University of Central Arkansas

Use of Technology and Home Exercise Compliance in Older Adults

By Chad Lairamore, PhD, PT, GCS, NCS and Sarah Walker, DPT

Patient compliance has been a consistent challenge to ensuring appropriate treatment within all fields of healthcare.^1-3 Not only is compliance crucial to decreasing healthcare costs by minimizing wasted healthcare dollars on repeated services where benefits are not fully realized; compliance by patients may become a factor in provider viability, with reimbursement impacted by the outcomes that clients achieve.^1,4,5 As healthcare continues to move toward value and outcome-based models of reimbursement, this old problem takes on a new perspective as reimbursements may soon be incentivized by, or even directly linked with, patient outcomes.^6-8 Additionally, for patients to receive appropriate medical treatment they must have a partnership with the care provider and be engaged in managing their own health care. The choices they make every day have the greatest impact on their wellbeing.^1,5 In fact the World Health Organization states that “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”⁵ Non-compliance is of particular importance in the older adult population, as data indicate that those over the age of 65 are less likely to perform their prescribed home exercise program.^9,10

Emerging evidence suggests that providing patients with a more engaging form of home exercise program beyond either the standard written or verbal instructions can result in an increase in patient compliance. In this time of rapidly advancing personal technology, one solution to improving compliance may lie in the palm of our hand through the appropriate utilization of smart devices. Smartphone and tablet applications are a readily available, familiar, and ubiquitous tool at the fingertips of most clinicians and patients.

This technology is currently grossly underutilized and unstudied, but could potentially serve to revolutionize patient outcomes by dramatically increasing rates of patient compliance. However, Individuals over the age of 65 represent the lowest demographic for smart phone usage with only 27% reporting having a smartphone.¹¹

To bridge this gap, we partnered students from the University of Central Arkansas Physical Therapy Department with older adults participating in a pro bono clinic associated with the course Adult Neurological Rehabilitation. Clients were loaned an iPad mini if they did not already own a smart device, and students instructed the clients on use of the smart device. The goals of this learning experience were to 1) facilitate improved engagement and home exercise program compliance, and 2) educate students on the potential use of technology for increasing patient engagement and compliance compared to standard printed home exercise programs.

In order to gauge patient compliance, we used the application Wellpepper during the pro bono clinic and for 1 month following the clinic. Wellpepper is an application that is used to create custom care plans, share and update exercises remotely, and track results.¹² The application was administered by student physical therapists using an iPad. With supervision from a licensed physical therapist, students created customized home exercise programs that were then available to clients via the application on their own personal device or the device that was lent to them. Within the app, therapists and students were able to change and update their client’s home exercises, and check in to see if they were being performed. This innovative system attempts to capitalize on the assumption that greater patient engagement and support, coupled with a more dynamic interface, can increase patient compliance.

Anecdotally, we found that clients fell into one of three categories. Those who already had a “relationship” with their smartphone or tablet were likely to engage with the application Wellpepper and perform their home exercise program on a regular basis. The clients who did not own a smartphone or tablet, but who demonstrated an interest in using the application, were also likely to engage with the home exercise program and have good compliance. In fact, several clients who fell in this category bought tablets to be able to continue their exercise routine. Finally, the clients who did not show an early interest in the technology were generally non-compliant with their home exercise program. These results are not surprising as previous research investigating elderly participants use of a home program found that compliance was influenced by the individual’s preference for the program structure and how that program was delivered.¹³

In conclusion, we found the use of smart devices may increase patient engagement and improve compliance for some older adults. However, smart device usage is not for everyone. Clinicians need to match instructional techniques with their client’s preference. Additionally, as instructors, we need to not only teach our students to use technology for increasing patient engagement, but also to use traditional instructional strategies as well as other alternative strategies to better match home programs to the patient’s preference.

