Feature Article
|
Weight Loss and Failure to Thrive: Evaluating and Motivating Older Adults Toward Recovery Dr. Resnick is Associate Professor at the University of Maryland School of Nursing, Baltimore, MD. Address for correspondence: Barbara Resnick, PhD, 5435 Watercress Pl, Columbia, MD 21045. E-mail: bresnick@umaryland.edu .
Weight loss in older adults is often associated with failure to thrive , a syndrome that involves progressive loss of physical and psychological function. The evaluation and management of individuals with failure to thrive is extremely challenging. A comprehensive evaluation should include exploration of physical, functional, social, and emotional problems, and initial treatment should focus on eradicating any identified problem. In addition, it is essential to evaluate the older adult’s motivation related to eating, and, if necessary, to implement interventions to strengthen motivation and thereby improve oral intake. Motivation is best evaluated using a model called The Wheel of Motivation , which provides a framework for developing interventions to improve motivation and facilitate recovery from weight loss and failure to thrive. (Annals of Long-Term Care: Clinical Care and Aging 2001;9[7]:21-31)
I nvoluntary weight loss— defined as a loss of 1-2% of body weight per week, 5% per month, or 10% in a six-month period—is a common problem in older adults. Specifically, it has been reported that approximately 20% of community-dwelling older adults consume less than 1000 kcal per day, and 15% have lost more than 5% of their body weight.1 This weight loss is often associated with, or leads to, failure to thrive (FTT)—a syndrome that involves progressive loss of physical and psychological function. FTT has high morbidity and mortality rates and incurs significant costs to the health care system.2,3 Moreover, the evaluation and management of individuals with FTT is extremely challenging, and often the final treatment is to perform comfort care measures. The case of Mrs. R, an 89-year-old white female living in a continuing care retirement community, demonstrated the important impact that nursing care can have on managing weight loss and FTT.
Case Study
Mrs. R is a schoolteacher who moved into a continuing care retirement community (CCRC) over 15 years ago. She has a supportive group of friends and former coworkers with whom she used to dine regularly. She participated in many of the trips and activities organized for the residents and volunteered in the health care center to transport patients, to visit with them, or to read to those with impaired eyesight. Although she has no immediate family, Mrs. R has a niece who visits her regularly. Mrs. R’s past medical history includes hiatal hernia in 1995; diverticulosis in 1997; left lower lobe fibrosis, venous stasis, kyphoscoliosis, hypothyroidism, and gastritis in 1995; and breast cancer in 1993, which resulted in a left mastectomy.
Although Mrs. R admits that she never had a big appetite, over the past year she has reported a persistent decrease in appetite and has made frequent clinic appointments to “get something for this.” Her physician started her on ranitidine hydrochloride, omeprazole, and cisapride, ýssuming that her decrease in appetite was due to gastrointestinal symptoms such as indigestion, burning, gas, and reflux. There was no improvement in her appetite or food intake with any of these medications. Mrs. R was also prescribed megestrol acetate 40 mg daily with no response in appetite. Her family and friends became increasingly concerned about Mrs. R’s poor appetite and weight loss. They reported that at meals Mrs. R would chew small bits of food, spit them into a napkin, and try to hide it away. When questioned about this behavior, Mrs. R explained that she simply could not force herself to swallow. Her weight decreased from 96.5 lb in August 1999 to 70 lb in March 2000 (26.5 lb in seven months—27% of her body weight). Along with the decreased intake of food, her fluid intake was also diminished, and in March 2000 she was admitted to an acute care hospital with dehydration, anemia, oral candidiasis, pneumonia, and FTT.
A work-up was completed in the acute care setting in order to rule out metastatic breast cancer, gastrointestinal disease, or a thyroid disorder. The work-up included laboratory work, a bone scan, upper and lower gastrointestinal series, and endoscopy. There were no abnormal findings on any of the diagnostic tests. Mrs. R was treated for dehydration and FTT with intravenous fluid replacement and total parenteral nutrition (TPN). She was treated with intravenous antibiotics for pneumonia, and with oral and systemic antifungal medications for candidiasis. Once the acute problems had been stabilized, intravenous fluids and TPN were stopped, and she was transferred from the acute care setting to a long-term care setting. At the time of discharge from the acute care setting, Mrs. R’s blood counts included a hematocrit of 10.5; hemoglobin of 31.6; electrolytes that were within normal limits; and a blood urea nitrogen of 20 with a creatinine of 0.6. Her albumin level was 2.8 and her weight was 67.7 lb. Medications at the time of discharge included megestrol acetate 40 mg daily and fluconazole 100 mg daily.
