronic diseases, and the barriers to accessing support and resources in this process. To provide evidence to support modification of the chronic disease self-management program (CDSMP) to include a home-care based component.

Method: Older adults with a chronic disease diagnosis were recruited from the Sacramento region. The sample included 54 older adults. Focus groups were conducted, with an average 5.4 participants in each. A grounded theory approach was used to code emergent themes.

Results: Barriers to active self-management were found to be depression, difficulty controlling weight and exercising regularly, fatigue, poor communication from physicians, lack of support from family, pain, and financial restrictions. Barriers to accessing resources included lack of awareness, physical symptoms, transportation issues, cost or lack of health insurance. The barriers to accessing resources were of most interest to the researchers given that they hoped to implement a home-based program. Most of the participants noted they would be interested in home visits.

Commentary: The purpose of this paper was to assess the interest in a home-based CDSMP program. Discovering these barriers developed support for their program, especially the barriers to accessing current resources, which were generally housed in a community facility.

Home based support for individuals with mobility, transportation and financial restrictions could boost CDSMP adherence and benefit older adults with multiple chronic conditions.

However, one difficulty that was identified was the challenge of accessing funding for these programs. Research showing the benefits of reducing hospital stays and future health care costs as a result of home based care would be beneficial.

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Leach, C. & Shoenberg, N. (2008) Striving for control: Cognitive, self-care and faith strategies employed by vulnerable black and while older adults with multiple chronic conditions. Journal of Cross-Cultural Gerontology, 23, 377-399 Purpose: To better understand how older adults cope with the experience of multiple chronic conditions.

Method: Before interviewing the participants, the researchers engaged in pilot interviews with five individuals in the target population to develop the open-ended research questions. The question guide was revised with four new participants, and then administered to a total of 41 participants for the body of the study. The sample criteria included older adults over 55 years old, with a modest income and at least two chronic morbidities. Questions elicited the intervieweesâ&#x20AC;&#x2122; personal circumstances, perceptions, health history and strategies to manage multiple chronic conditions.

Results: The main theme emerging from this qualitative analysis was that older adults with multiple chronic conditions strive to maintain control over their lives. The ways in which they attempted to do this originated in three ways: cognitive management, self-care and faith orientation. Cognitive management included becoming health vigilant, normalizing conditions, and comparing themselves to people worse off. Self-care activities consisted of taking medication regularly, dieting, exercising, and adapting daily activities. Black older adults were more likely to add faith-based interventions to improve their sense of control.

Commentary: This study contributed to the understanding of how materially-poor older adults manage multiple chronic conditions. The results found were consistent with other research in the area (see Loeb et al., 2003; Roberto & McCann, 2005).

This study drew upon Social Cognitive Theory (Bandura 1986), which highlights the role of three influences on behaviour: personal, behavioural and environmental. This study mainly relied on personal and behavioural influences to understand how older adults maintained a sense of control as they managed multiple chronic conditions. Extending the focus to environmental factors in future research may prove especially pertinent for resource-poor older adults, and is supported by other research identifying environmental barriers to healthy living (see Fuller et al., 2010).

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Lindsay, S. (2009) Prioritizing illness: Lessons in self-managing multiple chronic disease. Canadian Journal of Sociology, 34(4), 984-1002 Purpose: To understand how individuals self-manage and prioritize multiple chronic diagnoses.

Method: A total of 53 individuals were selected from a larger heart health study in the United Kingdom. Focus group interviews were conducted with 6-10 participants each. Leading questions asked participants to name and prioritize their illnesses; describe a typical day and how they coped with their conditions; and to offer advice to other sufferers. The transcripts were analyzed using NVivo software and were parsed for emergent themes.

Results: The participants highlighted the importance of prioritizing a main diagnosis, which helped them to keep symptoms under control and minimize disruption. Prioritization of conditions was impacted by the unpredictable nature of a disease, the inability to control it using medication, or the cascading effect it had on other comorbid conditions. Barriers to selfmanagement were also identified, and included challenges of maintaining weight, exercising, diet, lack of information or conflicting information from health care professionals, and managing stress and depression.

Commentary: This research focused on the processes used by older adults to manage multiple chronic illnesses, and therefore gave insight into the effectiveness of selfmanagement programs, which is the primary way chronic illness is managed. The measurement of multimorbidity has tended to reduce chronic illnesses to a numerical count of conditions. However, in this study, most individuals singled out a “main” illness towards which they directed their resources.

The identification of barriers to living well highlighted the theme of the inter-relatedness and cyclical nature between barriers and health behaviours. The participants noted that weight gain was a barrier to physical activity, and lack of physical activity in turn contributed to weight gain. It was difficult to break this cycle.

Some key concepts identified in this study included chronic illness trajectory and biographical disruption. Chronic illness trajectory (Corbin and Strauss, 1991), accounts for the physiological symptoms of a disease as well as the social context and changes in these factors over time.

Every individual’s trajectory will be different, even with the same diagnosis. An alternative to chronic illness trajectory has been identified in other research (see Paterson, 2001 for the Shifting Perspectives Model). Another key concept is biographical disruption (Bury, 1982), which refers to the impact caused by the disease on a person’s biography. It includes behavior/assumption disruption, self-concept disruption, and the response to disruption including mobilization of resources.

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Loeb, S., Penrod, J., Falkenstern, S., Gueldner, S. & Poon, L. (2003) Supporting older adults living with multiple chronic conditions. Western Journal of Nursing Research, 25(1), 8-29 Purpose: To explore strategies employed by older adults with multiple chronic conditions to manage their care.

Method: Qualitative interviews were conducted in a focus group setting with thirty-seven older adults aged 55yr+ with a minimum of two chronic diagnoses. Thematic and content analysis was completed via transcribed recordings of the interviews as a team.

Results: There were various themes of gaining, losing and maintaining capabilities that emerged from the focus groups, with maintenance being the predominant mode. There were seven coping strategies that emerged, which were framed as a means of “staying in control” and “keeping what I have”. These strategies were: relating with health care providers, medicating, exercising, changing dietary routines, seeking info, relying on spirituality/religion and engaging with life. Significant others were used to support daily efforts, while health care providers guided the health care plan. Coping was a dynamic, daily process, both responsive and proactive. Furthermore, there was an acknowledgement that the older adults had expertise over their own bodies, and that a positive relationship with a physician would recognize and act upon that expertise. Pharmacists were cited more frequently than nurses as being partners for self-care.

