title: Older Patients' Perspectives on Managing Complexity in CKD Self-Management.
abstract: OBJECTIVE
  Patients with CKD are asked to perform self-management tasks including dietary changes, adhering to medications, avoiding nephrotoxic drugs, and self-monitoring hypertension and diabetes. Given the effect of aging on functional capacity, self-management may be especially challenging for older patients. However, little is known about the specific challenges older adults face maintaining CKD self-management regimens.
  
  
  METHODS
  We conducted an exploratory qualitative study designed to understand the relationship among factors facilitating or impeding CKD self-management in older adults. Six focus groups (n=30) were held in August and September of 2014 with veterans≥70 years old with moderate-to-severe CKD receiving nephrology care at the Atlanta Veterans Affairs Medical Center. Grounded theory with a constant comparative method was used to collect, code, and analyze data.
  
  
  RESULTS
  Participants had a mean age (range) of 75.1 (70.1-90.7) years, 60% were black, and 96.7% were men. The central organizing concept that emerged from these data were managing complexity. Participants typically did not have just one chronic condition, CKD, but a number of commonly co-occurring conditions. Recommendations for CKD self-management therefore occurred within a complex regimen of recommendations for managing other diseases. Participants identified overtly discordant treatment recommendations across chronic conditions (e.g.,arthritis and CKD). Prioritization emerged as one effective strategy for managing complexity (e.g., focusing on BP control). Some patients arrived at the conclusion that they could group concordant recommendations to simplify their regimens (e.g., protein restriction for both gout and CKD).
  
  
  CONCLUSIONS
  Among older veterans with moderate-to-severe CKD, multimorbidity presents a major challenge for CKD self-management. Because virtually all older adults with CKD have multimorbidity, an integrated treatment approach that supports self-management across commonly occurring conditions may be necessary to meet the needs of these patients.
authors.affiliation: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs, Atlanta Veterans Affairs, Medical Center, Decatur, Georgia; and.|Departments of Medicine and.
authors.forename: C Barrett
authors.initials: CB
authors.lastname: Bowling
authors.affiliation: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs, Atlanta Veterans Affairs, Medical Center, Decatur, Georgia; and.|Departments of Medicine and.
authors.forename: Ann E
authors.initials: AE
authors.lastname: Vandenberg
authors.affiliation: Departments of Medicine and.
authors.forename: Lawrence S
authors.initials: LS
authors.lastname: Phillips
authors.affiliation: Epidemiology, Emory University, Atlanta, Georgia.
authors.forename: William M
authors.initials: WM
authors.lastname: McClellan
authors.affiliation: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs, Atlanta Veterans Affairs, Medical Center, Decatur, Georgia; and.|Departments of Medicine and.
authors.forename: Theodore M
authors.initials: TM
authors.lastname: Johnson
authors.affiliation: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs, Atlanta Veterans Affairs, Medical Center, Decatur, Georgia; and.|Departments of Medicine and.
authors.forename: Katharina V
authors.initials: KV
authors.lastname: Echt
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D057226:Information Seeking Behavior; D007389:Internal-External Control; D008297:Male; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000523:psychology* / Q000628:therapy*; D012648:Self Care; D012720:Severity of Illness Index; D058992:Social Participation; D012944:Social Support
keywords: African Americans; adult; blood pressure; chronic kidney disease; comorbidity; diabetes mellitus; focus groups; geriatric nephrology; gout; grounded theory; humans; hypertension; male; nephrology; qualitative research; renal insufficiency, chronic; self care; self-management; veterans