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Barriers to Health Promotion in Community Dwelling Elders Mary Ann Stark a , Carla Chase b & Alice DeYoung a a Bronson School of Nursing, Western Michigan University, Kalamazoo, Michigan b Occupational Therapy Program, Western Michigan University, Kalamazoo, Michigan

Available online: 06 Nov 2010

To cite this article: Mary Ann Stark, Carla Chase & Alice DeYoung (2010): Barriers to Health Promotion in Community Dwelling Elders, Journal of Community Health Nursing, 27:4, 175-186

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Barriers to Health Promotion in Community Dwelling Elders

Mary Ann Stark Bronson School of Nursing, Western Michigan University, Kalamazoo, Michigan

Carla Chase Occupational Therapy Program, Western Michigan University, Kalamazoo, Michigan

Alice DeYoung Bronson School of Nursing, Western Michigan University, Kalamazoo, Michigan

As the number of elders who live in the community increases, promoting their health and independ- ence is a priority of nursing care. As suggested in the Health Promotion Model, barriers can impede the practice of health promotionn. In this descriptive correlational study, community-dwelling elders 65 and older were recruited (N=141) to examine the relationship between attentional demands as mea- sured by the Attentional Demands Survey and health promotion. The results indicate that attentional demands may act as barriers, reducing elders’ ability to engage in health promotion. Community health nurses can focus care toward reducing attentional demands and improving health promotion.

As the baby boom generation (those born between 1941 and 1964) ages, the impact on communi- ties and health care will be significant, as their need for care and services grows and brings “dra- matic changes in health care and in society” (Young & Capezuti, 2010, p. 112). That trend contin- ues as the first of this generation reaches 65 in January 2011, with the number of those 65 and older steadily increasing from 35 million in 2000 to an anticipated peak of 71 million by 2030, with the fastest growing segment being those over 85 years old (Center for Disease Control and Prevention, 2003). Care at the home and community level will become even more important as the healthcare system prepares for this silver tsunami. The benefits of keeping older adults healthy in- clude their continued ability to participate and contribute to the life of the community, as well as spending less on medical costs and long-term care (Young & Capezuti, 2010). In addition, the ob- jectives that have been proposed for Healthy People 2020 reflect the importance of addressing the needs of this generation, particularly in the area of health promotion. Increasing elders’ manage- ment of chronic health conditions, encouraging engagement in leisure-time physical activities, and decreasing the risk of falls are all areas where health promotion may be beneficial (US Dept of Health and Human Services, 2009).

Address correspondence to Dr. Mary Ann Stark, PhD, RNC, Associate Professor, Bronson School of Nursing, Western Michigan University, 1903 W. Michigan Ave, Kalamazoo, MI 49008. E-mail:[email protected]

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When exploring best practices for home and community health promotion, it is important to consider the barriers to acceptance and compliance. Jansen’s (2006) work in attentional demands and its impact on the functional status of community-dwelling elders indicates that those tasks that require additional processing and more focused attention or concentration (higher attentional de- mands) may become more difficult with age and, thus, negatively impact the ability to manage daily activities to their satisfaction. The purpose of this study was to examine the attentional de- mands that might act as barriers to the practice of health promoting behaviors in community dwelling elders (65 and older).

THEORETICAL FRAMEWORK

The Health Promotion Model (HPM), which was developed with consideration of the multidi- mensional nature of persons and the unique environment in which each person functions, was the framework that guided this research (Pender, Murdaugh, & Parsons, 2005). This model considers factors that influence a person’s practice of health promoting behaviors, defined as those activities that attain positive health outcomes, improved health, or improved quality of life (Pender et al., 2005). Physical activity, good nutrition, healthy interpersonal relationships, stress management resources, spiritual growth, and a sense of personal health responsibility are attitudes and behav- iors that promote health (Walker, Sechrist, & Pender, 1987). This model allows for examining fac- tors associated with improved health promotion and allows focusing on personal and environmen- tal factors that influence health promotion (Young & Capezuti, 2010).