Commentary: Although not explicitly stated throughout the discussions with participants, there was a common thread of social support from close family that allowed the older adults to engage in the above strategies. This highlighted the importance of social support to enable those with MCC to have the opportunities to manage their health – it is not a solitary pursuit.

The implication of this finding is that strategies for self-management should also consider the available and necessary external supports for success.

An opportunity for further research is in empowering older adults to recognize the expertise they have in knowing their own bodies, and in fostering communication with professionals that capitalizes on this knowledge. Additionally, the role of pharmacists in the health care team is an area for further exploration, as well as reimagining the role of nurses to provide chronic condition support for older adults.

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LĂśffler, C., Kaduszkiewicz, H., Stolzenbach, C., Streich, W., Fuchs, A., van den Bussche, H., Stolper, F. & Altiner, A. (2012) Coping with multimorbidity in old age: A qualitative study. BMC Family Practice, 13, 45-53 Purpose: To use qualitative methods to understand how older adults cope with multiple chronic disease diagnoses.

Method: Narrative interviews were conducted to gain answers to the research question, which was: How do old aged multimorbid patients cope with their multiple chronic diseases? The sample included 19 older adults, average age 75 years, from Hamburg and neighboring suburbs in Germany. Data analysis was conducted using grounded theory, and through open, axial and selective coding.

Results: The interviews revealed that older adults coped with their multimorbidities in three main ways: social, emotional and practical coping. At the social level, coping meant attempting to sustain a meaningful life, which included adopting pets and adapting physical activities to improve participation. For those with less mobility, social coping was portrayed as maintaining autonomy, such as rejecting home care. Emotional coping included the way people felt about their conditions or limitations. Experiencing a mix of emotions was typical. Lastly, coping at a practical level involved the individual attempting to mitigate the negative aspects of their conditions. To these older adults, taking care of oneself was essential. All of these coping approaches were constructed to lead to pro-active behaviour.

Commentary: This research posed important questions regarding how older adults cope with multimorbidity as they age. The broad questions helped elicit some of the ways in which individuals manage their conditions. Furthermore, it attempted to expand the research base beyond single disease entities to the concept of multimorbidities. This movement has been supported by reports such as the American Geriatric Society Expert Panel (2012), which advocates for the inclusion of multimorbid older adults into clinical practice guidelines.

Since this paper was based in Germany, there was potential for cultural norms to have influenced the coping styles discussed. These influences were not discussed. Further, there was no discussion on potential overlaps between categories, wherein one description of coping may fit as both emotional and social, and how these categories influence each other.

Number or severity of chronic conditions did appear to have some impact, as those with lower mobility reported using a different approach to social coping.

Future research is needed to assess what sort of â&#x20AC;&#x153;pro-active behavioursâ&#x20AC;? these patients were engaging in. It would be beneficial to link the outcome measures to life satisfaction or quality of life indicators, which could then be measured.

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Newson, J., Huguet, N., Ramage-Morin, P., McCarthy, M., Bernier, J., Kaplan, M. & McFarland, B. (2012) Health behaviour changes after diagnosis of chronic illness among Canadians aged 50 and over. Statistics Canada, Catalogue #82003-XPE, Health Reports, 23(4) Purpose: To prospectively study health behaviour changes in older adults after they have been diagnosed with a chronic condition.

Method: Data were used from the Canadian Health Population Survey, which began in 1994/1995 and had follow-up data every two years until 2006/2007. Participants for this study were included if they were over 50 years at the first cycle, and subsequently developed a chronic disease during the study period, which were 5,404 individuals with a mean age of 65.4 years. Cycles 2 & 3 were used to compare health behaviour changes for a group of older adults who were not diagnosed with chronic illness. Data collection included self-reporting of chronic illness diagnosis for five conditions: heart disease, cancer, effects of stroke, chronic lung disease, and diabetes. Health behaviour measures included smoking cessation, physical activity, alcohol consumption, and fruit and vegetable consumption. Statistical analyses were performed to determine pre- to post-diagnosis health behaviours changes.

Results: Smoking cessation was the most commonly reported health behaviour change, most notably after diagnosis of heart disease, diabetes, cancer and stroke. Only individuals with diabetes reported greater leisure time physical activity, while alcohol consumption decreased for all diagnosis groups. The only significant change for fruit and vegetable consumption was that individuals diagnosed with diabetes increased daily intake from 4.4 to 5.2 servings per day.

Commentary: This study was a prospective, longitudinal design, and therefore was not subject to recall bias. Overall, it found very few changes in the health behaviours of the individuals diagnosed with serious chronic conditions. An interesting finding was that diabetes patients were most likely to make positive changes. Future research should explore why this is the case.

Most striking was the finding that older adults diagnosed with lung diseases were least likely to stop smoking, although intuitively this group would likely benefit the most from this lifestyle change.

This research highlighted the difficulty in attaining behaviour modifications, even after a â&#x20AC;&#x153;wake upâ&#x20AC;? call such as a chronic diagnosis. Future research in this area needs to focus on why these behavioural changes are not happening. Possible explanations included lack of knowledge on behalf of the older adult, and psychological or physical barriers. However, a broader perspective that includes community and environmental factors would perhaps reveal more universal pathways to health. Measures of multimorbidity were also not included, and would help explain the complexity and challenges of health behaviour modifications for older adults.

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Peel, M., McClure, R. & Bartlett, H. (2005) Behavioural determinants of healthy aging. American Journal of Preventative Medicine, 28(3), 298-304 Purpose: To present a literature review of studies that have explored behavioural factors linked to healthy aging. To highlight the positive aspects of modifiable behaviours, as opposed to dwelling on the dangers.

Method: A literature review was conducted by searching multiple databases. Inclusion criteria was narrowed to English papers, published between 1985-2003, with a primarily analytic epidemiological longitudinal design comparing behaviour to healthy aging, and study participants over 60 years of age. A total of 8 papers were included in the analysis.

Results: Evidence was found in the majority of the papers examined linking healthy aging with increased physical activity, being a non-smoker, maintaining normal weight ranges, and moderate alcohol consumption. No results were found for different diet regimes. Furthermore, combining regular exercise and non-smoking had a positive cumulative affect on healthy aging.

Commentary: Healthy aging was defined as a â&#x20AC;&#x153;lifelong process optimizing opportunities for improving and preserving health and physical, social and mental wellness; independence; quality of life; and enhancing successful life course transitionsâ&#x20AC;?. It is viewed as a multidimensional concept. At its basis is still the ideal that successful aging is possible only in the absence of disease. Studies that primarily included chronically ill older adults as the study population were excluded in the process.

