- Email: [email protected]
GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist Proficiency Statement 5
Geriatric Nursing xx (2016) 1e3
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
GAPNA Section
GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist Proficiency Statement 5 Laurie Kennedy-Malone, PhD, GNP-BC, FAANP, FGSA School of Nursing, University of North Carolina at Greensboro, United States
APRN Gerontological Specialist Proficiency Statement 5 The APRN Gerontological Specialist caring for complex older adults applies a system-based approach to assess, design, implement and evaluate effective educational strategies to optimize health-related outcomes. Critical to designing effective informed patient self-care management strategies for older adults, the APRN Gerontological Specialist (APRN-GS) first needs to be highly cognizant of the impact of normal aging on presenting multimorbidity and then the patient’s ability to learn how to safely manage his acute and chronic illness.1,2 Compounding the determination of readiness for self-care management is the need for the clinician to be aware of the patient’s health literacy level, social support status, functional and cognitive ability and financial resources to include type of insurance coverage.1,3,4 An individualized approach that includes disease-specific information along with strategies to enhance the patient’s activities of daily living and quality of life has proven to be effective with older adults.3 For older males as is the case described below, studies have shown that providing the male patient with a practical, action-oriented approach to integrating self-care management into their daily routine are more readily accepted than those that do not design interventions with these strategies in mind.5 Consider the case of an older male who is struggling with managing a new chronic disease. Case 5 Chief complaint, history of present illness and review of systems, past medical history Mr. P is a 79 year old Caucasian male accompanied by his wife of 55 years who presents to the Personalized Geriatric Care Clinic for medication review and disease state management. He has a history
E-mail address: [email protected]. 0197-4572/$ e see front matter http://dx.doi.org/10.1016/j.gerinurse.2016.08.011
of atrial fibrillation, gastroesophageal reflux disease, diabetes, and sleep apnea. He informs his nurse practitioner, an APRN-GS, who he is seeing for the first time that he was referred to the clinic by his primary care physician. He has been recently diagnosed with polymyalgia rheumatica (PMR) after an extensive work-up. His presenting symptoms were fatigue, muscle aches and decrease in appetite. Mr. P. related that at first he attributed the symptoms to old age, but with his wife’s insistence he sought medical attention. He was found to have an elevated sedimentation rate and a C-reactive protein level. He was started on prednisone 40 mg once a day. After eight weeks of treatment, he was tapered down to 20 mg a day. He reports that his symptoms did not initially abate following the prednisone regimen and he was very hesitant to continue with the medication. He reports weight gain, increased difficulty sleeping, and was also recently diagnosed with a urinary tract infection (UTI) and is currently being treated with cefdinir. His wife reports that his International Normalized Ratio (INR) level has been out of his therapeutic range the last two times it has been checked. He reports that he is not taking any over-the-counter medications. Mr. R is seeking information on the potential interactions of all his medications and how to enhance his self-care management strategies now that he has been diagnosed PMR, a new chronic condition. Constitutional: He denies having a fever either before diagnosed with PMR or prior to treatment for the UTI. He states his appetite is decreased although he has gained 10 lbs. since he was started on the prednisone which he believes is related to water retention. He relates feeling discouraged and having difficulty coping with his newly diagnosed medical conditions, however, denies any feeling of depression. HEENT & Skin: Denies any headaches or scalp pain. Reports no alteration in vision and states he sees an ophthalmologist once a year. With regards to hearing, he states that he feels his hearing is getting worse but refuses to wear a hearing aid. He states that he has at least two episodes of epistaxis a day that resolve in less than 5 min. He denies sore throat, no difficulty in chewing or swallowing. He relates that small areas of ecchymosis have appeared on his lower forearms since he has been on the
2
GAPNA Section / Geriatric Nursing xx (2016) 1e3