Understanding Weight Loss and FTT
There have been many definitions of FTT, including (1) a syndrome consisting of unintentional weight loss accompanied by other abnormalities such as anemia, chronic disease, impaired immune function, hypoalbuminemia, and hypocholesterolemia;4 or (2) a complex interaction of physiologic, social, and psychological issues leading to functional and cognitive decline and eventually death.5,6 Causes of weight loss and FTT can include underlying disease states such as cancer, or functional, social, or emotional problems. Aggressive attempts should be made to find the underlying cause of weight loss and FTT, but it is not always clear how extensive the evaluation should be. In all cases, the health care provider must discuss the risks and benefits of a work-up with the patient, the patient’s family, or the person appointed the power of attorney for the patient’s health care. Prior to the initiation of the work-up, all involved individuals must agree to consider treatment if a correctable or treatable condition is found.
One of the major concerns with FTT is the objective symptom of weight loss and protein-energy malnutrition. This commonly presents as a marasmus-like condition in which the individual’s reserves of protein and energy are depleted. The best indicators of protein-energy malnutrition are weight loss, low body weight (more than 10% below the average weight), low mid-arm circumference (less than 10.4 in), low cholesterol levels (less than 150 mg), and low albumin levels (less than 3.5 g/dL).
Causes of Weight Loss and FTT
Weight loss and FTT in the older adult are often caused by common diseases (ie, cancer, Parkinson’s disease, or dementia), which complicate conditions such as infection and treatments such as chemotherapy. The social causes of FTT and weight loss focus on the eating environment, the ability to obtain and prepare pleasant meals, and the dietary restrictions that make eating unpleasant. Psychological causes of FTT and weight loss may be even more prevalent in older adults and can include mood disorders such as depression. Cognitive problems associated with dementia and delirium also expose older adults to the risk of weight loss and FTT by making them prone to forgetting to eat, forgetting how to prepare foods, and at later stages even forgetting how to chew and swallow their food.
There are many physical and physiologic causes of weight loss, including metabolic disorders such as hyperthryoidism, drug side effects, oral infections such as candidiasis, alterations in taste and smell due to normal age changes, malabsorption of food, cancer, stroke with residual neurologic deficits, and chronic lung disease. Many of the causes of weight loss and FTT, such as cancers and underlying neurologic disorders, cannot be easily eliminated. Conversely, there are some treatable causes of weight loss that need to be aggressively evaluated so that appropriate interventions can be implemented.
Evaluating the Patient With FTT
The first step in evaluating the patient with FTT should be to obtain a comprehensive past medical history, as exacerbations of past medical problems can often result in FTT. Table I provides a review of the many medical problems that can impact nutritional status and cause FTT In addition to past medical history, it is essential to establish a comprehensive medication list. It may be useful to elicit the help of family members and friends to ensure that the medication list is comprehensive (ie, that all drugs from the refrigerator, bathroom, drawers, and cabinets have been identified).
Medication should be considered as a potential direct cause of FTT, especially if there has been a recent change in medication or in the dosage of a current medication. It is also possible that medications that were once useful can become toxic as the patient ages and/or changes physiologically. Table II provides a list of the common medication groups that can cause or contribute to FTT. Medications can also cause FTT due to their effects on cognition, behavior, and appetite. Diuretics and glucocorticoids, for example, can impair muscle strength. Neuroleptics can affect central neuromuscular control and can directly affect appetite. Other drugs, such as the selective serotonin reuptake inhibitors (SSRIs), may also directly alter appetite. Cholinesterase inhibitors—commonly used in older adults to improve memory—may result in vague gastrointestinal symptoms, which can result in decreased appetite, nausea, vomiting, or diarrhea. Digoxin, even at low or “therapeutic” levels can cause anorexia. The side effects of these medications may cause FTT by altering function and the ability to prepare and eat meals. When at all possible, attempts should be made to gradually eliminate medications and/or reduce dosages.
Careful recording of history related to the social situations of older individuals is also essential. Consideration should be given to lifestyle changes, such as a recent loss of a relationship, a recent institutionalization, financial concerns, abuse or neglect by families/caregivers, or the inability to obtain a food source or prepare meals. Family members and friends with whom the individual dines should also be questioned regarding changes in the patient’s eating behavior, changes in intake, and ability to obtain groceries in the home setting.