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Sells, D., Sledge, W., Wieland, M., Walden, D., Flanagan, E., Miller, R. & Davidson, L. (2009) Cascading crises, resilience and social support within the onset and development of multiple chronic conditions. Chronic Illness, 5, 92102 Purpose: To better understand the experience of multiple chronic conditions, from their onset and accrual to varied coping mechanisms. Particular attention was paid to social support and resilience.

Method: Thirty-three participants were selected from a primary care center in New Haven, on the basis of having multiple chronic diagnoses. Qualitative interviews were employed to elicit responses, with questions that prompted elaboration on health matters and coping mechanisms. The resulting transcripts were rigorously analyzed for themes and meaning units.

Results: The average age of participants was 50.4 years. The analysis revealed that the participants commonly reported an experience of “cascading crises” leading to loss, and a subsequent effort to adapt. Giving and receiving social support were also common themes.

Commentary: The common theme of “cascading crises” reflected the concept of the chronic illness trajectory (Corbin and Strauss, 1991, see Lindsay, 2009). Both of these terms are process oriented, and describe how subsequent diagnoses and ability to cope create unique experiences for each individual. The authors introduced the two-hit theory, adapted from biomedical research, in which a second diagnosis or limitation has a greater impact since it occurs when the individual is in a period of reorganization.

The interviews also revealed that coping with multiple chronic diagnoses was not only accomplished through receiving social support, but also through giving support to others. The participants described being able to give support as a way to transcend their diseases and reclaim an aspect of themselves that was important to them, even though they were limited by a chronic illness. Future research and interventions should expand upon this finding.

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Thorne, S., Paterson, B. & Russell, C. (2003) The structure of every day self-care decision making in chronic illness. Qualitative Health Research, 13(10), 13371352 Purpose: To use qualitative methods to explore the daily decisions made for self-care by individuals with chronic conditions. This is a notably important area of study, since the vast majority of chronic condition management is handled by the individual, and consists of a multitude of daily decisions.

Method: Twenty-two participants were chosen on the basis that they had one of the following diagnoses: diabetes (Type 1 & 2), HIV/AIDS, or multiple sclerosis. Rationale for choosing these diagnoses was that they each represent different difficulties associated with chronic conditions, from medical management and lifestyle modifications, to stigma, prognosis, and visibility. Each of the participants had several years of experience with their chronic condition. Data collection took place over one year, and included interviews, think aloud sessions and focus groups.

Qualitative analysis revealed common themes and patterns.

Results: Self-care management was revealed to begin with a conscious decision to take control of their condition, and then subsequent actions to maintain control. Learning bodily cues was important to understanding the disease, however it was most common in diabetes patients. Self-care management on a daily basis also included managing social relationships, treatments, health care and lifestyle. Learning to measure their day-to-day status was a critical element of self-care. Participants reported using experts and biomarkers, relying on individual standards of health, and acknowledging the complexity of their condition as tools in selfmanagement.

Commentary: This article concluded with a description of self-care management as a â&#x20AC;&#x153;complex developmental process that occurs within the context of a disease trajectory, health care culture, and a uniquely meaningful lifeâ&#x20AC;?. The authors stressed the importance that selfmanagement cannot be over-generalized, since it depends on a plethora of variables.

However, this research helps direct future investigations into self-care routines that may elicit the best care protocols and how health care professionals can best support self-management.

This study did not look specifically at older adults, nor did it include measures of multimorbidity, which would add another layer of complexity and therefore warrant further investigation.

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Zausniewski, J., Chaeweon, C. & Krafik, K. (2001) Social cognitive factors predicting the health of elders. Western Journal of Nursing Research, 23, 490503 Purpose: To examine the relationships of learned resourcefulness, help responses and health self-determinism; to analyze the help responses (self help, informal and formal help seeking) by their contribution to the health of older adults with chronic conditions.

Method: The 137 participants were recruited from a convenience sample of older adults, with an age 62-102. Data were obtained through structured face-to-face interviews and questionnaires, which included a list of chronic conditions (0-26), self control schedule, health self-determinism index, help seeking behaviour scale, and a sickness impact profile.

Results: Women and African American older adults displayed higher resourcefulness scores, and number of chronic conditions was inversely linked to resourcefulness. Higher resourcefulness, in turn, was linked to higher informal help seeking, but not formal help seeking. Conversely, health self-determinism was correlated to self-help and formal help seeking, but not informal help seeking. Lastly, higher resourcefulness was correlated with better self-reported physical and psychosocial health.

Commentary: The hypothesis that help responses would predict the physical and psychosocial health of older adults is based on a social cognitive model for predicting health (Norman & Conner, 1995). This model integrates a five stage theory of behaviour change including the concepts of learned resourcefulness, help responses and health selfdeterminism. Learned resourcefulness was considered to be a repertoire of skills that enable a person to seek help from others. This is an essential link between the availability of social resources and actually accessing those resources.

The authors provided validity and reliability information on the measurement tools they used.

However, it was noted that there may be more reliable and appropriate measures to use in future studies. For example, health self-determinism failed to predict health status, and functional status and activities of daily living were omitted from the collected data. Also, a sample of 137 participants limited generalizability. The implications of these findings are that help-seeking behaviour is a complex and individually defined process. Longitudinal and prospective studies may help elicit the nature of this relationship between help seeking and learned resourcefulness, and how to maximize its potential benefits for living well.

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b) Formal Care: Creating Prepared, Proactive Practice Teams American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity (2012) Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of American Geriatrics Society, 60, E1-25 Purpose: To create an approach for clinicians to optimally care for older adults with multimorbidity that accounts for multiple conditions, patient preferences, prognosis and feasibility. Intended to guide clinicians through the complex process of caring for older adults with multimorbidty.

Method: An expert panel was convened to identify important elements of care for older adults with multimorbidity. They decided upon five key components: patient preferences, interpreting the evidence, prognosis, clinical feasibility, and optimizing therapies and care plans. A structured literature review was conducted on each domain, and a relevant article review was conducted based on articles that the expert panel members deemed highly relevant to the field of study. Additionally, barriers to providing care for older adults with multimorbidity were identified throughout all domains.

Results: Guidelines for eliciting patient preferences: recognize when an older adult is facing a preference-sensitive decision, ensure the patient is adequately informed about risks of benefits of the treatment options, and elicit patient preferences only after they are sufficiently informed.

Challenges in this area include lack of time to complete these steps, and lack of complete information on conditions and their interactions to guide decision-making. Improving the interpretation of evidence was guided by five principles: evaluating the applicability and quality of the evidence, identifying the outcomes, anticipated benefits and potential harms, discovering the absolute risk reduction, and assessing the time horizon to outcomes.