prednisone. Heart &Chest: He denies any chest pain, palpitations or coughing. He does have dyspnea on exertion and when orthopneic. He believes the dyspnea has increased with his recent weight gain. He does use a CPAP machine at night to sleep and keeps the head of his bed elevated. Abdomen: Denies nausea, vomiting or diarrhea. Reports that he has normal bowel movements, denies melena and hematochezia. Genitourinary: Reports that urinary frequency and urgency has decreased since he was prescribed an additional week of antibiotics for the UTI. Musculoskeletal/Neurological: Reports mild generalized musculoskeletal pain, denies any specific periarticular or joint pain or swelling. He denies any paresthesias, tremors, or abnormal movements or recent falls. Endocrine/Hematological: Reports elevations in his blood sugars with home glucose monitoring since he has started on prednisone, denies any additional bleeding besides the epistaxis and relates bruising on lower forearms to local trauma. Family and social history Mr. P. has a 12th grade high school education and retired from working in the produce section of local supermarket 15 years ago. He still drives, occasionally plays golf and enjoys reading. He had a 15 year history of two packs a day of cigarette smoking, but was able to quit without any medical intervention. He reports however that he did gain weight following smoking cessation but has weighted around 180 lbs. for the past 15 years. He reports occasional drinking of beer or wine. He states that he does try to walk 1e2 miles a day, but recently has been too fatigued to walk. He and his wife have two married children whom live within a 20 mile radius of their parents. Mr. P. lives in a continuing care retirement community. His father died at age 75 from complications from diabetes mellitus and his mother died at age 84 from heart failure. Physical examination Mr. P appears to be well nourished and is alert and oriented. His vital signs were: BP ¼ 122/78 mmHg (standing); Pulse ¼ 76 beats per minute; Temperature, 98.6 F orally; Respirations ¼ 18 breaths per minute; Weight ¼ 190 pounds; Height 70 inches. Visual acuity 20/30 bilaterally with corrective lenses. HEENT: Normocephalic, Hair sparse, PERRLA, soft cerumen noted bilaterally, canal not impacted. Nose: No apparent petechiae, small area of dried clotted scab noted. Pharynx and oral cavity without erythema, or exudates. Dentures well fitting, Mucus membranes moist. Neck supple without lymphadenopathy, ROM limited. Thyroid non-palpable. Skin: Noted areas of ecchymosis on lower forearms, skin warm to touch. Chest: Clear to auscultation at bases, Heart and Peripheral Vascular: Heart rate irregular, þ1 peripheral edema, Distal pulses þ2 bilaterally. Abdomen: Bowl sounds in all four quadrants, non-tender, non-distended, no masses or hepatosplenomegaly, no abdominal bruits. Rectal/Genitourinary: FOB negative. Musculoskeletal: No joint nodularity, no erythema or swelling or tenderness upon palpation of hands, wrists, elbows, hips, knees, ankles or metatarsals, mild tenderness elicited on shoulder girdle when palpated, no erythema noted. Neurological: Cranial Nerve IeXII intact. All deep tendon reflexes þ3, Strength on upper and lower extremities both distal and proximal 4þ/5. Comprehensive approach to patient education and self-care management In the case of Mr. P., it became apparent early in the assessment phase, that he was interested first in learning more about
how to manage PMR over a long duration of time and seeks information on the impact of long term corticosteroids on his other chronic conditions (GERD, diabetes), interactions with his other medications, and the potential for side effects to include various types of infections, cataracts, osteoporosis and gastrointestinal bleeding6,7 The APRN-GS discussed the anti-inflammatory condition with him. She provided Mr. P and his wife written information about PMR and the side effects of long-term corticosteroid use. She had Mr. P. describe in his own words his perception of PMR and the effect on his other comorbidities. He also acknowledged now knowing more about the interactions between corticosteroids and his other medications such as warfarin and metformin. He is concerned about the side effects of long-term corticosteroids, but feels better equipped to recognize underlying complications from prednisone. By using the “Tell-Back-Collaborative Inquiry” method, the APRN-GS affirmed the patient’s current knowledge of the treatment for his condition and corroborates the importance of remaining on his medications despite resolution of his clinical symptoms.8 Mr. P. and his wife now realize that PMR is an inflammatory process that often requires long term corticosteroid use and awareness of new symptoms resulting from corticosteroid use need to be reported to his primary care provider at the time of onset to prevent further complications. While Mr. P has been on anticoagulation treatment with warfarin for atrial fibrillation for over 10 years, he historically had stable INR levels. In reviewing Mr. P.’s INR levels, the APRN-GS noted the elevation beyond his therapeutic range of 2e3 and that his dose has needed more frequent adjustment following the diagnosis of PMR. She explained to Mr. P and his wife the reasons for the recent variance in the INR level. Elevations in INR levels for this patient could be attributed to being prescribed prednisone, he recently was placed on omeprazole for GERD, an extended regimen of cefdinir for the UTI, self-treating with cranberry juice during early symptoms