Fall 2008

Redirecting Resistance
By Joseph M. Casciani, PhD
Aging Well
Vol. 1 No. 4 P. 20

Dealing effectively with resistant older adults requires a careful assessment of the reasons underlying such resistance and devising appropriate methods for altering resistant behaviors.

There is an art and a science to understanding resistance in older adults and what approaches will be helpful for changing behavior. The art of understanding resistance requires taking into account an individual’s perceptions and interpretations of what he or she is facing, the motivation to comply with the recommendation, and what age-related barriers get in the way. The science of understanding resistance requires recognition that there are stages we all go through to take on new behaviors—stages that are predictable and require unique, individualized approaches.

For older adult clients who are resistant to complying with healthcare prescriptions, one challenge lies in involving them in their own care. This involvement is effective for reducing resistance because it allows the behavior change to be internally rather than externally directed. In a sense, this approach requires the elder to become responsible for his or her own decision making and behavior change. Alternatively, by not moving toward increased self-management, or what is sometimes referred to as patient-driven care, we continue to rely on the power relationship between the advisor and the client and face the inherent risks and pitfalls of this power struggle.

In a review of the research literature on patient compliance, as many as 50% of patients treated for chronic medical conditions did not comply with treatment plans, such as taking medications or modifying health risk behaviors related to an unhealthy diet, smoking, or excessive alcohol use. Even in the face of the most compelling reasons to alter one’s behavior patterns and the most dire health consequences, we know that advice, logic, and persuasion frequently do not work. How many times have we tried to change our own behaviors after reading or hearing the best advice from the highest authorities?

There is, of course, more involved than good intentions or setting new goals. Fortunately, behavior science can now tell us what works and what it takes to overcome resistance and bring about successful change.

Roots of Resistance
Why are some older adults resistant? Reasons such as fear of change, mistrust, and resentment toward the person doing the advising are common. A person’s coping skills may be very limited. Too often, we see denial as the older adult’s only way to manage unpleasant news. Such denial can be very weak or fragile. To take away this defense may leave the elder vulnerable to more anxiety and perceived threats than he or she can manage. Other limited coping mechanisms, such as emotional withdrawal or uncontrolled anger, also play a role in how older adults resist dealing with unpleasant or unwanted advice.

Personality factors, such as suspiciousness or paranoia, will of course influence how compliant a client is. Even what may be called a healthy questioning of authority, a phenomenon we’re likely to see increasingly in the baby boomer generation, causes the individual to seek alternative opinions and healthcare approaches. For other elders, there may be a measure of shame or embarrassment causing the resistance to care. This is sometimes seen in patients with respiratory disorders, such as chronic obstructive pulmonary disease following a lifelong history of smoking. The individual is now faced with a grim prognosis and health risk behaviors that are difficult to explain to the healthcare provider.

A specific aspect of resistance is manifest by not complying with prescriptions. Medication noncompliance is a major issue for tens of thousands of healthcare recipients throughout this country (see below). There are numerous reasons for it, including limited physical function and physical barriers such as elders who are confined to wheelchairs or beds and functional barriers such as memory loss and forgetfulness, confusion, cost, and inadequate instruction. Research cites the quality of the doctor-patient communication and the information patients receive as additional factors affecting adherence to treatment recommendations.

Limited cognitive functioning can also explain an individual’s failure to follow the prescription for care. In the early to middle stages of a dementing illness, an elder’s comprehension, complex reasoning, and executive decision making can be impaired. To further complicate the situation, we often overestimate how much dementia patients understand of what is being communicated, given their tendency to minimize or mask their extent of cognitive loss and to appear as though they understand everything. This sometimes explains why the behavior of an elder with dementia is often incongruent with what was discussed during an earlier visit or conversation.

Another explanation for resistance is the degree of misunderstanding, misinterpretation, or irrational thinking an individual experiences. For example, in its simplest form, the purpose of a treatment plan may not be clear to the client. Misinterpreting information, often seen as attributing fault or blame to someone or something else, will generally get in the way of getting the facts straight and taking appropriate action based on the evidence presented. The older adult who blames the insurance company for disallowing or delaying reimbursement shifts the focus away from following the prescription for behavior change.

The final factor of resistance in older adults is that of mastery and control over one’s environment. Failing health, limited choices, and considerable personal losses take away an older adult’s sense of control. These losses and disappointments are unending for some elders: “I may not have a say in the progression of my diabetes, but I do have a say over what I do in my own world, who I listen to, and what advice I follow.” This is the uncomplicated and yet understandable thinking and self-talk that elders may entertain.

These are but a few of the explanations for older adults’ noncompliant, resistant behaviors. Right or wrong, logical or illogical, it must be said that inroads to successful behavior change are more likely when we take these reasons into consideration.

Relieving Resistance
In recent years, an important distinction has been made between compliance and adherence. Compliance [question into author] has the connotation of authority, and subordinating to the person or system in authority often brings with it a measure of distrust and resentment. Adherence, on the other hand, doesn’t carry the same connotation of enforcement and subordination. Rather, it implies more of a collaborative effort and dialogue between the advisor and client.

A third term that is gaining in popularity, especially in the United Kingdom, is concordance. This refers to greater involvement of the client in the treatment process, including more information about care options and more of a trusting two-way collaboration between parties.

This trend toward greater collaboration is a very positive development. The more an older adult is engaged in his or her own care, the more likely it is to have a lasting effect. Several elements make up the collaborative process, including the following:

• Empathy, understanding, and two-way communication: Respect the client’s autonomy and decision making; accept his or her mindset and the values, perceptions, and feelings that accompany this position.