Challenges include lack of time, heterogeneity, and limited generalizability. Prognosis for older adults with multimorbidity included identifying the life expectancy and other outcomes within the short, mid and long term to prioritize care. Challenges include the interaction effects of conditions that complicate predicitions, and uncertainty inherent in prognostic tools. Clinical feasibility referred to balancing what clinicianâ&#x20AC;&#x2122;s want and what an individual is ready to accept.

The coordination between treatment complexity and patient ability is a challenge. Lastly, optimizing therapies and care plans was mainly concerned with avoiding contraindicated medications and polypharmacy.

Commentary: Clinicians play an important role for older adults to learn about and manage their chronic conditions. A key factor that has been identified throughout the literature is that incorporating patient preferences in the design of a care plan can significantly improve the effectiveness of care provided. This also includes appreciating the patientsâ&#x20AC;&#x2122; social and family support network, and their integration in the care decision process. Furthermore, a humble approach by physicians will acknowledge the limitations of physician directed care (see Hurd Clarke & Bennet, 2013).

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Fried, T., Tinetti, M., Iannone, L., O’Leary, J., Towle, V. & Van Ness, P. (2011) Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Archives of Internal Medicine, 171(20), 1854-1856 Purpose: To explore the use of an outcome prioritization tool to aid patients and physicians in determining the best method of care when competing outcomes arise due to multimorbidity.

Method: Participants were recruited from seniors’ centers and one assisted living center in Conneticut, and were excluded if they exhibited dementia. The main outcome variable assessed was the prioritization of four health outcomes: staying alive, maintaining independence, reducing pain, and reducing or eliminating other symptoms. The proportions of individuals choosing different priorities, the strength of each outcome, and the within group mean score for each outcome was calculated.

Results: Maintaining independence was the health outcome most commonly prioritized by this sample of older adults (76%). Among those ranking independence as the most important, reduction of symptoms was generally secondary and staying alive the least important. For the majority of those who ranked staying alive as most important, maintaining independence was second.

Commentary: This research provides a tool that could be implemented in the health care system to help individuals understand where their own priorities lie, as well as facilitate discussion with their physicians regarding treatment options and treatment “trade-offs”. The identification of better ways to support decision making is a goal of the Expanded Chronic Care Model (see Barr et al., 2003). Future research would be beneficial to test this tool in a clinical setting, and in longitudinal studies on how older adults perceptions and priorities change over time.

Research should also address whether there are similarities and differences between the people in each priority-ranking group. What characteristics are common among those who choose the reduction of symptoms versus those who prioritize staying alive? Are there differences between individuals with and without disability?

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Sevick, M., Trauth, J., Ling, B., Anderson, R., Platt, G., Kilbourne, A. & Goodman, R. (2007) Patients with complex chronic diseases: Perspectives on supporting self-management. Journal of General Internal Medicine, 22(3), 438444 Purpose: To use a case study to illustrate the difficulties of self-management of comorbid disease and opportunities to support self-management.

Method: A case study was used to explore complex chronic disease care of a man in end stage renal failure.

Results: This study highlighted a few of the concerns affecting individuals, especially older adults, diagnosed with complex chronic diseases. The first area of concern was negotiating goals of care, and it was suggested that increasing patient participation in goal setting could enhance their willingness to engage in self-care. Second, patient-physician communication was emphasized, with aspects of patient driven and physician driven communication efforts both being important to effective self-care techniques. Third, engaging patients in behaviour change was identified as a basic tenet in virtually all self-care literature. Fourth, informationprocessing burden needs to be decreased for chronically ill individuals, and the study cited other research that has shown lower adherence when demands are increased. This was noted to be especially poignant for individuals with complex or conflicting disease protocols. Lastly, minimizing the negative impact on health related quality of life was reported, which was also identified as a significant contributor to self-management programs. The processes by which self-management of complex chronic disease and health related quality of life were linked were threefold: direct effects of the disease, effects from the prescribed treatment, and psychosocial strain from coping with the disease and treatment.

Commentary: This paper gave a broad overview of important aspects of formal support of self-management of complex chronic diseases. Areas for future research stemming from this paper include re-analyzing current behaviour change models and determining whether they are applicable to multimorbid populations, with the goal of creating interventions for individuals with complex diagnoses. Furthermore, since individuals with multiple chronic conditions may require multiple behaviour modifications, research is needed on the sequence, prioritization, type and duration of support needed to sustain positive change. For older adults, research is needed on how to best present information to avoid information processing burden, and to assess whether computer based programming is appropriate and effective.

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Tinetti, M., Bogardis, S. & Agostini, J. (2004) Potential pitfalls of diseasespecific guidelines for patients with multiple conditions. The New England Journal of Medicine, 351(27), 2870-2874 Purpose: To alert researchers and clinicians to the importance of investigating the long term harms and benefits of adhering to disease-specific guidelines in patients with coexisting health conditions.

Method: A review of possible dangers associated with polypharmacy in clinical practice.

Results: Considerations to be made when helping a patient manage multiple prescriptions include the individuals attitude and preference toward various health outcomes, and whether the recommended prescription will aid them in meeting these health goals. A specific concern for older adults and those with multimorbidities are that they have typically been excluded from empirical tests on the efficacy of the prescribed medications. Furthermore, these trials are typically short term in nature, therefore limiting their generalizability to the safety of such products over the span of a chronic condition. Increasing the number of medications is associated with an increased risk of adverse effects.

Recommendations from this paper were to increase basic and clinical research to assess the affects of multiple medications, and the evaluation of these drugs on a broad range of physical, mental, cognitive and other outcomes to be standardized to aid in the decision making process regarding health tradeoffs for patients. Additionally, time to treat and absolute risk reduction should be explicit to ensure the medication will be beneficial within the patients expected lifetime.

Commentary: This paper provided considerations for patients with multiple chronic conditions as they may be subject to polypharmacy. Since prescriptive interactions may play a role in the health of older adults it is essential to promote continued research into the implications of polypharmacy for those with multiple chronic conditions. This sort of critical review questioned whether medicine has been focusing on what is good for the disease or good for the patient. In a patient centered approach to health care it is essential to understand how polypharmacy impacts the daily lives of individuals living with multiple chronic conditions.

A recurring theme in the focus for future research is the ability for physicians and other caregivers to incorporate the priorities of the patient into the health care plan. Such considerations may include side effects of medication, impact on functional and social abilities, and cost of medication.

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Vogeli, C., Shields, A., Lee, T., Gibson, T., Marder, W., Weiss, K. & Blumenthal, D. (2007) Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management and costs.