In the HPM, individual characteristics (such as age, gender, and self-esteem) and previous behavior are considered, as they are thought to influence whether an individual participates in health-promoting behaviors (Pender et al., 2005). In addition, the HPM suggests that there are behavior-specific cognitions and affect that influence motivation for specific health promoting behaviors. These factors are ones that are often modifiable and subject to nursing intervention. Perceived barriers to action is an- other factor thought to influence health promoting behaviors and amenable to nursing interventions. These barriers to action can be actual or perceived barriers, such as time, inconvenience, difficulty of the behavior, and expenses as well as personal costs (Pender et al., 2005). When barriers are high and readiness to act is low, health promoting behaviors are less likely (Pender et al., 2005).

One potential barrier to health-promoting behaviors may be attentional demands, which are factors that can serve as distractions or competing stimuli to the ability to focus or direct attention. The ability to focus, or pay attention, is important for daily activities, including health promotion, and functioning and may be especially difficult in situations where there are distractions (Jansen, 2006; Stark & Cimprich, 2003). For the elderly, age-related changes and new life circumstances can serve as attentional demands that may act to deter health-promoting behavior. Jansen and Keller (1999) proposed that attentional demands be described within four domains. The first do- main is physical-environmental, and includes external factors such as noise, poor lighting, and weather (Jansen & Keller, 1999). Presence of stairs and poor building design may make navigat- ing the environment difficult, and serve as a barrier to health-promoting activities. The second do- main is informational, and includes factors that make perception and information processing diffi- cult. Hearing and vision changes may make it difficult for a person to interact in some health promotion activities such as attending an exercise class. The third domain is behavioral demands, which are factors that interfere or restrict activities (Jansen & Keller, 1999). A sense of vulnerabil-

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ity or changes in physical mobility may limit health promotion behaviors. Affective demands are emotions, worries, or preoccupations that must be inhibited for daily functioning (Jansen & Keller, 1999). Feelings of loss, loneliness, and worries about health or safety might interfere with health promoting activities. Thus, attentional demands may be barriers (either perceived or actual) to the practice of healthy behaviors for elderly persons. In research with elderly, commu- nity-dwelling women (65 and older), Jansen and Keller (2003) found that women who reported more attentional demands also reported more depressive symptoms and poorer health than women with fewer attentional demands. In a later study of elder men and women, those with fewer attentional demands also reported better health than those with more attentional demands (Jansen, 2006). Although the presence of attentional demands is theoretically related to the practice of health promoting behaviors in the HPM, empirical research supports that attentional demands are related to health (Jansen, 2006; Jansen & Keller, 2003).

The effects of aging and the rate of change with age vary from person to person, however, there are some general changes to be considered when exploring a relationship between attentional de- mands and health promotion. Physically, the body slows in its ability to react to changes in the en- vironment—both in quick responses to a challenge involving balance or movement and in slower responses as when attempting to reach homeostasis following environmental temperature changes (Kail & Cavanaugh, 2010; Ojha, Kem, Lin, & Winstein, 2009; Shumway-Cook & Woollacott, 2000). Cognitive changes can be described similarly in that fluid intelligence, which is the ability to respond quickly to multiple stimuli and to problem-solve, slows down with age. On the other hand, crystallized intelligence, which is stored knowledge gathered over a lifetime, does not de- crease substantially in the absence of disease (Kail & Cavanaugh, 2010). The combination of these normal age-related changes can lead to the need for more focused attention on tasks, espe- cially more complicated ones such as driving. This higher attentional demand can reduce the abil- ity to effectively multitask, can require greater energy expenditure overall, and may lead to a de- crease in participation in some higher-level tasks, including health promoting behaviors. In this way, attentional demands may act as barriers to health promotion.

The relationship between attentional demands and health promotion has not been explored in community dwelling elders. If these barriers are amenable to interventions, elders might be more inclined to practice health promotion. The research questions proposed for this study are: (a) Is there a relationship between attentional demands and health promotion? And (b) Is there a differ- ence between younger (65–74 years old), older (75–84 years old), and oldest (85 and older) elders in their attentional demands?

