Older Women with Cardiovascular Disease: Perceptions of Initial Experiences and Long-Term Influences on Daily Life

ABSTRACT

In 2004, we conducted qualitative interviews with 29 White women diagnosed with cardiovascular disease (CVD) living in Southwest Virginia, aged 69 to 92 years (M age = 79.2 years; SD = 6.8); time since diagnosis ranged from 1 to 50 years (M = 14.3; SD = 11.2). We explored the women's initial illness episode and the influence of CVD on their current daily functioning, family activities and relationships, and social engagement. The women were slow to seek help for CVD symptoms. Postrecovery, 62% of women perceived their heart disease as influencing change in their daily lives. The influence of CVD varied depending on how congruent behavior changes were with their sense of self.

KEYWORDS:

• older women
• aging
• cardiovascular disease
• family
• social activities
• daily life
• life-course

INTRODUCTION

Cardiovascular disease (CVD) refers to a group of disorders related to the heart and circulatory system, including coronary heart disease (myocardial infarction [MI, or heart attack] and angina pectoris [chest pain]), heart failure, stroke, aneurysm, peripheral arterial disease, arrhythmia, and hypertension (Merck, 2008). An estimated 27 million older adults have one or more types of CVD, making it the leading cause of death for both men and women age 65 years and older in the United States (American Heart Association, 2008). Older women are at a particular disadvantage for diagnosis and treatment because of the lingering perception that CVD is a man's problem and is accompanied by pain (Efre, 2004; Lockyer, 2005).

The CVD literature focused on the initial illness episode and short-term recovery after diagnosis has revealed a dynamic process underlying treatment-seeking behavior and recovery (Brink, Karlson, & Hallberg, 2002; Rosenfeld, Lindauer, & Darney, 2005). Several individual and sociodemographic variables influence the process, including the differential effects of personality, health beliefs, perceived risk, knowledge about CVD, presence of other health conditions, age, social network members, and family history. Findings from the CVD literature investigating gender differences provide evidence that men and women experience the initial cardiac event differently, but identify common biopsychosocial factors that influence those experiences. Women are more likely to experience their first heart attack, or receive a CVD diagnosis, approximately 10 years later than men (Arnold et al. 2005; Robinson, et al., 2006). In addition, women's symptoms are experienced and described differently than men (Arslanian-Engoren, 2005; Lockeyer, 2005). Acute symptoms (e.g., debilitating pain, labored and difficult breathing) have been associated with early treatment-seeking behavior regardless of sex (Arslanian-Engoren, 2005; Brink et al., 2002), however; symptoms most commonly experienced by women are nonacute (e.g., persistent weakness, shortness of breath) and may go undiagnosed for hours, days, months, or years (Efre, 2004; Lockyer, 2005).

Once diagnosed with a CVD, women must learn to adapt to any physical limitations and shifts in independence and dependence within their relationships. As women age, they generally experience impaired functioning in more than one area of life, and previous illness-related demands are never really eliminated (Penrod, Gueldner, & Poon, 2003; Roberto, Gigliotti, & Husser, 2005). The way in which older women perceive their health conditions influences how they react to them and their ability to manage and cope with them. It is not uncommon for older women to dismiss condition-specific symptoms and consequences as part of the normal wear and tear of the aging process. Thus, illness perceptions contribute significantly to the explanation of short- and long-term psychosocial variability in response to disease (Royer, 1998).

Most research conducted postcardiac event has explored relationships between physical and psychosocial outcomes (e.g., functional status, quality of life, depression, perceived stress, social support, coping, mood, and affect). Although study samples did not always focus on older women specifically, evidence from this robust literature suggested that women with depression, perceived stress, and low social support were less likely to experience a successful recovery (de Jonge, Spijkerman, van den Brink, & Ormel, 2006; White & Groh, 2007). The majority of these short-term quantitative studies followed women, on average, 11 to 12 months. Missing from the literature are investigations that examine how living with CVD influences the daily lives of older women several years after a diagnosis. In the only study we are aware of that examined daily life after a cardiac event with follow-up beyond 2 years, Nickel and Chirikos (1990) assessed factors influencing long-term functional disability. Data collected from 147 women and 252 men over 8 to 9 years (participants were interviewed five times) revealed that older women with angina were at greatest risk for diminished functional capacity. Our research goes beyond a focus on functional capacity and investigates how CVD influences women's daily lives and social relationships. Specifically, we explored older women's perceptions of their initial cardiac episode that led to diagnosis, and the long-term influences of CVD on their daily lives and relationships.