of the UTI and his overall decrease in appetite. They both were concerned about the patient’s frequent nosebleeds. The APRN-GS offered to contact Mr. P.’s primary physician about the persistent nosebleeds and recommend a referral to an otolaryngologist. Both Mr. P and his wife voiced concerns about the unstableness of the INR level because of the potential harmful effects of being out of therapeutic range At this time the APRN-GS felt is important to review warfarin management with the couple to ease their concerns. A recent study found that patients on anticoagulant medications who actively engaged in behaviors targeted to maintain their therapeutic INR range had their apprehensions of being on a medication they deemed harmful, alleviated.9 Mrs. P. was interested in obtaining an updated list of foods that contain Vitamin K that she could include in Mr. P’s diet as he had been instructed by his primary care physician who monitors his INR levels to increase foods that contain Vitamin K. Mrs. P admits that had not strictly followed the dietary recommendations prior to this visit due her concerns about his poor appetite, but now has a better understanding of the rationale for this [nonpharmacological] approach. Mr. P. reported that he appreciated learning about the interrelatedness of his conditions and the accompanying treatments. He has agreed to try resuming his previous walking regimen, increasing his tolerance gradually. Mr. P noted the importance of also ‘adding in’ time-limited rest periods to elevate his lower extremities (if swelling was noted). Part of his daily activity will be timed built in to rest with his feet elevated when noted lower extremity edema. Along with assistance from his wife, he will be more selective of the foods that he eats and strive for a more
GAPNA Section / Geriatric Nursing xx (2016) 1e3
well-balanced diet. He has agreed that maybe smaller more frequent meals may be easier to tolerate while his appetite is decreased. He made an appointment for a subsequent visit with the APRNGS to discuss his diabetes management in light of long-term corticosteroid use and also potential ways to for him to avoid infections and other complications. Bratzke and colleagues found that it is common for older adults to want to prioritize one chronic condition to self-manage and then adjust management of conditions over time as treatments are changed or discontinued.9 The APRN-GS will be able to evaluate the effectiveness of the tailored approach to patient self-care management at a follow-up appointment before engaging the patient in further management of care. Summary Successful patient self-care management for an older patient with multimorbidities will depend on a skilled clinician using a comprehensive approach that relies on multi-faceted teaching strategies. It is imperative for the APRN-GS to assess the patient’s willingness to engage in his/her care, provide both written instructions and verbal coaching, and recognize that the patient may choose to prioritize one condition at a time (until a sense of mastery and/or health outcomes are achieved). Tailoring self-care management educational sessions with patients employing evidencebased strategies will aid in the patient’s ability to cope with their illness as well as optimize overall well-being.
3
References 1. Gerontological Advanced Practice Nurses Association (GAPNA). GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist. Pittman, NJ: Author; 2015. 2. Van het Bolscher-Niehuis M, den, Ouden M, de Vocht H, Francke A. Effects of self-management support programmes on activities of daily living of older adults: a systematic review. Int J Nurs Stud. 2016;6:230e247. 3. Vernooij RWM, Willson M, Gagliardi AR, The members of the Guidelines International Network Implementation Working Group. Characterizing patientoriented tools that could be packaged with guidelines to promote selfmanagement and guideline adoption: a meta-review. Implement Sci. 2015;11: 52. http://dx.doi.org/10.1186/s13012-016-0419-1. 4. Marcus C. Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Health Psych Behav Med. 2014;2(1):482e495. http://dx.doi.org/10.1080/ 21642850.2014.900450. 5. Galdas P, Darwin Z, Fell J, et al. A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable selfmanagement support interventions are for men with long-term conditions (SELF-MAN). Southampton (UK) NIHR J Libr; http://dx.doi.org/10.3310/hsdr03340 (Health Services and Delivery Research, No. 3.34.) Available from: http://www. ncbi.nlm.nih.gov/books/NBK311083/; 2015 Aug. 6. Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia rheumatica and giant cell arteritis: a systematic review. JAMA. 2016;315(22):2442e2458. http:// dx.doi.org/10.1001/jama.2016.5444. 7. Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013;9:30. 8. Kemp EC, Floyd MR, McCord-Duncan E, Lang F. Patients prefer the method of “tell back-collaborative inquiry” to assess understanding of medical information. J ABFM. 2008;21(1):24e30. 9. Bratzke LC, Muehrer RJ, Kehl KA, Lee KS, Ward EC, Kwekkeboom KL. Selfmanagement priority setting and decision-making in adults with multimorbidity: a narrative review of literature. Int J Nurs Stud. 2016;52(3): 744e755.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