METHODS

To address the research questions, a descriptive correlational survey design was used. Following institutional review board approval from the university where we teach, a sample of community dwelling elders was recruited from senior centers, churches, and community agencies. Signs were posted in some sites, and a research assistant personally attended some senior groups to invite par- ticipation. Anyone who was interested was given a packet that included a consent document, three research questionnaires, and a postage-paid addressed envelope. If the participant consented to participate, the participant could complete the questionnaires and return them via the postal ser- vice. Data were collected between May and July 2008 in a county in southwest Michigan.

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A sample of elders (65 and older) that lived independently in the community was recruited. Al- though many elders live in the community, their ability to navigate and participate in the commu- nity may be deterred by barriers they encounter. Health promotion is vital to maintaining their in- dependence. Thus, community-dwelling elders were the population of interest. The researchers invited anyone who was age 65 or older and could read, write, and understand English to partici- pate if they were at one of the recruitment sites and lived independently. The final sample included 141 elders, with 46.1% of the sample (n=65) age 65 to 74, 38.3% (n=54) age 74 to 85, and 15.6% (n=22) age 85 and older. The sample was mostly female, White, educated; most were not em- ployed but did volunteer (see Table 1).

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TABLE 1 Description of Sample

n % Mean SD Range

Gender Male 49 34.8 Female 92 65.2

Race Caucasian 139 98.6 African American 1 .7 Latino 1 .7

Marital status Married 84 59.6 Widowed 42 29.8 Never married 4 2.8 Divorced 11 7.8

Residence Apartment 20 14.2 House 121 85.8

Number of others in residence Lives alone 52 31.6 One other person 82 58.2 Two or more 6 4.3

Highest education Grammar school 1 .7 Some high school 7 5.0 Graduated high school 38 27.0 Some college 37 26.2 Graduated college 58 41.1

Employed Employed 12 8.5 Not employed 129 91.5

Volunteer Yes 96 68.1 No 44 31.2

Age 76.1 7.2 65–94 Hr worked per week 20.8 15.9 3.5–50 Hr volunteer per week 5.4 4.2 .25–20 Hr per week in other activities 2.9 2.2 0–15

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Instruments

The two major concepts of interest to this study were health promotion and attentional demands that may serve as barriers to the practice of health promotion. Three research measures were used for this study. The first instrument was the Health Promoting Lifestyles Profile II (HPLP II; Walker, et al., 1987) that was developed to measure the components of a healthy lifestyle (Pender, Murdaugh, & Parsons, 2001). This instrument has demonstrated content, construct, and criterion-related validity (Walker & Hill-Polerecky, 1996). The 52-item tool contains statements regarding behaviors used to promote health to which the respondent is instructed to indicate one of four descriptors (never, some- times, often, and routinely). The mean of all items was calculated for an overall HPLP II score, as di- rected by the HPLP II authors. In addition, six subscales were calculated by finding the mean of the items of that subscale (Walker et al., 1987). The subscales were health responsibility (HR), physical activity (PA), nutrition (NUTR), spiritual growth (SG), interpersonal relations (IPR), and stress management (SM). For all scales, a higher score indicates greater health promotion; possible scores ranged from 1 to 4. When reliability was tested, the HPLPII had test–retest stability after 3 weeks and internal consistency (Walker & Hill-Polerecky, 1996). For this sample, internal consistency, as measured by Cronbach’s alpha for the HPLPII, was .95. The Cronbach’s alpha for the subscales were .83 (HR), .87 (PA), .85 (NUTR), .86 (SG), .82 (IPR), and .76 (SM).

The second instrument used for this study was the Attentional Demands Survey (ADS) that was developed to measure elders’ attentional demands, factors in daily living that require mental effort to negotiate (Jansen & Keller, 1999). If many attentional demands are encountered, the elder is more prone to mental fatigue and ineffective functioning in daily life. The ADS has four do- mains with corresponding scales, physical-environmental (PE), informational (INF), behavioral (BEH), and affective (AF). The 42 item ADS listed demands that elders might encounter and asks that they indicate effort required for this demand on a five point scale (not at all=0; somewhat =2; a lot=4). Items in the individual scales were summed according to instructions; higher scores indi- cated more demands (Jansen & Keller, 1999). In this sample, the total ADS (sum of all items) had a Cronbach’s alpha of .96. Internal consistency computed by Cronbach’s alpha for the individual scales was .90 (PE), .91 (INF), .84 (BEH), and .88 (AF).