References:

Martin LR, Williams SL, Haskard KB, DiMatteo MR. The challenge of patient adherence. Therapeutics and Clinical Risk Management. 2005;1(3):189-199.
Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. Journal of C`linical Pharmacy and Therapeutics. 2001;26(5):331-342.
Campbell R, Evans M, Tucker M, Quilty B, Dieppe P, Donovan J. Why don’t patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. Journal of Epidemiology and Community Health. 2001;55(2):132-138.
Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy.15(3):220-228.
Adherence to Long Term Therapies – Evidence for Action. Wolrd Health Organization 2003: http://www.who.int/chp/knowledge/publications/adherence_report/en/.
VanLare JM, Conway PH. Value-based purchasing—national programs to move from volume to value. New England Journal of Medicine. 2012;367(4):292-295.
Miller HD. From volume to value: better ways to pay for health care. Health Affairs. 2009;28(5):1418-1428.
Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program In: Services TUSDoHaHSaTCfMM, ed. CMS website 2009:31. ????
Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Physical Therapy. 1999;79(3):270-277.
Riel H, Matthews M, Vicenzino B, Bandholm T, Thorborg K, Rathleff MS. Efficacy of live feedback to improve objectively monitored compliance to prescribed, home-based, exercise therapy-dosage in 15 to 19 year old adolescents with patellofemoral pain- a study protocol of a randomized controlled superiority trial (The XRCISE-AS-INSTRUcted-1 trial). BMC Musculoskeletal Disorders. 2016;17:1-12.
Smith A. U.S. Smartphone Use in 2015. 2015; http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/.
Weiler A. mHealth and big data will bring meaning and value to patient-reported outcomes. mHealth. 2016;2(1).
Simek EM, McPhate L, Hill KD, Finch CF, Day L, Haines TP. What are the characteristics of home exercise programs that older adults prefer?: A cross-sectional study. American Journal of Physical Medicine & Rehabilitation. 2015;94(7):508-521.

The Importance of Nutrition Assistance in Older Adulthood

by Alicia S. Landry, PhD, RD, LDN, SNS, Assistant Professor/University of Central of Central (UCA)

After age fifty, there are many metabolic and physiologic changes impacting the nutritional needs of an individual. A slower metabolic rate with age is due to a decrease in muscle mass; this results in lower caloric needs. Many older people experience difficulty obtaining sufficient nutrients to support or achieve optimal health. These challenges may be related to inadequate dentition or swallowing issues, cognitive and psychosocial changes, as well as insufficient income. Inadequate energy intake can eventually lead to chronic fatigue, depression, and a weakened immune system.1

As health practitioners, it is critical that we encourage older adults to consume nutrient-dense diets. The significance of this was noted in 2006 when the inclusion of separate nutrition recommendations for individuals 70 and over2 was made. Meeting daily protein requirements is essential for the aging adult because protein provides essential nutrients for the maintenance of bone structure and muscle mass. The Recommended Dietary Allowance for protein is 0.66 grams/kilogram/day for adults over 70 years of age, however, recommendations for older adults suggest that 1.2 grams/kilograms/day will meet the needs of many older adults. Carbohydrate in the form of high quality fiber, more complex carbohydrates and few simple starches or sugar should equate to 130 grams/day. Fats are the most efficient source of energy but there is no determined recommendation so these should be chosen wisely and should include fats with omega 3 and omega 6 fatty acids.2 Adequate Calcium and vitamin D are also important in the diets of older adults.

Older adults may experience changes in taste and appetite. Physical ailments, prescription medications, and loss of a significant other may impact appetite; emotional factors such as loneliness and depression can affect diet and appetite. Limited budgets may make affording food needed to support a balanced, healthy diet difficult.