GAPNA Section
GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist Proficiency Statement 5 Laurie Kennedy-Malone, PhD, GNP-BC, FAANP, FGSA School of Nursing, University of North Carolina at Greensboro, United States
APRN Gerontological Specialist Proficiency Statement 5 The APRN Gerontological Specialist caring for complex older adults applies a system-based approach to assess, design, implement and evaluate effective educational strategies to optimize health-related outcomes. Critical to designing effective informed patient self-care management strategies for older adults, the APRN Gerontological Specialist (APRN-GS) first needs to be highly cognizant of the impact of normal aging on presenting multimorbidity and then the patient’s ability to learn how to safely manage his acute and chronic illness.1,2 Compounding the determination of readiness for self-care management is the need for the clinician to be aware of the patient’s health literacy level, social support status, functional and cognitive ability and financial resources to include type of insurance coverage.1,3,4 An individualized approach that includes disease-specific information along with strategies to enhance the patient’s activities of daily living and quality of life has proven to be effective with older adults.3 For older males as is the case described below, studies have shown that providing the male patient with a practical, action-oriented approach to integrating self-care management into their daily routine are more readily accepted than those that do not design interventions with these strategies in mind.5 Consider the case of an older male who is struggling with managing a new chronic disease. Case 5 Chief complaint, history of present illness and review of systems, past medical history Mr. P is a 79 year old Caucasian male accompanied by his wife of 55 years who presents to the Personalized Geriatric Care Clinic for medication review and disease state management. He has a history
E-mail address: [email protected]. 0197-4572/$ e see front matter http://dx.doi.org/10.1016/j.gerinurse.2016.08.011
of atrial fibrillation, gastroesophageal reflux disease, diabetes, and sleep apnea. He informs his nurse practitioner, an APRN-GS, who he is seeing for the first time that he was referred to the clinic by his primary care physician. He has been recently diagnosed with polymyalgia rheumatica (PMR) after an extensive work-up. His presenting symptoms were fatigue, muscle aches and decrease in appetite. Mr. P. related that at first he attributed the symptoms to old age, but with his wife’s insistence he sought medical attention. He was found to have an elevated sedimentation rate and a C-reactive protein level. He was started on prednisone 40 mg once a day. After eight weeks of treatment, he was tapered down to 20 mg a day. He reports that his symptoms did not initially abate following the prednisone regimen and he was very hesitant to continue with the medication. He reports weight gain, increased difficulty sleeping, and was also recently diagnosed with a urinary tract infection (UTI) and is currently being treated with cefdinir. His wife reports that his International Normalized Ratio (INR) level has been out of his therapeutic range the last two times it has been checked. He reports that he is not taking any over-the-counter medications. Mr. R is seeking information on the potential interactions of all his medications and how to enhance his self-care management strategies now that he has been diagnosed PMR, a new chronic condition. Constitutional: He denies having a fever either before diagnosed with PMR or prior to treatment for the UTI. He states his appetite is decreased although he has gained 10 lbs. since he was started on the prednisone which he believes is related to water retention. He relates feeling discouraged and having difficulty coping with his newly diagnosed medical conditions, however, denies any feeling of depression. HEENT & Skin: Denies any headaches or scalp pain. Reports no alteration in vision and states he sees an ophthalmologist once a year. With regards to hearing, he states that he feels his hearing is getting worse but refuses to wear a hearing aid. He states that he has at least two episodes of epistaxis a day that resolve in less than 5 min. He denies sore throat, no difficulty in chewing or swallowing. He relates that small areas of ecchymosis have appeared on his lower forearms since he has been on the
2
GAPNA Section / Geriatric Nursing xx (2016) 1e3