Theoretical Framework

Three theoretical frameworks guided our investigation. The integration of a life-course perspective and the trajectory model of chronic illness informed the development of the research protocol and analysis process. A life-course perspective posits that individual lives are linked and unfold in a broader social context (Elder, 1977). It recognizes that aging is a lifetime accumulation of social, behavioral, and biomedical trajectories that interact to influence beliefs about health, responses to illness, and attitudes toward health care provisions provided by family members and health care professionals. The trajectory model of chronic illness (Corbin & Strauss, 1988) brings attention to the key problems (e.g., pain, limited energy) imposed by an individual's health conditions and the basic strategies used to manage them. A third theory guided our analysis of treatment-seeking delay: Leventhal's self-regulatory model of illness behavior (Nerenz & Leventhal, 1983) suggests that individuals use an adaptive system to regulate both their emotional state, and the level of danger present during an illness episode. The adaptive system includes three stages: representation of the threat, (I am having trouble breathing), action planning or a coping response (I will wait to see if it passes), and appraisal or monitoring of the situation (am I still having trouble breathing?).

Research Questions

Integrating the life-course perspective with the trajectory and regulatory models provided a holistic lens through which to examine how multiple forces interacted with and influenced the women's perceptions of CVD-related changes in their lives. Our primary research questions were: What was the women's initial experience that led to a diagnosis of CVD, and how did living with CVD influence the older women's current daily functioning, family activities and relationships, and social engagement?

METHODS

The data collected for this study were part of a larger, longitudinal, mixed-methods investigation of psychosocial and behavioral influences on older women's daily health management strategies when living with multiple chronic conditions. In 2000, the Center for Gerontology at Virginia Polytechnic Institute and State University (Virginia Tech) generated a representative database of community-dwelling adults aged 65 years and older living in Southwest Virginia (for details see Blieszner, Roberto, & Singh, 2001–2002). The women in this sample had been contacted and interviewed by telephone twice prior to their participation with in-depth, face-to-face interviews, which were conducted in the spring of 2004. Of the 58 women interviewed (for details see Roberto et al., 2005), 29 reported a diagnosis of cardiovascular disease; their qualitative data were the focus of this analysis.

Sample

All of the women were White and ranged in age from 69–92 years (M = 79.2; SD = 6.8). The women reported a range of cardiovascular diseases, including arrhythmia (n = 11; 38%), hypertension (n = 19, 66%), angina (n = 5; 17%), aneurysm (n = 1; 3%), peripheral arterial disease (n = 1; 3%), and valve problems (n = 2; 7%). Seventeen (59%) of the women had had at least one heart attack, two (7%) had experienced a stroke, and five (17%) women had a pacemaker. On average, at the time of the interview, the women had been diagnosed with CVD for 14 years (SD = 11.2). Table 1 provides information about the women's diagnosis, disease timeline, perceived health status, and the domains that were significantly influenced by their heart condition. We used pseudonyms to protect the identity of the women.

TABLE 1 Timeline of CVD Diagnosis, Type of CVD, Number of Other Health Conditions, and Domain Change

Pseudonym	Current age	Yrs since diagnosis	˚Type of heart disease	Yrs since heart attack	∗Health conditions	+Health rating	Domain changes	^† Domain change
Nadia	69	5	HP, Heart Attack	3	1	Good	3	DF, FAR, SE
Ophelia	70	5	Arrhythmia, HP	–	2	Fair	3	DF, FAR, SE
Katie	71	12	Angina, HP, Heart Attack	11	1	Fair	1	FAR
Dale	72	20	CAD, HP	–	4	Fair	2	DF, SE
Clarissa	75	13	CAD, HP, Heart Attack	4	2	Good	1	DF
Jodi	78	25	Aneurysm, HP	–	2	Good	3	DF, FAR, SE
Yolanda	79	3	CAD, HP, Heart Attack	3	2	Fair	1	FAR
Mindy	80	50	Arrhythmia	–	3	Fair	2	FAR, SE
Josylen	81	15	CAD, HP, Heart Attack	15	1	Fair	1	DF
Winifred	81	30	Arrhythmia. HP	–	3	Fair	1	SE
Zena	82	6	Angina, HP, Arrhythmia	–	1	Fair	2	DF, SE
Hazel	82	29	Arrhythmia, HP, Heart Attack	19	3	Fair	2	DF, SE
Wanetta	82	15	Arrhythmia, HP	–	1	Good	1	SE
Pearl	83	2	Angina, CAD, Stroke, HP, Heart Attack	2	2	Fair	3	DF, FAR, SE
Yvette	84	16	CAD, Heart Attack	4	4	Poor	3	DF, FAR, SE
Leanne	87	14	CAD, Heart Attack	14	2	Poor	2	DF, SE
Justine	89	6	Arrhythmia, Heart Attack	7	2	Fair	3	DF, FAR, SE
Vivienne	91	19	CAD, HP, Heart Attack	7	3	Fair	2	DF, SE
Fatima	69	4	CAD, Heart Attack	4	1	Fair	0	–
Sophie	71	1	CAD, HP	–	3	Fair	0	–
Henrietta	71	2	Arrhythmia, Heart Attack	2	3	Poor	0	–
Inga	72	20	Angina, CAD, Heart Attack	16	2	Fair	0	–
Annette	74	20	CAD, HP, Heart Attack	9	3	Fair	0	–
Elysia	77	22	Angina, HP	–	1	Fair	0	–
Zelda	78	21	Arrhythmia	–	2	Good	0	–
Violet	83	3	Arrhythmia	–	1	Fair	0	–
Agnus	85	5	CAD, Heart Attack	2	1	Excellent	0	–
Barbara	89	8	Arrhythmia, HP	–	0	Fair	0	–
Jacqueline	92	24	Stroke, HP, Heart Attack	24	2	Fair	0	–
˚CAD = Coronary Artery Disease, HP = Hypertension; ∗Does not include CVD diagnosis; +Women were asked to rate their health as excellent, good, fair, or poor; ^†DF = Daily Functioning, FAR = Family Activities and Relationships, SE = Social Engagement.