The third research instrument was a demographics questionnaire that we developed for the study. Age, gender, employment status, and volunteer work are examples of items included in this tool.

Data Analysis

Data were entered into SPSS 16.0 and cleaned. Descriptive statistics were determined for all vari- ables of interest; scales were computed. Appropriate nonparametric and parametric tests of asso- ciation were run as determined by the research questions. An alpha of .05 was determined a prior.

RESULTS

The first research question asked whether there was a relationship between attentional demands (ADS) and health promotion (HPLPII). There was a moderate negative correlation between HPLPII and the total ADS scale (r= –.48, p=.000). A negative correlation was found between

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HPLPII and each of the four ADS scales (physical-environmental r= –.42, p=.000; informational r= –.47. p=.000; behavioral r= –.39, p=.00; affective r= –.40, p=000). Elders who perceived more attentional demands also had fewer health promoting behaviors.

The second research question asked whether there were differences between three age groups in their perception of attentional demands. Means were calculated for ADS for each age group (see Table 2). To test whether the differences were significant, one-way ANOVA was computed for each of the ADS scales and the total ADS score. There was a significant difference on the total ADS between the 65–74 age group and the 75–84 age group, but no difference between the oldest group (85 and older) and either of the two younger groups (F=3.72, df=2,136, p=.027) when Bonferroni post hoc tests were performed. The 75- to 84-year-olds had the highest attentional de- mands as measured by ADS and the 65- to 74-year-olds had the least. In addition, there were sig- nificant differences in informational (F=4.62, df=2,137, p=.011) and behavioral (F=3.36, df=2, 137, p=.038) scales between these two age groups, similar to that observed on the total ADS (see Table 2). On all ADS scales, the 75- to 84-year-olds had higher means than the younger age group (65–74); the 75- to 84-age-year-old group reported more attentional demands than the younger group (see Table 2). To determine the effect that the increased perception of attentional demands might have on health promotion, the correlation between ADS and HPLPII was determined for each age group (65–74 year olds, r= –.40, p=.001; 75–84 year olds, r= –.56, p=.000; 85 and older, r= –.55, p=.009) showing that attentional demands had a greater effect on the two older groups than the youngest group.

To further explore the attentional demands of the three age groups, the means reported by each group for each of the 42 items of the ADS were calculated and ranked. Items with higher means in- dicated the item created more effort in daily life. The top five items for each group are listed in Table 3. The demands which the sample found least affected their daily functioning are listed in Table 4. Not having enough light and having to move were demands that each age group identified as problematic. Of particular interest is that for all age groups, managing medications required very little effort for this sample of elders.

As attentional demands are thought to be amenable to nursing interventions (Jansen, 2006), re- lationships between demographic attributes of the group and the primary variables of interest in this study were explored. There were no differences in ADS (t=.42, df=137, p=ns) or HPLP II (t=–.42, df=139, p=ns) when marital status was considered (married or currently single, which in- cluded never married, divorced, or widowed). In addition, there was no difference between men and women on ADS (t=.76, df=137, p=ns) or HPLPII (t=–1.42, df=121.72, p=ns). There was a

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TABLE 2 Attentional Demands by Age Groups

Attentional Demands Survey (ADS) Scale

65–74 Age Group (n=65)

75–84 Age Group (n=54)

85 and Older Age Group (n=22)

M SD M SD M SD

Physical-environmental 20.5 10.4 25.1 12.2 26.3 10.7 Informational 10.8 9.1 15.7 10.1 15.5 8.0 Behavioral 5.9 4.9 8.5 6.5 6.6 5.4 Affective 14.3 8.4 17.4 9.9 16.0 9.1 Total ADS 51.8 26.9 66.7 36.1 64.4 28.3

