Physio finding: best methods for setting health goals

Older patients with one or more long-term conditions may respond best to multiples strategies, with several different elements, to help them create shared health related goals and priorities with health care professionals, concludes a systematic review of the available evidence. 

 

The researchers carried out the review because of the lack of specific guidance on shared goal setting for patients aged 65+ with several health issues. They looked at studies that compared a multifactorial approach with usual care.

 

They identified eight relevant studies, including five randomised controlled trials, which involved either a single intervention directed specifically at collaborative goal or health priority setting or a multifactorial intervention that included these elements. 

 

• PrefCheck, in which patients and GPs rate the importance of each health issue; 
• Guided Care, comprising self-management, motivational interviewing, and caregiver support; 
• Guided Care Program for Family and Friends, which focuses on enabling and supporting the carer; 
• Helping Older People Experience Success (HOPE), which combines community living, social, and healthy living skills with preventive care coordinated by a nurse; 
• Collaborative Care Model, which emphasises psychological wellbeing; and Integrated Systematic Care for Older People, with an emphasis on GP/nurse-led proactive integrated care. 

One study – a single-factor intervention on 322 patients – had no significant impact on clinician-patient agreement.  Four of the studies (904, 183, 387 and 1921 patients, respectively) involved interventions combining several elements. 

 

These showed statistically significant effects on goal setting, according to the Patient Assessment of Chronic Illness Care (PACIC) goal setting subscale, as well as on the number of advance directives made, or the inclusion of goals in care plans. 

 

These interventions shared in common an explicit focus on a clearly defined goal or priority setting by a healthcare professional and care planning. 

 

But it isn’t clear which mix of components makes the difference, say the researchers, who add that all the studies had some methodological flaws.  Neeltje PC A et al. Collaborative goal setting with elderly patients with chronic disease or multimorbidity: a systematic review.  BMC Geriatrics 2017.  

Collaborative goal-setting has been defined as ‘a process by which healthcare professionals and patients agree on a health-related goal’. [1] However, this concept is still being developed. In setting goals with patients, physiotherapists – as with other clinicians – need to find approaches for what the authors describe as ‘revealing and reconciling their own and their patients’ priorities’. 

 

For older adults with multiple conditions, the authors suggest that disease-specific guidelines may not always be applicable. However, the authors recognise a need for an even better understanding of what is meant by ‘collaborative goal-setting’ and ‘health priority-setting’ interventions. In turn, this could help to inform the development of relevant outcome measures for analysing and evaluating these types of interventions.

 

Bodenheimer T et al. Goal setting for behavior change in primary care: an exploration and status report. Patient Educ Councs 2009; 76(2):174-80.  

 

High intensity resistance and impact training is not usually recommended for postmenopausal women with osteoporosis because of their perceived heightened fracture risk.  But a new study suggests that these fears may be unfounded and that contrary to received wisdom this type of training may actually improve bone density and strength in older women.

 

The researchers base their findings on a clinical trial of 101 women in their mid-60s with low/very low bone density, who were either randomly assigned to 30 minutes twice weekly of supervised high intensity impact exercise for eight months or a programme of home-based low intensity exercises over the same period.

 

Bone mineral density of the lumbar spine and proximal femur were assessed before and after both interventions, as were measures of functional performance. These included the time taken to get up from a chair, functional reach, and back and leg strength.

 

High intensity resistance and impact training was more effective than low intensity exercise:  it improved functional performances, bone density and strength without any side effects.

 

‘Even women with very low bone mass could tolerate the high loading required to increase bone mineral density as long as it was introduced gradually with close attention to technique,’ commented Dr Belinda Beck, lead study author. 

 

‘The simultaneous improvement in functional performance suggests our exercise programme provides dual protection from osteoporotic fracture by also preventing falls,’ she added. Journal of Bone and Mineral Research  2017.