Journal of General Internal Medicine, 22(3), 391-395 Purpose: To perform a literature review to summarize the current knowledge of multiple chronic conditions and the effects these have on care management, quality and associated costs to health care.

Method: The literature review was conducted using MEDLINE database, beginning with the terms “comorbidity” and “chronic disease” published between January 2000 and March 2007.

Further selection criteria narrowed the field to the final 163 articles, by parsing for the Mesh terms prevalence, quality, access, delivery of care, patterns of care, morbidity, mortality, and expenditures. Articles that were not published in core journals, had anonymous authors, or didn’t have an abstract were excluded.

Results: The prevalence of multiple chronic conditions reported in this literature review was 21% for the general population and 62% in people over the age of 65. Understanding the health consequences of multiple chronic diseases was found to be poorly understood. Quality of care for people with chronic conditions was reported as being suboptimal due to the difficulties in coordinating care. These challenges included multiple medications and remembering care management advice. However, there were a few exceptions in which medical care contact for one condition aids in the detection and treatment of a secondary issue, thereby improving quality. Lastly, costs of care, where reported, were shown to increase with number of chronic conditions, and to use a large proportion (78%) of health care spending in the US. Commentary: This literature review identified gaps in the current multiple chronic condition literature. One of these was that there was little research on the clustering of diseases within individuals, and the possibilities of underlying mechanisms that make some older adults more susceptible to disease (see Marengoni et al., 2009). One example of this that has received some attention is the metabolic syndrome. Understanding these disease relationships may contribute to our understanding of the health consequences of multiple chronic conditions. In terms of health care costs, self-management programs have been shown to reduce spending.

However, these programs need more research into their effectiveness before findings can be generalized to the whole population. Other programs, such as case management, also deserve exploration to determine whether they can improve the health outcomes, reduce costs, and enhance quality of care for individuals with multiple chronic conditions. There is a need to conduct longitudinal, large-scale studies to generate an in depth understanding of disease etiologies and severities.

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c) Health Care System Reform Barlow, J., Singh, D., Bayer, S. & Curry, R. (2007) A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions. Journal of Telemedicine and Telecare, 13, 172-179 Purpose: To compile the current research on telecare for older adults to elicit benefits for individuals and systems.

Method: Seventeen e-databases were searched, revealing 8,666 articles. These were parsed down to 98 randomized trials and observational studies included in this study. The key findings were synthesized in narrative form due to the variety of research included.

Results: Of the 98 studies, 67 papers focused on information and support systems, 31 on monitoring clinical indicators, and two on home safety alert systems. The largest focus populations were diabetes and heart failure patients. Studies examining vital signs monitoring found inconsistent results at a personal level, and for certain conditions monitoring reduced health service use. There was insufficient evidence on the benefit of safety and security monitoring. Proactive telephone information support was associated with improved clinical outcomes and reduced hospitalizations; however, these findings were not conclusive for email/internet support.

Commentary: This review identified gaps in the current literature on telecare for older adults with chronic conditions. Future studies should aim to fill these gaps to support effective policy for the provision of care in the community. For example, more research is needed for diseases other than diabetes and heart disease.

Future studies should also consider the components of telecare, and the context in which it is provided to understand how and why some interventions are more successful than others.

Additionally, research into how older adultsâ&#x20AC;&#x2122; perceive and interact with telecare is warranted.

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Bayliss, E., Edwards, A., Steiner, J. & Main, D. (2008) Processes of care desired by elderly patients with multimorbidities. Family Practice, 25, 287-293 Purpose: To explore older adults’ perspectives on the processes of care desired when diagnosed with multiple chronic conditions.

Method: Qualitative interview style, with 26 participants aged 65-84 years. Individuals were recruited from local HMOs based on a diagnosis of osteoarthritis, depression and diabetes at a minimum. Transcripts were analyzed with software to depict themes.

Results: The researchers found the following themes when they asked participants what they wanted from their care providers: convenient access to providers, continuity of care, clear communication of care plan, individualized and coordinated care, and to “be heard”.

Commentary: The researchers chose to specifically interview individuals who were diagnosed with osteoarthritis, diabetes, and depression because the management of one of these conditions may exacerbate another (ie. exercising for diabetes may be inhibited by pain from osteoarthritis.) Complex and conflicting diagnoses, also called discordant diagnoses, are an important area of study especially for a patient centered model.

This research provided support for integrated care models, in that it highlighted many of the same themes that define integrated care. Specifically, this research supported the implementation of a primary contact within the care system that coordinates, personalizes and ensures that the patient is heard. Improving older adults’ interaction with the medical community is an important step for improving the lives of individuals with multiple chronic conditions.

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Boyd, C., Boult, C., Shadmi, E., Leff, B., Brager, R., Dunbar, L., Wolff, J. & Wegener, S. (2007) Guided Care for multimorbid older adults. The Gerontologist, 47(5), 697-704 Purpose: To test the feasibility of a new health care role for nurses, designed to improve quality of life and efficiency of resource use for older adults with multimorbidity Method: A pilot program of the six of the eight Guided Care principles was implemented for one year with one guided care nurse (GCN) and two primary physicians. The six responsibilities of the GCN were to assist in the assessment, planning, monitoring, coaching, coordination of care transitions, and accessing community resources. The two responsibilities that were excluded from the trial were chronic disease self-management support, and education/support for caregivers. The goal of the pilot program was to elicit physician and patient feedback on the effectiveness of this new position.

Results: At the end of the program, the physicians were enthusiastic about the role of the guided care nurse. They found that it enhanced communication and coordination among providers, offsetting unreimbursed tasks. Feedback from patients and their families was equally enthusiastic about the guided care program. These results have led to the initiation of a two-year, cluster-randomized controlled trial of the program. Initial findings from that study advocate for detailed descriptions of the role, responsibilities and scope of the GCN position, nurses from a variety of backgrounds, educational programs to prepare nurses for guided care, and gaining support from physicians as critical for the success of the program.

Commentary: This pilot program offered enthusiasm for a new role within the health care system for nurses, aimed to enhance the navigation of the system by older adults with multiple chronic conditions. Expanding the roles of nurses in chronic care has been supported in other research (see Loeb et al., 2003). A strength of the research is that it has been built off the chronic care model (CCM). Since the expansion of the model into the Expanded CCM (Barr et al., 2003), it would be useful to revisit this research and identify ways in which the GCN is relevant within the expanded model.