A review of systems is an important part of the comprehensive history and examination, as it helps the health care provider to identify acute problems that may be causing the weight loss and FTT. Table III provides an overview of particularly relevant areas to focus on. If, for example, the patient complains of dry mouth, interventions such as a change in medication or the use of hard candies or bottled saliva should be implemented. Similarly, pain—musculoskeletal, neurogenic, or visceral in origin—can decrease appetite and ultimately cause weight loss. If the older patient cannot participate in a review of systems because of cognitive problems, it should be conducted with a primary caregiver.
The physical examination should follow the review of systems and focus on potentially treatable causes of FTT and weight loss. The older adults should be examined for possible sites of infection (most commonly noted are urinary, pulmonary, and skin infections), areas of inflammation or sources of pain, organ failure (ie, cardiac, pulmonary, or renal), and malignancy. Common malignancies in this population include breast, lung, and bowel cancers; appropriate screenings should be considered if the patient is willing to participate in them. Assessing joints for swelling, warmth, or pain, and documenting functional performance are also essential. A comprehensive head, neck, and oral examination should focus on evaluating oral hygiene, missing teeth, poor-fitting dentures, ulcerations, decreased jaw range of motion or function, and inspection for suspicious lesions or enlarged lymph nodes. The abdomen should be carefully examined for evidence of epigastric discomfort, constipation, obstruction, masses, or organomegaly.
The history and physical will direct the need for additional laboratory tests. There are standard tests to evaluate FTT and weight loss, including a complete blood count, electrolytes, consideration of renal and liver functions, serum cholesterol and albumin levels, thyroid-stimulating hormone level, urinalysis, and chest x-ray. Stool should also be tested for occult blood. Testing will help to identify acute and chronic medical problems that can be treated, and thereby improve appetite and willingness to eat.
Identification of potential causes of FTT and weight loss in older adults should result in the implementation of appropriate treatments, given that the patient is willing to undergo these treatments. However, it should be recognized that even when the cause is identified and appropriate treatment is implemented, it may take weeks, or even months, to note improvement in the patient’s oral intake and weight. For individuals in whom no reversible cause of weight loss is identified, it is essential to evaluate their motivation related to eating, and to implement interventions that will strengthen motivation and therefore improve oral intake. Motivational interventions are also useful for those patients in whom there may be an identifiable cause of weight loss—reversible or irreversible.
Motivation in Older Adults Motivation is an important factor in the older adult’s willingness to participate in functional activities.7,8 Unfortunately, motivation is not often addressed, nor are the interventions that can be utilized to improve motivation in activities of daily living, such as eating. Often, the older adult is perceived as unwilling to participate, and the caregivers perform the necessary functional act by spoon-feeding or tube-feeding the individual.
By definition, motivation is the inner urge that moves or prompts a person to action;9 it comes from within the individual, and primarily affects how behavior is activated and maintained. Motivation refers to the need, drive, or desire to act in a certain way to achieve a certain end.10 Motivation should be differentiated from compliance. Compliance occurs when the patient follows instructions and orders. Motivation is not something that health care providers can give patients, but rather something that they can improve in patients by implementing interventions that encourage patients to engage in a particular activity.
Evaluating Motivation: The Wheel Because motivation is multidimensional and impacted by a variety of factors,11 it is useful to evaluate motivation of the older adult using a larger model (Figure). The model, or Wheel of Motivation , incorporates prior research,9,12-16 and is a pictorial representation of the many factors that influence motivation. Considering each of these factors will help guide caregivers toward appropriate interventions to strengthen motivation in the older adult.
Beliefs. Belief in one’s capability to perform a certain activity, and in the outcome or benefits of that activity, has a significant influence on motivation and behavior. 9,12-16 Believing, for example, that one can eat a full meal without having pain, and that eating more will improve one’s overall health and well-being, can increase motivation to eat and improve oral intake.
Physical Sensations. Physical sensations, such as pain or shortness of breath, can have a major impact on motivation.9,13,14,17,18 These physical sensations influence the older adult’s belief in his or her ability to safely perform a specific activity, as well as his or her willingness to perform that activity. Fatigue associated with eating, for example, may decrease the older adult’s willingness and ability to enjoy a meal and consume a sufficient amount of food. Pain associated with eating and/or meal preparation may likewise decrease the older adult’s eating behavior.