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positive and weak but significant relationship between age and attentional demands (r=.24, p=.005); age was not related to health promotion (r=–.13, p=ns). As the sample was very homoge- nous on race, a relationship between race and attentional demands or health promotion could not be explored. When those who had a high school education or less was compared to those who had attended at least some college (or more), there was a significant difference on both the ADS (t=2.29, df=137, p=.024) and HPLPII (t=–4.21, df=139, p=.000). Those with more education per- ceived fewer attentional demands (M=55.25, SD=28.8) and had more health promoting behaviors (M=2.94, SD=.45) than those with less education (ADS M=68.04, SD=35.2; HPLPII M=2.6, SD=.46). Those who were employed (M=61.6, SD=31.5) had significantly lower ADS scores than

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TABLE 4 Demands That Were Least Difficult by Age Groups

65 to 74 years of age 1. Managing medications 2. Going to the doctor or clinic or special appointment 3. Reading or responding to mail

75 to 84 years of age 1. Managing medications 2. Feeling sad about your present life situation 3. Not enough living space

85 and older 1. Being along or isolated 2. Managing medications 3. Other people do not listen or understand you

TABLE 3 Greatest Attentional Demands Reported by Age Groups

65 to 74 years of age 1. Not enough light 2. Uncomfortable or harsh weather conditions 3. Having to move 4. Missing family or friends who have died or live far away 5. Noise distractions

75 to 84 years of age 1. Uncomfortable or harsh weather conditions 2. Buildings that are hard to find your way around in 3. Not enough light 4. Having to move 5. Missing family or friends who have died or live far away

85 and older 1. Trouble hearing 2. Having to move 3. Bright sunlight and glare 4. Not enough light 5. Noise distractions

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those who were not employed (M=36.6, SD=21.4) (t=2.69, df=137, p=.008) although the number working was small (see Table 1). There was no difference between those who were employed and those who were not on HPLPII. On the other hand, those who volunteered had significantly higher means on HPLPII (M=2.88, SD=.46) than those who did not (M=2.71, SD=.51; t=–2.05, df=138, p=.042). They also had lower ADS (M=56.06, SD=30.86) than those who did not volunteer (M=66.19, SD=32.11; t=1.76, df=136, p=.080).

In summary, attentional demands were negatively and significantly associated with health pro- motion in this sample of community dwelling elders. There were significant differences among age groups with elders 75 to 84 years old reporting significantly more attentional demands than those in the younger group. Older groups reported more attentional demands than the younger group of elders and this was associated with decreased health promotion.

DISCUSSION

The significant negative relationship between attentional demands and health-promoting life- style in elders is consistent with the HPM (Pender et al., 2005). With aging, elders have declin- ing physical, social, and cognitive abilities that can serve as barriers to health promotion activi- ties. On the ADS scale, this sample had higher scores on the total ADS scale than what was reported in studies of other community dwelling elders indicating the presence of more attentional demands (Jansen, 2006; Jansen & Keller, 2003). On only one of the scales (affec- tive), did the current sample have a slightly lower score (15.8) than what Jansen and Keller (2003) reported (15.9).

The HPM suggests that some personal demographic characteristics may influence health pro- motion behaviors. Consistent with what was reported by Jansen (2006), there was no relationship between ADS and marital status. In this study, there was a weak but significant positive correla- tion between the ADS and age, which was not present in Jansen’s research. Elders in our study who worked or volunteered had lower ADS scores than those who did not work or volunteer. Per- ceiving fewer attentional demands may make working and volunteering easier, in addition to en- couraging health promoting behaviors.

A relationship between ADS and health has been reported. In previous studies, more attentional demands were associated with poorer self-reported health and difficulty in daily functioning (Jansen, 2006; Jansen & Keller, 2003). This can be explained by the HPM. As elders encounter attentional demands that serve as barriers to health promoting behaviors, health may be impacted.