prednisone. Heart &Chest: He denies any chest pain, palpitations or coughing. He does have dyspnea on exertion and when orthopneic. He believes the dyspnea has increased with his recent weight gain. He does use a CPAP machine at night to sleep and keeps the head of his bed elevated. Abdomen: Denies nausea, vomiting or diarrhea. Reports that he has normal bowel movements, denies melena and hematochezia. Genitourinary: Reports that urinary frequency and urgency has decreased since he was prescribed an additional week of antibiotics for the UTI. Musculoskeletal/Neurological: Reports mild generalized musculoskeletal pain, denies any specific periarticular or joint pain or swelling. He denies any paresthesias, tremors, or abnormal movements or recent falls. Endocrine/Hematological: Reports elevations in his blood sugars with home glucose monitoring since he has started on prednisone, denies any additional bleeding besides the epistaxis and relates bruising on lower forearms to local trauma. Family and social history Mr. P. has a 12th grade high school education and retired from working in the produce section of local supermarket 15 years ago. He still drives, occasionally plays golf and enjoys reading. He had a 15 year history of two packs a day of cigarette smoking, but was able to quit without any medical intervention. He reports however that he did gain weight following smoking cessation but has weighted around 180 lbs. for the past 15 years. He reports occasional drinking of beer or wine. He states that he does try to walk 1e2 miles a day, but recently has been too fatigued to walk. He and his wife have two married children whom live within a 20 mile radius of their parents. Mr. P. lives in a continuing care retirement community. His father died at age 75 from complications from diabetes mellitus and his mother died at age 84 from heart failure. Physical examination Mr. P appears to be well nourished and is alert and oriented. His vital signs were: BP ¼ 122/78 mmHg (standing); Pulse ¼ 76 beats per minute; Temperature, 98.6 F orally; Respirations ¼ 18 breaths per minute; Weight ¼ 190 pounds; Height 70 inches. Visual acuity 20/30 bilaterally with corrective lenses. HEENT: Normocephalic, Hair sparse, PERRLA, soft cerumen noted bilaterally, canal not impacted. Nose: No apparent petechiae, small area of dried clotted scab noted. Pharynx and oral cavity without erythema, or exudates. Dentures well fitting, Mucus membranes moist. Neck supple without lymphadenopathy, ROM limited. Thyroid non-palpable. Skin: Noted areas of ecchymosis on lower forearms, skin warm to touch. Chest: Clear to auscultation at bases, Heart and Peripheral Vascular: Heart rate irregular, þ1 peripheral edema, Distal pulses þ2 bilaterally. Abdomen: Bowl sounds in all four quadrants, non-tender, non-distended, no masses or hepatosplenomegaly, no abdominal bruits. Rectal/Genitourinary: FOB negative. Musculoskeletal: No joint nodularity, no erythema or swelling or tenderness upon palpation of hands, wrists, elbows, hips, knees, ankles or metatarsals, mild tenderness elicited on shoulder girdle when palpated, no erythema noted. Neurological: Cranial Nerve IeXII intact. All deep tendon reflexes þ3, Strength on upper and lower extremities both distal and proximal 4þ/5. Comprehensive approach to patient education and self-care management In the case of Mr. P., it became apparent early in the assessment phase, that he was interested first in learning more about
how to manage PMR over a long duration of time and seeks information on the impact of long term corticosteroids on his other chronic conditions (GERD, diabetes), interactions with his other medications, and the potential for side effects to include various types of infections, cataracts, osteoporosis and gastrointestinal bleeding6,7 The APRN-GS discussed the anti-inflammatory condition with him. She provided Mr. P and his wife written information about PMR and the side effects of long-term corticosteroid use. She had Mr. P. describe in his own words his perception of PMR and the effect on his other comorbidities. He also acknowledged now knowing more about the interactions between corticosteroids and his other medications such as warfarin and metformin. He is concerned about the side effects of long-term corticosteroids, but feels better equipped to recognize underlying complications from prednisone. By using the “Tell-Back-Collaborative Inquiry” method, the APRN-GS affirmed the patient’s current knowledge of the treatment for his condition and corroborates the importance of remaining on his medications despite resolution of his clinical symptoms.8 Mr. P. and his wife now realize that PMR is an inflammatory process that often requires long term corticosteroid use and awareness of new symptoms resulting from corticosteroid use need to be reported to his primary care provider at the time of onset to prevent further complications. While Mr. P has been on anticoagulation treatment with warfarin for atrial fibrillation for over 10 years, he historically had stable INR levels. In reviewing Mr. P.’s INR levels, the APRN-GS noted the elevation beyond his therapeutic range of 2e3 and that his dose has needed more frequent adjustment following the diagnosis of PMR. She explained to Mr. P and his wife the reasons for the recent variance in the INR level. Elevations in INR levels for this patient could be attributed to being prescribed prednisone, he recently was placed on omeprazole for GERD, an extended regimen of cefdinir for the UTI, self-treating with cranberry juice during early symptoms of the UTI and his overall decrease in appetite. They both were