This research has already resulted in new studies, including an expansion of this pilot program to a two year study. Additional research will be beneficial to explore the other 2 principles of guided care that were not applied in this pilot, and to extend this research into the Canadian context.

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Institute of Medicine (2012) Living well with chronic illness: A call for public health action. Washington, DC: The National Academies Press.

Purpose: To guide the policy and decision making process regarding the development and implementation of cross-cutting and coordinated care to reduce the burden of chronic conditions.

Method: The Institute of Medicine established a committee to undertake this consensus study.

Seven questions were presented to the committee, the answers to which form the basis of the recommendations made to the United States Center for Disease Control and Prevention (CDC).

Results: The report contained seventeen recommendations to the CDC. Those that were most pertinent to future research in this field included the selection of a variety of chronic conditions to study, which represent variation in organ systems, functional outcomes, long term clinical manifestations, and disease progressions, with cross-cutting clinical, functional and social implications. Research on multiple chronic conditions (MCCs) was recommended, including monitoring potential taxonomies of MCCs and improving surveillance techniques to capture the complexity. Additionally, evaluations of current programs, including federally funded prevention programs, was recommended, as well as continued research on the adoption of long term healthy lifestyles. The committee recommended research on reduction of health disparities across populations, and the development of evidence based policy goals and objectives. Further recommendations also included the evaluation of existing health care models, such as the chronic care and expanded chronic care models, with an emphasis on cooperative care.

Commentary: This document provides a comprehensive analysis of chronic disease care from an American perspective. It would be beneficial to ask similar questions within the Canadian health care system, and to create a guideline for promoting research and policy development in this area. The recommendations made for future research provide a reference for developing research initiatives.

The final section of the report outlines the evidence for non-peer reviewed models of care delivery for individuals with chronic conditions. Accessing the grey literature on current practices in Canada is an important consideration for future study, so that researchers can work with health care providers to create comprehensive, empirically supported best practices and policy guidelines.

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Lorig, K., Sobel, D., Stewart, A., William Brown Jr., B., Bandura, A., Ritter, P., Gonzalez, V., Laurent, D. & Holman, H. (1999) Evidence suggesting that chronic disease self-management programs can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37(1), 5-14 Purpose: To methodically examine the impact of the chronic disease self-management program (CDSMP), which does not have disease-specific bias, on three measures of health outcomes.

Method: Participants were recruited through a variety of media sources, and prior to entering the study had to confirm a diagnosis of at least one of the following: chronic lung or heart disease, stroke, or chronic arthritis. The total of 952 participants were not cognitively impaired or undergoing chemotherapy. Before data collection, the participants were randomly assigned to either the treatment group, which received the 7 week, 2.5 hour per session, CDSMP program, or the control group, which received the program at the end of the trial. The outcome measures collected were health behaviors, health status and health service utilization, via self-reported, mail-in forms. Results were analyzed comparing the treatment and control groups at six months on the outcome variables, using analysis of covariance.

Results: Compared to the controls, the group that received the CDSMP reported statistically significantly improved health behaviors following the intervention, as well as improvement in health status variables. No differences were found in pain, shortness of breath, or psychological well-being. Furthermore, the treatment group had fewer hospitalizations, and spent significantly fewer nights in the hospital.

Commentary: This research was one of the original papers to examine heterogeneous approaches to chronic disease management. This program represents an avenue for the selfmanagement of diseases regardless of specific diagnoses or comorbidities. It was beneficial to include a cost analysis of the program as it highlighted the importance of preventive measures to improve our health care system. Another positive attribute is the use of lay leaders to administer the programs, many of who are older adults with chronic conditions themselves. It would be interesting to study the health outcomes of the lay leaders, as they are likely benefitting from a deeper understanding of course material, and from being in a position of respect and leadership.

Since it is known that depression has a large impact on living well, future studies and iterations of the CDSMP should add a component that addresses the psychological well-being of the participants. This outcome was one of the only categories in which the program provided no significant improvements. Criticisms of the CDSMP also include a lack of cultural responsiveness as well as a lack of attention to contextual and support factors.

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Parekh, A., Goodman, R., Gordon, C. & Koh, H. (2011) Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life. Public Health Reports, 126, 460-473 Purpose: To describe an “action-oriented” approach to reforming health care in the US to enhance the quality of life and health outcomes for those with multiple chronic conditions.

Method: This framework was the result of a federal departmental workgroup from the US Health and Human Services, on the issues facing individuals with multiple chronic conditions (MCC) as they navigate the health care system. Additional stakeholders from 250 organizations helped shape the final report.

Results: The framework proposed four goals to improve the health and quality of life for individuals with multiple chronic conditions. The first goal is to foster health care and public health system changes to improve health outcomes. This will be accomplished by the identification of evidence-based care models, defining the appropriate health care outcomes for people with MCC, developing payment reform and incentives, implementing and using health information technologies, promoting preventative efforts, and purposefully evaluating care models. The second goal is to maximize self-care management of MCC, through facilitating self-care, home care and community services, and providing tools for medication management. The third objective is to provide better tools and information to health care professionals. This will be accomplished via the identification of best tools and practices, enhancement of health professional training, and inclusion of MCC in guidelines. The fourth goal is to facilitate research to fill knowledge gaps, which will be lead by increasing external validity of trials, understanding the epidemiology, increasing clinical, community and patient centered research, and addressing health disparities in MCC research.

Commentary: Health care in Canada has some fundamental differences when compared to the American health care system. However, the centrality of “siloed” care, which is most effective for acute (not chronic) illness, is a barrier to living well for older adults in Canada as well. In addition to translating this work to the Canadian context, this framework would be enhanced by the inclusion of the perspectives of those living with MCC and their families, as well as those in other levels of government.

Future research that may take inspiration from this framework include a revitalization of recruitment strategies and measurement tools to accurately identify those with MCC, expansion of research into self-care and self-management support for those with MCC, and an enhancement of information technology use within the health care system. Additionally, it is essential to identify the social determinants of health and address health inequities throughout the population.

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d) Community Support: A Socio-ecological Approach Angus, J. & Reeve, P. (2006) Ageism: A threat to aging well in the 21st century.

Journal of Applied Gerontology, 25, 137-152 Purpose: To outline the ways in which stereotypes of aging and ageism inhibit older adults from aging well.

Method: A conceptual paper reviewing the ways in which ageism is pervasive in social, historical, political and cultural manifestos.

Results: Ageism is the process of stereotyping and prejudicing of a group of people based on their age, typically older adults, who are characterized in terms of being a “burden”. This process has the effect of exaggerating and homogenizing traits. Researchers are not immune to this societal pressure, and ageism may affect how research is defined and carried out, as well as how it is interpreted and implemented. Research can also contribute to the power imbalance between professional knowledge and the practices of the older adults themselves.