Individualized Care. Individualized care has an important influence on motivation to perform a given activity. In individualized care, the individual characteristics of the patient are taken into consideration.19 With regard to eating behavior, this might include personal food preferences and meal schedules. Other techniques, such as using kindness and humor, empowering older adults to take an active part in their care, providing gentle verbal persuasion to perform an activity, and giving positive reinforcement after performing, can help older adults feel cared for and cared about, and can strengthen their motivation. 13 Eating with an older adult in the long-term care setting and gently encouraging him or her to continue to eat demonstrates caring and can stimulate increased intake.
Social Support. Social supports, described as emotional and material resources provided by other persons,20 can directly serve as powerful external motivators. Social supports can strengthen motivation by (1) providing encouragement to, for example, finish a snack between meals; (2) helping the older adult feel cared for and cared about; and (3) helping to establish goals such as regaining self-care abilities, and being able to return home alone.13,14,18,21 Social supports can also motivate older adults by reminding them of their capabilities to perform activities, and of the benefits that they will receive if they continue to perform those activities.22-24
Spirituality. Spirituality is a belief in and a feeling of interconnectedness with a power greater than oneself.25,26 For the elderly, spirituality includes their hope related to illness and their perception of the meaning and purpose of life. Hope, in particular, has been noted to make a difference in the recovery process. With regard to eating behavior, building on and encouraging the hope of getting stronger can motivate the patient to increase oral intake.
Identification of Goals. The ability to identify a goal has a significant impact on motivation. 12 Goals are more likely to be effective when they are developed by, or at least with, the individual, and are rooted in his or her beliefs and expectations.27 Examples of goals that can be used to motivate the older adult to increase oral intake include recovering from an acute illness, being able to care for oneself, or being able to return home. Goals are most effective when they are related to a specific behavior, challenging but realistically attainable, and achievable in the near future.12
Self-Determination. The individual’s personality or self-determination also influences motivation and behavior. Older adults reported that it was their own personalities, their determination, and their own firm resolutions and adherence to those resolutions that motivated them to recover from acute events and illnesses.13,14,18,28-30
Successful Performance. Successful performance of a given activity is one of the best ways to increase confidence in one’s ability to perform that activity. Moreover, recognition of the benefits of a behavior is particularly effective in motivating the older adult to continue that behavior. For example, eating a full meal three times a day without pain, shortness of breath, or fatigue, and simultaneously recognizing feelings of increased energy, strength, and weight gain, can motivate the older adult to continue with that activity. Older patients do not always make the connection between a specific behavior and its outcome, and they need to be frequently reminded of this.
Summarizing the Wheel. Older adults are a heterogeneous group with very rich and diverse life experiences. Therefore, the factors that facilitate motivation in one individual may not work as effectively for another. The Wheel of Motivation provides health care workers with a format for exploring the factors that influence an individual’s motivation. Once these different factors and their impact on motivation and behavior are identified, interventions to improve motivation can be developed.
Interventions That Strengthen Motivation and Improve Oral Intake
Table IV displays a variety of interventions to strengthen motivation in the older adult. Beliefs related to a specific activity can be strengthened by using the following interventions:12,13,31 (1) practicing and successfully performing the activity; (2) receiving verbal encouragement for one’s capability to perform the activity, and reinforcement about the benefits of performing the activity; (3) contact with other similar individuals who are performing the activity successfully; and (4) decreasing unpleasant sensations during the activity such as pain, shortness of breath, fear, or fatigue. Actions such as scheduling a rest period prior to eating, having the individual use oxygen while eating, reassuring the individual that he or she is capable of eating and that eating will help recovery, and having the individual eat with others can all motivate the patient to increase oral intake.
There are a variety of ways in which to provide individualized care, including recognizing specific differences and special needs of the patient such as rest periods, food preferences, or the need for a flexible mealtime; using gentle verbal persuasion to eat and positive reinforcement once a sufficient amount of food/fluid has been consumed; empowering the individual to take an active part in his or her daily food intake by identifying food preferences; and using kindness and humor.
In the long-term care setting, social supports (ie, families and visitors) can make mealtime enjoyable by sharing stories and experiences with the older patient. Teaching families and visitors how to provide verbal encouragement and positive reinforcement for eating, and encouraging these loved ones to express excitement about each small gain in oral intake and weight, can be very effective in motivating the elderly.