Although the sample in this study reported more attentional demands when compared to other samples (Jansen, 2006; Jansen & Keller, 2003), they also reported more health-promoting behav- iors when compared to other samples that included elders (Acton & Malathum, 2000; Callaghan, 2006; Lee, 2009). Age, marital status, and gender were not associated with health promoting be- haviors in this sample of elders, as has been reported in other research (Acton & Malathum, 2000). In another sample that included adults of a large age range (21–79), employed adults had fewer health promoting behaviors than those who were retired (Acton & Malathum, 2000). This was not the case in this study of elders, although those who volunteered reported more health-promoting behaviors than those who did not volunteer. The finding that the elders with more education en- gaged in more health promoting behaviors has been reported elsewhere (Acton & Malathum, 2000).

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Increasing health-promoting behaviors in elders may have many benefits. In a study of elders (60 and older), Armer and Conn (2001) found that physical activity was significantly associated with self-rated health. In a study of men who were 55 and older, Loeb (2004) reported that men who practiced more health-promoting behaviors also reported better health. In addition, health promotion has been linked to spirituality with elders reporting more spirituality also engaging in more health promoting behaviors (Armer & Conn, 2001; Callaghan, 2006).

The findings of our study suggest that interventions to reduce attentional demands may al- low community dwelling elders to increase their health promoting behaviors and potentially im- prove their health. Many nursing interventions to reduce attentional demands in the physi- cal-environmental, informational, behavioral, and affective domains have been proposed (Jansen, 2006). Although the effects of aging may increase attentional demands, this research suggests that the greatest increase in attentional demands occurred in the 75- to 84-year-old group. The subjects who were 85 and older did not see a significant increase in attentional de- mands. That the 85-year-old and older subjects are still living in the community may suggest that they are reasonably healthy and least affected by attentional demands related to aging. El- ders who have many attentional demands may no longer be able to live in the community at this age. Thus, the 65- to 74-year-old age group might be a target group for interventions to reduce elders’ attentional demands.

Many of the items that the elders in this study found most demanding (see Tables 3 & 4) were physical or environmental demands (Jansen & Keller, 1999). The physical environment can be modified proactively to support independence and safety by providing handholds for stability, vi- sual cues for sequencing or better lighting for reading medication information. Lawton (1982), a pioneer in the field of environmental gerontology, explored interactions between older adults and the environment. He created the theoretical framework used to study how the physical environ- ment could act as barriers or as a support to function, recognizing that needs change with age, ill- ness, or injury. Over the years, his work has led to studies that support the effectiveness of environ- mental modifications as an important part of an intervention package that reduces nursing home admissions, reduces falls and fear of falling that leads to inactivity, and supports continued inde- pendence (Beswicket et al., 2008; Gillespie, Gillespie, Robertson, Lamb, Cumming, & Rower, 2003). Even minor changes to the physical environment can increase ease of use and support healthy behaviors in a variety of ways.

Medication adherence is an important health-promotion behavior employed by the elderly, with approximately 74% of community-dwelling elders taking at least one prescription medica- tion (Swanland, Scherk, Metcalf, & Jesek-Hale, 2008). The item managing medications re- quired the least effort for the first two age groups according to the findings in this study. How- ever, McDonald-Miszczak, Neupert, and Gutman (2008) reported that elderly subjects overestimated their adherence with medication, with younger-old adults’ self-reports less accu- rate than those of the older-old adults. Cognitive status, executive function, and working mem- ory have been correlated positively in studies addressing medication adherence in commu- nity-dwelling elderly (Insel, Morrow, Brewer, & Figueredo, 2006; McDonald-Miszczak et al., 2008). In both studies, the elderly subjects were less accurate in managing medications when distractions or busyness occurred between the time they remembered that a medication needed to be taken and when they actually took the medication. Although the elderly adults in this study did not perceive medication management as an attentional demand, their actual adherence is unknown.