• Give the elder permission: Remind the client that he or she has choices and, importantly, strengthen the elder’s sense of empowerment, helping him or her to reclaim a feeling of control over the environment.

• Good listening skills: The first stage in overcoming resistance is to listen to the individual’s position without passing judgment, to create a climate for change, and to open the door to considering alternative views and ideas. This means listening to the reasons for the resistance—the lack of trust, the poor coping ability, or the attempts to hold on to some semblance of control—and not offering a quick fix because if there were a quick fix, it would have worked already.

• Point out discrepancies: Sometimes an elder voices new goals and a desire for change yet continues to demonstrate the original behaviors. In these instances, it can be useful to point out the discrepancies between the goal and the behavior, effectively having the elder explain the remaining resistance in his or her own terms from his or her own perspective.

• Value self-directed behavior over externally directed behavior: Two factors come into play—the importance of change and the confidence of the individual in his or her own ability to bring about a change (e.g., self-efficacy). Assessing and reassessing the importance of change and self-efficacy on a scale from 1 to 10 during each conversation is an accurate and reliable predictor of successful change that is initiated from within.

• Roll with resistance: Resist pushing an older adult before he or she is ready. Push and the individual pushes back.

• Focus on solutions: Have the elder describe what will be different after the change occurs or when adhering to the prescription—how will he or she know that the prescribed plan is being followed, and how will others know? After identifying what the client will do differently, recommend that he or she engages in that new behavior. Here is an example of the solution-oriented approach: “Well, if I were watching my diet like I’ve been told,” she may say, “I would get up every morning and plan my meals for the day ahead of time.”

If the client adopts this approach and engages in this new behavior, it occurs whether the desire or intent is present at all and, with even minimum reinforcement, is likely to be repeated. This illustrates how a new behavior can change one’s thinking rather than the other way around.

• Monitor the elder’s cognitive functioning: If there are mental barriers or cognitive limitations to the individual’s understanding about the reasons for change, other approaches will be needed.

• Mobilize family and other caregivers: Informal, unpaid caregivers have an opportunity to support the elder in his or her behavior change by acknowledging and reinforcing movement in a positive direction. Caregivers can also strengthen the importance of the change and help build the client’s confidence to carry out the change. Others can more easily accomplish this attention, reinforcement, and support when they are included in the process.

Moving in the Right Direction
Respecting an older adult’s right to be a part of the prescription for change also requires that the elder respects the helper’s time constraints and, sometimes, the helper’s limited availability. Listening takes time. And with demographics showing a steady increase in the number of older adults, coupled with the challenge to provide an adequate supply of professionals, paraprofessionals, and direct care workers, there will likely be even greater pressure to rely on external directives to elicit cooperation in the aging population. To the extent that professional and paraprofessional caregivers can resist this temptation, those changes that come about from partnering and collaborating with the client will be more lasting and successful. Any listening is better than none.

Working with older adults involves both challenges and frustrations, not the least of which is their common tendency to not follow prescriptions and to resist recommendations, especially when their physical well-being is at stake. As healthcare professionals and other caregivers encourage more participation, collaboration, and decision making with older resistant individuals, self-management can be expected to increase. This will create a beneficial impact on both the individual and the healthcare system.

— Joseph M. Casciani, PhD, is a geropsychologist with a 30-year career working with older adults, their families, and staff in long-term care settings. Founder and president of Concept Healthcare, an interactive training and education company devoted to integrating behavioral health insights, approaches, and principles in the overall healthcare of older adults, he has recently returned to consulting with nursing homes about the delivery of behavioral health services to residents in these settings.

Containing Costs
Noncompliance with medical recommendations is taking its toll on healthcare costs in the United States. For the pharmaceutical industry alone, it is estimated that the cumulative effect of patients failing to adhere to their treatment regimens costs the pharmaceutical industry worldwide more than $70 billion per year, according to Business Wire. Here are some estimates on the healthcare costs related to failing to follow medical treatment recommendations:

• According to an early study on hospitalizations published in 1990 in the Archives of Internal Medicine, noncompliance is directly responsible for the admission of 380,000 patients to nursing homes each year, or roughly 23% of all nursing home admissions.
• In at least 60% of nursing home admissions, one authority has reported that noncompliance was a greater factor than the person’s actual medical condition (Meichenbaum & Turk, 1987).

• Noncompliance leads to 3.5 million hospital admissions annually in the United States, or 11% of all admissions, according to a 1995 review from the National Council on Patient Information and Education.

• Among older adults, 40% of all hospital admissions are due to medication-related problems, according to a 1998 International Journal of Nursing Studies article.

• The mean cost per admission in these cases of medication noncompliance has been estimated at $2,150, and noncompliance is the single most important cause for hospital readmission (Meldon, Ma, & Woolard, 2003).

• The World Health Organization estimated in 2003 that in developed countries, only 50% of patients suffering from chronic diseases follow treatment recommendations.

The consequences of noncompliance with medical treatment recommendations appear to include higher healthcare costs, possibly unnecessary healthcare costs, and poorer health outcomes. Any approach that improves adherence and overcome resistance to these medical prescriptions will undoubtedly have a significant impact on both the physical and emotional well-being of the older adult population and on the health outcomes of this age group.

— JMC

References
Meichenbaum, D. & Turk, D. (1987). Facilitating treatment adherence: A practitioner’s guidebook. New York: Plenum Press.

Meldon, S. W., Ma, O. J., & Woolard, R. (eds.) (2003). Geriatric emergency medicine, First Edition. American College of Emergency Physicians.