Identification of goals that are realistic and appropriate is a very important step in motivating the older adult to perform. The development of realistic goals may require an interplay between the health care provider and the older adult so that he or she can fully understand and determine realistic outcomes. For example, a goal of taking 30 cc of fluid every hour may be more realistic than a full 8-oz glass of fluid, and may help motivate the individual to increase intake. Social supports can also be involved in identifying goals. An institutionalized older adult can be motivated to increase oral intake by setting a goal of being able to visit with family members once a certain amount of fluid or food is consumed or a certain weight is achieved. Exploring, with the older adult, his or her beliefs about God and prayer and encouraging traditional rituals and practices can heighten the individual’s spirituality. Religious holidays are a wonderful opportunity to encourage increased intake of the special foods only offered at that time of the year; eggnog at Christmastime, challah (special egg bread) on the Sabbath, and festive cakes and cookies for other holidays should be encouraged.
Case Study and the Wheel of Motivation
Despite a very extensive medical work-up, Mrs. R had no identifiable cause of FTT or weight loss. She was discharged from the hospital to a skilled nursing facility within the CCRC. It was assumed that it would be easier for her to consume a soft diet; thus puréed foods and liquid supplements were ordered. Mrs. R continued to complain of having no appetite and simply could not force herself to eat. She remained in bed and was too weak to actively participate in physical therapy or activities within the facility. Her weight continued to decline and she was anemic and dehydrated. A decision was made to provide “comfort care,” and her family hired a private-duty nursing assistant, DS, to sit with her in the afternoons and early evenings.
The nursing assistant began by encouraging Mrs. R to eat regular foods, exploring and obtaining food preferences, and offering meals in a pleasant setting. At the same time, DS insisted that Mrs. R sit up in a geri-chair each afternoon, and developed a sitting schedule to increase the amount of time Mrs. R was out of bed. The nursing assistant repeatedly tried to encourage Mrs. R to increase her oral intake by bringing in her favorite foods, and initially spoon-feeding those foods to her.
Day after day, DS repeatedly informed Mrs. R that she had to eat and drink to get better, to get stronger, to be able to go to the dining room with her friends, to visit with her family, and maybe even to get back to her own apartment. Sitting with her each evening, DS encouraged Mrs. R to eat her evening meals and take some supplements, and slowly achieve a consistent increase in the amount she could and would eat. Small goals were set, such as taking several cans of a supplemental drink daily, or finishing a reasonable portion of food. DS left notes and instructions for the regular daytime staff to assist them in continuing what she was doing with Mrs. R in the evening. Specifically, she suggested food preferences and a sitting and eating schedule, and she spoke with the nursing staff and Mrs. R’s primary care physician about changing the patient’s diet from puréed foods to solid foods. Since Mrs. R was now getting out of bed and sitting in the geri-chair, DS asked if the physical therapist could reevaluate and work with Mrs. R to regain functional activities such as walking.
Participation in therapy was also a slow process, but progress was made. Initially, the therapist started with Mrs. R standing at the parallel bars. Over an eight-week course of treatment (with physical therapy three times per week), Mrs. R was able to regain her ability to ambulate with a walker. The therapist, much like DS, used gentle verbal encouragement and provided individualized care that addressed Mrs. R’s specific needs. For example, if Mrs. R felt that she was too tired to go to therapy at a certain time of the day, the therapy session was rescheduled so that she could rest.
Mrs. R has gained almost 20 lb, is now able to ambulate independently with a rolling walker through the entire facility, and is independent in all personal care activities. She has resumed going to the main dining room and eating with her friends, and has even restarted some of her volunteer work reading to other residents. While she still reports that she has no appetite, she is able to force herself to eat and continues with supplemental feedings to increase calories. When asked what helped her recover, Mrs. R credited the loving nursing care she received and the help of a Supreme Being.
Conclusion
Understanding weight loss and FTT, and carefully evaluating older adults who present with this syndrome, is an important first step in the treatment process. If any reversible causes of the syndrome are identified, these can be treated. Regardless of the underlying cause of FTT, it is helpful to evaluate the motivation of the older patient and to implement interventions that can encourage them to engage in recovery behaviors such as increasing oral intake. The Wheel of Motivation provides a useful framework to evaluate motivation and identify and direct interventions. In the case study presented, a variety of techniques, including individualized care, social supports, strengthening beliefs through verbal encouragement, setting small and attainable goals, and decreasing unpleasant sensations associated with the desired behavior, all helped to motivate Mrs. R to eat and to increase her activity. Mrs. R was therefore able to return to her prior level of physical function and to improve her overall quality of life.
Acknowledgment
The author would like to thank Mrs. Dora Smith for sharing her expertise as a nursing assistant, and for her wonderful work with older adults.
References
1. Wilson MG, Vaswani S, Liu D, et al. Prevalence and causes of undernutrition in medical outpatients. Am J Med 1998;104:56-63.