concerned about the patient’s frequent nosebleeds. The APRN-GS offered to contact Mr. P.’s primary physician about the persistent nosebleeds and recommend a referral to an otolaryngologist. Both Mr. P and his wife voiced concerns about the unstableness of the INR level because of the potential harmful effects of being out of therapeutic range At this time the APRN-GS felt is important to review warfarin management with the couple to ease their concerns. A recent study found that patients on anticoagulant medications who actively engaged in behaviors targeted to maintain their therapeutic INR range had their apprehensions of being on a medication they deemed harmful, alleviated.9 Mrs. P. was interested in obtaining an updated list of foods that contain Vitamin K that she could include in Mr. P’s diet as he had been instructed by his primary care physician who monitors his INR levels to increase foods that contain Vitamin K. Mrs. P admits that had not strictly followed the dietary recommendations prior to this visit due her concerns about his poor appetite, but now has a better understanding of the rationale for this [nonpharmacological] approach. Mr. P. reported that he appreciated learning about the interrelatedness of his conditions and the accompanying treatments. He has agreed to try resuming his previous walking regimen, increasing his tolerance gradually. Mr. P noted the importance of also ‘adding in’ time-limited rest periods to elevate his lower extremities (if swelling was noted). Part of his daily activity will be timed built in to rest with his feet elevated when noted lower extremity edema. Along with assistance from his wife, he will be more selective of the foods that he eats and strive for a more
GAPNA Section / Geriatric Nursing xx (2016) 1e3
well-balanced diet. He has agreed that maybe smaller more frequent meals may be easier to tolerate while his appetite is decreased. He made an appointment for a subsequent visit with the APRNGS to discuss his diabetes management in light of long-term corticosteroid use and also potential ways to for him to avoid infections and other complications. Bratzke and colleagues found that it is common for older adults to want to prioritize one chronic condition to self-manage and then adjust management of conditions over time as treatments are changed or discontinued.9 The APRN-GS will be able to evaluate the effectiveness of the tailored approach to patient self-care management at a follow-up appointment before engaging the patient in further management of care. Summary Successful patient self-care management for an older patient with multimorbidities will depend on a skilled clinician using a comprehensive approach that relies on multi-faceted teaching strategies. It is imperative for the APRN-GS to assess the patient’s willingness to engage in his/her care, provide both written instructions and verbal coaching, and recognize that the patient may choose to prioritize one condition at a time (until a sense of mastery and/or health outcomes are achieved). Tailoring self-care management educational sessions with patients employing evidencebased strategies will aid in the patient’s ability to cope with their illness as well as optimize overall well-being.
3
References 1. Gerontological Advanced Practice Nurses Association (GAPNA). GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist. Pittman, NJ: Author; 2015. 2. Van het Bolscher-Niehuis M, den, Ouden M, de Vocht H, Francke A. Effects of self-management support programmes on activities of daily living of older adults: a systematic review. Int J Nurs Stud. 2016;6:230e247. 3. Vernooij RWM, Willson M, Gagliardi AR, The members of the Guidelines International Network Implementation Working Group. Characterizing patientoriented tools that could be packaged with guidelines to promote selfmanagement and guideline adoption: a meta-review. Implement Sci. 2015;11: 52. http://dx.doi.org/10.1186/s13012-016-0419-1. 4. Marcus C. Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Health Psych Behav Med. 2014;2(1):482e495. http://dx.doi.org/10.1080/ 21642850.2014.900450. 5. Galdas P, Darwin Z, Fell J, et al. A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable selfmanagement support interventions are for men with long-term conditions (SELF-MAN). Southampton (UK) NIHR J Libr; http://dx.doi.org/10.3310/hsdr03340 (Health Services and Delivery Research, No. 3.34.) Available from: http://www. ncbi.nlm.nih.gov/books/NBK311083/; 2015 Aug. 6. Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia rheumatica and giant cell arteritis: a systematic review. JAMA. 2016;315(22):2442e2458. http:// dx.doi.org/10.1001/jama.2016.5444. 7. Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013;9:30. 8. Kemp EC, Floyd MR, McCord-Duncan E, Lang F. Patients prefer the method of “tell back-collaborative inquiry” to assess understanding of medical information. J ABFM. 2008;21(1):24e30. 9. Bratzke LC, Muehrer RJ, Kehl KA, Lee KS, Ward EC, Kwekkeboom KL. Selfmanagement priority setting and decision-making in adults with multimorbidity: a narrative review of literature. Int J Nurs Stud. 2016;52(3): 744e755.