Many of the negative stereotypes of older adults are tied to “myopic views of productivity”, which devalue the ways in which older adults have and do contribute to their communities.

They are also driven by the additional negative connotations associated with dependency and it’s implications in aging. To combat ageism we need to consider how social and material resources (not chronological age) may enhance or detract from an individuals’ ability to contribute to society. For example, the most important predictors of poor health are low social status, weak social networks, and stress early in life.

Ageism has had some positive effects for older adults as well: it has garnered support for research and policy on behalf of older adults, and stimulated research in the field of gerontology. This has been a driving force for support, legitimacy, and sympathy for the “plight” of the aged, again reinforcing the stereotypes.

Commentary: This article highlighted the place of aging/ living well within the social, cultural and political context, which has a critical effect on the experience of aging. The authors point out concern that those working on behalf of older adults may be contributing to the “common sense reality” of ageism, and must be aware of the paradoxical discourses between selfreliance and dependency.

Future research on living well as an older adult should acknowledge the political, cultural, and historical context in which older people experience ageism. Furthermore, aging research will benefit from an analysis of intersecting variables in older adults lives, such as culture, gender and socioeconomic status, to reveal the heterogeneity of this population. This should include a reflexive analysis of one’s own assumptions of aging and how one can decrease the power imbalance between different types of knowledge.

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Barr, V., Robsinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D. & Salivaras, S. (2003) The expanded chronic care model: An integration of concepts and strategies from population health promotion and the chronic care model. Hospital Quarterly, 7(1), 73-82 Purpose: To propose an expanded chronic care model based on the chronic care model and evidence from population health promotion.

Method: Evaluate the current chronic care model, and expand it to include principles of population health promotion to create a more holistic, inclusive and effective model.

Results: Criticism of the original chronic care model (Wagner et al., 1999) centers on the inadequacy of representing the broader role of the community in chronic care. Research in population health promotion (PHP) offers evidence of the effectiveness of such partnerships, for example the emphasis on societal change rather than individual responsibility. PHP also includes social determinants of health as important variables that are generally excluded from clinical conceptualizations of health care. Lastly, it emphasizes that, with such a broad conception of health, health care systems cannot be expected to be solely responsible, but to act as collaborators within the community to initiate change.

The expanded chronic care model (expanded CCM) positions the health care system as a “porous” entity within the broader circle of the community. This represents the flow of information, resources, and people between health care and the community. Additionally, aspects of the health care system “straddle” the border between health care and the community, underscoring the shared responsibility of these tasks. Under the community heading, three tasks have been delineated: building healthy public policy, creating supportive environments, and strengthening community action. Bubbles of community support have also been added to both the individual as an activated and informed patient, and to the prepared, proactive practice team. Outcomes of the expanded CCM include population health outcomes as well as functional/clinical outcomes.

Commentary: This research outlined the contributions that principles of population health promotion have made to evidence based practice. The inclusion of these principles within the expanded chronic care model provided a broader understanding of how communities can work to promote the health of their citizens, both within the health care system and from a collaborative perspective. The shift in responsibility from individuals to social systems that include the social determinants of health has been promoted in other research (see Koehn et al., 2009), especially for vulnerable older adults.

Future research opportunities arising from this research include program evaluation and participatory research based on the model, and research on the development of new ways to support clients and health care professionals from within the community. It also provides a structure from which to identify gaps in the current literature.

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Jang, Y., Mortimer, J., Haley, W. & Graves, A. (2004) The role of social engagement in life satisfaction: Its significance among older individuals with disease and disability. The Journal of Applied Gerontology, 23(3), 266-278 Purpose: To discover the impact of social engagement on life satisfaction, and to gauge whether this effect has a different impact on individuals with disease without disability, and those with disease and disability.

Method: A sample of 466 participants, aged 60-84 years, was drawn from the larger Charlotte County Healthy Aging study. Participants were asked to confirm diagnosis of chronic conditions, functional status was measured with the Activities and Instrumental Activities of Daily Living, Physical Performance, and Functional Health Scales. Social networks were measured using the Lubben Social Network Scale, and social activity was based on the following five questions answered on a Likert Scale: talking on the phone, visiting friends, taking courses, participating in discussion groups, and going to social clubs, church or synagogue activities. Life satisfaction was measured with the Life Satisfaction Index. The sample was thus divided into individuals with disease without disability (n=186) and individuals with both disease and disability (n=168) and the social activity, network and life satisfaction variables were compared.

Results: Individuals with both disease and disability had lower participation in social activities and lower life satisfaction. However, their life satisfaction was more closely linked to social engagement than their disease without disability counterparts.

Commentary: This study helped validate the notion that disability has a greater impact on life satisfaction than mere disease count. Additionally, since it was found that life satisfaction has a greater correlation with social engagement in older adults with disease and disability, there is even greater pressure to provide opportunities to promote social engagement for those in this category.

This study was not able to depict whether these correlations represent a causal effect, since they were based on a cross-sectional study. An alternative explanation for the findings may be that individuals with higher social engagement were able to delay disability. Future research would benefit from exploring changes in disease, disability, life satisfaction, and social relationships over time. Perhaps all of these factors work in a cyclical cause-and-effect fashion, and therefore an intervention in any area will benefit the process of improving life satisfaction. It would also be useful to gain a larger sample size to incorporate the differences in individuals with no disease and no disability, and in those with disability, without chronic disease.

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Koehn, S., Jarvis, P. & Kobayashi, K. (2011) Taking care of chronic disease: An approach for Canadaâ&#x20AC;&#x2122;s aging ethnic population: A workshop. Final Report, iCARE Purpose: To begin to address the existing evidence gap on approaches to self-management and self-management support for ethnic minority older adults with chronic conditions. To acknowledge the various challenges that chronic conditions present and to build upon existing strengths in the community.

Method: A roundtable workshop was hosted to elicit the views of multiple stakeholders, including immigrant older adults and their families, policy makers, clinicians, multicultural settlement workers, and academics. Two main questions were asked of the participants: To what extent do current self-management support models address the needs of immigrant older adults? What are â&#x20AC;&#x153;promising practicesâ&#x20AC;? for this group and what can we learn from them?

In addition to the discussions, there were a number of presentations from different stakeholders and experts to stimulate discussion.

Results: Important conclusions arising from the workshops included the importance of reaching out to vulnerable populations, building links between primary care and communities, and providing supports to health care providers. The interactive effects of social determinants of health were highlighted, as they impact individual and community abilities to experience and manage chronic conditions.