2. Fox KM, Hawkes WG, Magaziner J, et al. Markers of failure to thrive among older hip fracture patients. J Am Geriatr Soc 1996; 44(4):371-376.
3. Wallace JI, Schwartz RS, LaCroix AZ, et al. Involuntary weight loss in older outpatients: Incidence and clinical significance. J Am Geriatr Soc 1995;43(4):329-337.
4. Roubenoff R, Harris TB. Failure to thrive, sarcopenia, and functional decline in the elderly. Clin Geriatr Med 1997;13:613-622.
5. Palmer RM. ‘Failure to thrive’ in the elderly: Diagnosis and management. Geriatrics 1990;45(9):47-55.
6. Hildebrand JK, Joos SK, Lee MA. Use of the diagnosis “failure to thrive” in older veterans. J Am Geriatr Soc 1997;45:1113-1117.
7. Resnick B. Functional performance of older adults in a long-term care setting. Clin Nurs Res 1998;7:230-249.
8. Resnick B. Efficacy beliefs in geriatric rehabilitation. J Gerontol Nurs 1998;24(7):34-44.
9. Kemp B. Motivation, rehabilitation and aging: A conceptual model. Topics in Geriatric Rehabilitation 1988;3(3):41-52.
10. Glickstein J. Motivation in geriatric rehabilitation. Focus on Geriatric Care and Rehabilitation 1990;3:1-3.
11. Resnick BM. Geriatric motivation: Clinically helping the elderly to comply. J Gerontol Nurs 1991;17(5):17-20.
12. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: WH Freeman; 1997.
13. Resnick B. Self-Efficacy in Geriatric Rehabilitation [doctoral dissertation]. College Park, MD: University of Maryland; 1996.
14. Resnick B. Motivation in geriatric rehabilitation. Image J Nurs Sch 1996;28(1):41-45.
15. Clark DO. Physical activity and its correlates among urban primary care patients aged 55 years or older. J Gerontol B Psychol Sci Soc Sci 1999;54(1):S41-S48.
16. Borkan J, Quirk M. Expectations and outcomes after hip fracture among the elderly. Int J Aging Hum Dev 1992;34(4):339-350.
17. Rejeski WJ, Craven T, Ettinger WH Jr, et al. Self-efficacy and pain in disability with osteoarthritis of the knee. J Gerontol B Psychol Sci Soc Sci 1996;51(1):P24-P29.
18. Resnick B, Spellbring AM. Understanding what motivates older adults to exercise. J Gerontol Nurs 2000;26:34-42.
19. Happ MB, Williams CC, Strumpf NE, Burger SG. Individualized care for frail elders: Theory and practice . J Gerontol Nurs 1996;22(3):6-14.
20. Chogahara M. A multidimensional scale for assessing positive and negative social influences on physical activity in older adults. J Gerontol B Psychol Sci Soc Sci 1999;54(6):S356-S367.
21. Fleury JD. Empowering potential: A theory of wellness motivation. Nurs Res 1991;40(5):286-291.
22. Duncan TE, McAuley E. Social support and efficacy cognitions in exercise adherence: A latent growth curve analysis. J Behav Med 1993;16(2):199-218.
23. O’Brien-Cousins S. Exercise cognition among elderly women. Journal of Applied Sport Psychology 1996;8:131-145.
24. O’Brien-Cousins S. Elderly tomboys? Sources of self-efficacy for physical activity in late life. Journal of Aging and Physical Activity 1997;5(2):229-243.
25. Haase JE, Britt T, Coward DD, et al. Simultaneous concept analysis of spiritual perspective, hope, acceptance and self-transcendence. Image J Nurs Sch 1992;24(2):141-147.
26. Hicks TJ Jr. Spirituality and the elderly: Nursing implications with nursing home residents. Geriatr Nurs 1999;20(3):144-146.
27. D’Andrade R, Strauss C. Human Motives and Cultural Models. New York, NY: Cambridge University Press; 1994.
28. Marin RS. Differential diagnosis and classification of apathy. Am J Psychiatry 1990;147:22-30.
29. Resnick B. The wheel that moves. Rehabil Nurs 1994;19(4):240-241.
30. Ryan RM, Frederick C. On energy, personality, and health: Subjective vitality as a dynamic reflection of well-being. J Pers 1997;65(3):529-565.
31. Resnick B. Testing the effectiveness of the WALC Program. J Gerontol Nurs. In press.
Annals of Long-Term Care - ISSN: 1524-7929 - Volume 9 - Issue 07 - July 2001 |