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IMPLICATIONS FOR NURSING

The findings of this study help to inform nursing care of community-dwelling elders in several ways. First, nurses working with community-dwelling elders often address health promotion ac- tivities regardless of the current health status of the client. Knowing the domains of attentional de- mands can assist nurses and others involved in caring for community dwelling elders in identify- ing health maintenance and illness/injury prevention needs so as to teach adaptive skills for normal aging and assist in primary prevention. Commitment to a new health behavior requires fo- cused attention and continuous problem-solving. For example, senior centers reach a wide audi- ence and provide health promotion education, screening, and interventions through a variety of programs. By focusing on attentional demands that may deter health promoting behaviors, elders may find health promoting behaviors to be achievable. In addition, teaching elders how to reduce attentional demands may improve daily functioning in other areas (Jansen, 2006).

This research also informs care for secondary prevention, or early diagnosis and treatment of illness, as elders who encounter high attentional demands may experience more barriers to health promotion. For example, elderly persons with a new diagnosis of congestive heart failure must ad- dress a number of changes simultaneously to manage their illness. New medications need to be learned and a strategy to take them accurately must be planned. Diet restrictions require altering grocery shopping habits, as well as eating habits, with new recipes needing to be learned. Being aware of, and interpreting the meaning of, physical changes requires attention as well.

In tertiary prevention, or recovery and rehabilitation, nurses can focus on interventions to re- duce attentional demands for clients after an injury or illness so as to facilitate recovery and inde- pendence. Nurses may find that an assessment tool such as the ADS may help in identifying el- derly clients at greater risk for problems in managing a complex chronic illness. Adaptations to the environment, assistive technology, or new techniques may provide support for these necessary and important changes. Other home care team members, such as occupational therapists, can as- sess, recommend, and train in the use of these techniques to support nursing goals. An example of this would be when someone who is diabetic has a stroke with residual weakness on one side of the body. New methods for monitoring blood sugar levels, for storing and opening medications or pre- paring healthy foods may be necessary to manage medical issues appropriately with this new physical challenge in order to support health promotion.

Second, the findings of this study suggest that although the ADS has been used as a research tool (Jansen & Keller, 1999), adapting it for clinical assessments may be beneficial. Health care providers who are aware of high attentional demands can more easily identify supportive services to help clients maintain independence and health-promotion behaviors. Routinely monitoring attentional demands, such as during annual exams or screenings, changes in magnitude or do- mains of demands can indicate need for further evaluation and for interventions to reduce attentional demands (Jansen, 2006). For example, home care and hospice staff can assess the attentional demands of elderly caregivers that may interfere with learning about new medications, physical or occupational therapy exercises, or symptom management. Supportive interventions can be introduced to increase the likelihood of success. Primary health care providers could use an assessment of attentional demands during annual physicals to monitor the client’s ability to man- age attentional demands. High scores in a particular domain or scores increasing over time may in- dicate that the client needs supportive services or transition to assisted living. Adaptation and test- ing of the ADS as a clinical assessment is needed.

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In this study, the 75- to 84-year-old age group had the most significant increase in attentional demands. They also reported the strongest relationship between ADS and health promotion, sug- gesting that this group encounters more barriers that interfere with their ability to continue activi- ties that promote health. The findings of this study suggest that community health nurses or other care providers should consider targetingyounger elders with interventions to reduce attentional demands so that they might have tools and strategies in place before the demands become over- whelming. Reducing barriers such as attentional demands may empower elders to engage in health promotion that will better support them living in and contributing to the community.

There are some limitations of the study that must be considered. First, the sample was very ho- mogeneous and highly educated. This suggests that they have resources not available to many el- ders. Second, this was a survey and has all the limitations of survey research; who actually com- pleted the survey is not known. Third, the health status and diseases of the individuals in this sample is unknown. Their attentional demands and health promotion may be related to their cur- rent health status, rather than attentional demands. Last, that attentional demands serve as barriers was an application of the HPM; the research design does not allow for attribution of causation.

In summary, elders experience some changes during aging that affect attention. The results of this study suggest that these attentional demands can affect their health promotion. Nurses and other health care providers who care for community-dwelling elders can help the elders, their fam- ilies, and the communities in which they live to take measures to reduce demands (Jansen, 2006). In doing so, nurses have an opportunity to impact elders’ ability to engage in health promoting activities.

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