“While federally funded programs provide food to millions of older adults each year, there are still many older adults going hungry.3 Food assistance programs can improve nutritional well-being, functional independence, and quality of life.1 General assistance programs such as the Supplemental Security Income (SSI), is intended to increase a person’s income to the defined poverty threshold. However, if SSI benefits are paying for expenses like medications and doctor visits, there may not be enough left for nutrient-dense food. Federal nutrition assistance through the United States Department of Agriculture (; http://www.fns.usda.gov/programs-and-services) include the Supplemental Nutrition Assistance Program (SNAP) and Senior Farmers’ Market Nutrition Program. Unfortunately, only about eight percent of participants in SNAP are aged 60 or over. Many eligible older adults report a “stigma” associated with receiving food assistance and therefore never try to obtain the benefits. According to USDA guidelines, households may have $2,250 in countable resources, such as a bank account, or $3,250 in countable resources if at least one person is age 60 or older, or is disabled. Resources that are not considered include homes and land, resources of people who receive SSI, resources of people who receive Temporary Assistance to Needy Families (TANF), and most retirement (pension) plans. An income test is performed and deductions for medical and shelter costs are included.

“Meals and snacks are provided by Adult Day Care Centers. Commodity foods can be obtained through the USDA’s Commodity Supplemental Food Program. Adult Day Cares are funded through the Child and Adult Care Food Program (CACFP) which provides aid to adult care institutions to provide nutritious foods for the health and wellness of older adults and disabled persons. The Commodity Supplemental Food Program supplements older adults’ diets with foods like low-fat dry milk, juice, rice, oats, peanut butter, dry beans, as well as canned meats, fruits, and vegetables.

“The US Department of Health and Human Services (US DHHS) administers the Older Americans Act Nutrition Program which includes Congregate Nutrition Services, Home-Delivered Nutrition Services, and the Nutrition Services Incentive Program. All people 60 and over as well as their spouses are eligible to receive meals through US DHHS programs regardless of income. The Home-Delivered Nutrition program aims to serve frail, homebound, or isolated individuals who are age 60 or over. The Nutrition Services Incentive Program provides grants to states, territories, and eligible tribal organizations that provide congregate and home-delivered meal programs, like senior centers and Meals on Wheels programs. A sample meal pattern that would be served daily at a congregate feeding site or home-delivered may be seen in Table 1. A very helpful resource may be found with the Older Americans Act Nutrition Programs Toolkit provided online by the National Resource Center on Nutrition, Physical Activity & Aging. Privately funded nutrition resources for aging adults include the National Foundation to End Senior Hunger, Feeding America, local food banks, as well as Meals on Wheels Association of America and others. Meals on Wheels provides a nutritious meal, visit, and safety check with each delivery. Depending on the funds available and the sponsor organization, days/times of delivery and meal composition varies. Regardless, older adults receiving Meals on Wheels food often are able to live at home, independently for a longer time.
Not only is the number of older adults continuing to grow, many older adults are experiencing inadequate savings and retirement. Adequate nutrition can save healthcare dollars and significantly improve quality of life for our aging adults. All health professionals can promote healthy nutrition practices in older adults and identify signs of malnourishment, feeding difficulties, or psychosocial changes impacting nutrient intake.

Table 1. Sample Meal Pattern


Food Type	Recommended Portion Size
Protein foods	3 oz., cooked portion
Vegetables and fruits	Two ½ cup portions
Enriched white or whole grain bread or alternative	1 serving (one slice bread or equivalent)
Butter or margarine	1 tsp
Dairy	8 oz. fat-free or low-fat milk or calcium equivalent
Dessert	One ½ cup serving (fruit, pudding, gelatin, ice cream, sherbet, etc.)
Source: US Department of Health and Human Services

References:
1. Drewnowski A, Shultz JM. Impact of aging on eating behaviors, food choices, nutrition, and health status. J Nutr Health Aging. 2001;5:75–79
2. Otten JJ, Hellwig JP, Meyers LD, editors. IOM. Dietary Reference Intakes: The essential guide to nutrient requirements. Washington, DC: The National Academies Press; 2006.
3. Coleman-Jensen, A., Rabbitt, M., Gregory, C., & Singh, A. (2015). Household Food Security in the United States in 2014, Table 2. USDA ERS.