Transcript Applying Motivational Interviewing to Geriatric Medicine

The University of New Mexico Health Sciences Center
SCHOOL OF MEDICINE
Applying Motivational Interviewing
to Geriatric Medicine
Keri Bolton Oetzel, Ph.D., MPH
Carla Herman, MD, MPH
Lisa Gibbs, MD
Supported by a grant from the Donald W. Reynolds Foundation
Objectives
• Identify at least three approaches to effective
communication
• Assess a patient’s readiness to change
• Determine how this assessment of readiness to
change can be used clinically to develop
constructive dialogue about behavior change
• Identify case examples in the care of older adults
and/or their caregivers suitable for MI techniques
Definition of MI
• “A person-centered, directive method of
communication for enhancing intrinsic
motivation to change by helping clients
explore and resolve ambivalence.”
Miller & Rollnick (2002)
How is MI Different?
Why Use MI?
• 1st meeting matters!
• MI + Active treatment
• Bigger effect with minority samples than with
Anglo/White samples
• Broadly applicable
• Increases treatment retention
• Increases treatment adherence
Studies of Interest
• MI & Cardiac Care (Watkins et al, 2007)
– n=411
– MI leads to improvement in patient mood 3
months post stroke
• Adherence to Medication (Solomon et al,
2010)
– n=879
– MI leads to improved medication adherence for
people with osteoporosis
Studies of Interest Continued
• Anxiety & Older Adults (Stanley et al, 2009)
– n=134
– CBT with MI resulted in greater improvement in
worry severity, depressive symptoms, and general
mental health
MI in Geriatrics
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Using a walker
Moving into assisted living
Stopping driving
Decreasing drinking
Attending day care
Talking with family members, inviting family
members to engage in a different way
• End-of-life discussions
Spirit of MI
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Develop Discrepancy
Avoid Argumentation
Roll with Resistance
Express Empathy
Support Self-efficacy
Develop Discrepancy
• Awareness of consequences is important
• A discrepancy between present behavior and
important goals will motivate change
• The patient should present the arguments for
change
Avoid Argumentation
• Arguments are counter productive
• Defending breeds defensiveness
• Resistance is a signal to change strategies
Roll with Resistance
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Momentum can be used to good advantage
Perceptions can be shifted
New perspectives are invited but not imposed
The patient is a valuable resource in finding
solutions to problems
Express Empathy
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Acceptance facilitates change
Skillful reflective listening is fundamental
Ambivalence is normal
Respond to a patient’s ambivalence as
understandable, comprehensible, and valid
Support Self-efficacy
• Belief in the possibility of change is an
important motivator
• The patient is responsible for choosing and
carrying out personal change
• There is hope in the range of alternative
approaches available
Helpful Skills
• Using And vs But
• Asking Permission
• Assessing Readiness/Importance/Confidence
And versus But
But…
• I want my dad to be
healthy, but…
• It might be a problem,
but everyone in my
family…
• You’ve made a lot of
changes, but…
And…
• I want my dad to be
healthy and I don’t want
to deprive him
• It might be a problem and
I am confused because
everyone in my family has
diabetes
• You’ve made a lot of
changes, and some things
are more difficult than
others
Advice Giving & Asking Permission
• MI adherent only if you have permission
– Ask permission
– They ask for it
– Give permission to disregard it
Assessing Readiness to Change
• On a scale of 0-10, how ready are you to think
about________?
0
1
2
3
4
5
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7
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10
• Backward question: Why a 5 and not a 3?
• Straight question: Why a 5?
• Forward question: What would it take for you
to move from a 5 to 7?
Future Directions
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Inter-professional Model
Teaching MI/Core Faculty
Using MI in Teams
Curriculum for MI in Geriatrics
SIM Labs