Commentary: Research on self-management support for ethnic minority older adults underscores the need to assess and access community resources to provide opportunities to live well with chronic conditions. This workshop provided valuable information on the needs of older adults, and on the importance of an engaged and activated community. This is an area of the Expanded Chronic Care Model (Barr et al., 2003) that deserves more research attention.

Future research was recommended to create supportive community partners, and to work collaboratively with diverse health care workers to support immigrant older adults to manage their chronic conditions.

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Martin, C. & Peterson, C. (2009) The social construction of chronicity â&#x20AC;&#x201C; A key to understanding chronic care transformations. Journal of Evaluation in Clinical Practice, 15, 578-585 Purpose: To outline how chronicity has developed as a social and clinical phenomenon, and to argue for the contemporary analysis of social constructionist theory in the face of impending health care reform.

Method: This paper represented a historical reflection and critique regarding the tensions between the constructions of chronicity from two viewpoints: hermeneutic and empirical. A third direction is also identified, namely â&#x20AC;&#x153;mixed methodsâ&#x20AC;?, in which the two view points attempt to be reconciled and synthesized.

Results: Without careful consideration to the social construction of chronic disease or illness, emerging models of health care will not be effective in addressing the needs of the individuals they purport to serve. This paper reviews the social constructionist perspective, in which reality is constructed through human action, and its interpretation creates a meaningful world.

Research on chronic conditions has helped create a picture of the diversity of experience in chronic illness (hermeneutic), as well as developed fragmented evidence based practices (empirical). Although there is research and knowledge generated in both, it is the empirical or evidence based medicine that guides funding, payment, and decision-making. This has led to polypharmacy, fragmented services and barriers to access. Chronicity must be understood as a social experience that shapes the lives of those with chronic conditions, as well as a medical experience.

Commentary: This article brought up many valid points in considering the evolution of primary care from an acute setting to a place that may facilitate living well with chronic conditions. If the social aspects of chronic conditions are not identified and incorporated, then the whole person is not being treated, and the outcomes will be limited. Bridging the gap between hermeneutic and empirical knowledge, and giving value to different types of knowledge will increase the voice of the patient within the primary care setting.

Future research is needed to develop social theory and critique chronic care models that are not responsive to the social circumstance of older adults with chronic conditions. This becomes increasingly important as multiple chronic conditions complicate evidence-based medicine. Furthermore, discovering avenues for wellness and therefore redefining measures of wellness within the chronic condition experience will be an ongoing challenge for those with chronic conditions and their support systems.

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Naaldenberg, J., Vaandrager, L, Koelen, M. & Leeuwis, C. (2012) Aging populations everyday life perspectives on health aging: New insights for policy and strategies at the local level. Journal of Applied Gerontology, 31, 711-736 Purpose: To understand how older individuals experience healthy aging in their communities, and how local resources may provide a pathway to health.

Method: A total of 79 participants completed the interviews for this study, with a diverse range of ages and from both rural and urban communities. The interview approach was face-to-face, in depth and open ended to gain detailed narrative responses. Four general research questions guided the interviews: What are aging personsâ&#x20AC;&#x2122; views on healthy aging? What do aging persons perceive to contribute to a supportive environment, what influences their perception of their ability to use the resources, and are existing facilities recognized as relevant and do aging persons use them? This process was aided by newspaper clippings of local programs and the identification of six themes of health: loneliness, mobility challenges, caregiving burden, being overweight, falling incidents and psychological issues. Answers were coded into the four research questions for analysis.

Results: Health and aging were intricately related, but were not linearly related. When older adults spoke of the challenges they faced, they were embedded in the context of everyday life.

A wide variety of resources were cited to create a supportive environment. They were separated into physical and social resources, with mobility and communication as moderating factors. Familiarity and proximity were important aspects of supportive resources. Influences on perceived ability to use resources were divided into positive influences, which were characterized by feelings of being in control, and negative influences, which were characterized by uncontrolled changes. Lastly, perceptions of the local facilities and programs were hindered by three factors: focus of the programs on risk factors, isolating health themes, and having an age associated with the program.

Commentary: This study presented user feedback, an important program evaluation phase that all community service providers should engage in to provide better programs and to understand the perceptions of their current services. It supported previous research that aimed to understand how older adults perceive their health, which ultimately should guide how interventions can improve their health. This type of study helps bridge the gap between research and application.

Implications of this research for living well are that older adults should be included in program development to ensure that the programs are coherent with their sense of healthy aging. This will improve participation and the overall health of the community.

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Vassilev, I., Rogers, A., Sanders, C., Kennedy, A., Blickem, C., Protheroe, J., Bower, P., Kirk, K., Chew-Graham, C. & Morris, R. (2011) Social networks, social capital and chronic illness self-management: A realist review. Chronic Illness, 7, 60 - 78 Purpose: To review the literature on how social networks support chronic illness management.

Method: A realist review was employed, and involved a database search for the following key words: social support, social network, psychosocial support, community-based support, chronic illness, chronic disease, self-care, and self-management. Both qualitative and quantitative studies were included. A total of 61 papers were selected for in depth review.

Results: The types of social networks identified were networks of dyadic relationships, affective communities, and networks of networks. The functions of social networks in long term condition management (LTCM) were to shape knowledge, discourse and narratives, to define normalcy, deviance and stigma, negotiation of LTCM work, to act as a buffer for formal care, or as a substitute of formal care. Properties of networks vary between the different types and the nature of the communication, as well as the size and type of relationships within ones personal community. Furthermore, networks can have positive and negative valence effects on an individuals health. It is suggested that there is an optimum balance between the amount and type of work that is offered and required between members of the community. Outcomes of the studies included professionally defined outcomes, such as health behaviours and biomedical indicators, and patient centered outcomes such as happiness and well-being.

Commentary: This study began to fill the gap between individual-focused self-management literature and the hypothesized benefits of social networks on long-term condition management. It has been argued that the experience of chronic illness is deeply embedded in the social experience, and therefore it follows that our social networks and support systems play a role in coping and living well (see Martin, 2009) From this study it is clear that there has been some research in the area of social networks and chronic condition management, however the authors were still unable to answer some of their original questions, such as: for whom do networks work, and in what circumstances? What are the underlying mechanisms implicated? To better understand how to support older adults with multiple chronic conditions it is necessary to step away from individual-only models, which propagate inequalities, and towards a more inclusive strategy that includes social and community resources, such as the Expanded Chronic Care Model (Barr et al., 2003).

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