Procedures

Upon approval of the study protocol from the Virginia Tech Protection of Human Subjects Committee, three research assistants employed by the Center for Gerontology (including the first author) began contacting eligible women by letter, then phone. Audiotaped, semistructured, in-person, individual interviews were completed between March and June of 2004. Before the interview began, interviewers explained the purpose and details of the research project to the women and received signed consent. Each interview took place in the women's homes and lasted approximately 2 hours. A professional transcriber transcribed the tapes verbatim; the researchers verified the transcripts with the tapes.

Interview Questions

The interview protocol began with open-ended questions that systematically explored the women's experiences en route to their diagnosis (e.g., what was their own and their family's initial reactions to the diagnosis, what kinds of advice did they receive from health care professionals). Then to prompt the women to think specifically about how their heart condition influenced their daily lives, we asked them to rate, on a 7-point scale from 0 = no change to 6 = extreme change, how much their heart condition had changed their daily lives in three domains: daily functioning, family activities and relationships, and social engagement. For example, we asked the following four questions about daily functioning: In general, how much does your heart condition interfere with daily activities? How much has your heart condition changed your ability to complete daily activities? How much has your heart condition changed your ability to do household chores? How much has your heart condition changed the amount of satisfaction or enjoyment you get from daily activities? The interviewer then summarized their ratings across the questions (e.g., “It appears that your heart condition has resulted in few [some, many] changes in your daily activities) and asked them to elaborate by describing a typical day. Interviewers asked follow-up questions and encouraged the women to describe and explain their experiences in as much detail as possible. The process was repeated in each of the three domains.

Coding and Data Analysis

While remaining open to emergent themes from the data, Leventhal's self regulatory model of illness behavior helped guide the first phase of analysis. The first author read and reread the transcripts using an open coding procedure noting nouns, verbs, trends, and storylines related to the women's initial episodes of, and experiences with, CVD. Following open coding the first author noted specific themes and categorized the data according to women's symptoms, attributions of their symptoms, and their reactions to both their symptoms and diagnosis. Tallies informed the analysis of global themes that emerged between the categories. The second author verified the coding, categories, themes, and findings.

The second phase of analysis began by grouping the women according to how they rated the influence of heart disease within the three domains of daily functioning, family activities and relationships, and social engagement. During the interview, the women rated change on a scale from 0–6; we used the median score of 3 to identify women who perceived the greatest influence of CVD on their daily lives. Women who rated change greater than 3 on any of the questions within each domain were considered to have experienced a large degree of change in that domain and were the primary focus of the analysis. The first author analyzed the women's narratives for common themes in each of the domains separately, and then compared the data across domains. The second author provided conceptual guidance and verified themes and findings. Using axial coding procedures, we further explored if age, time since diagnosis, and the presence of other health conditions influenced the women's perception of change in their daily lives due to their heart disease. Strategies employed to enhance trustworthiness and general rigor included researcher triangulation, the use of analytical memos, and the examination of negative case evidence, or those narratives that departed from initial themes and impressions.

FINDINGS

The women's initial experiences leading toward diagnosis of CVD echoed previous findings; it was common for the women to experience symptoms without recognizing them as such. Once the women received a diagnosis, adjustments made in their daily lives to manage their heart disease varied. Women who experienced intense, life-saving operations allowed themselves adequate recovery time and generally heeded their physician's advice. Over time, as the women grew accustomed to living with CVD, they paid less attention to the disease, unless they experienced symptoms. The women talked about knowing their bodies and “slowing down” in general as they grew older, but expressed some uncertainty about what was causing this change—their heart disease, old age, other health conditions, or a combination of these factors.

Initial Experience and Diagnosis

The women had difficulty correctly interpreting their symptoms due to the interaction between their beliefs about their own health (e.g., their risk for CVD, the presence of other health conditions, a tendency to attribute symptoms to age) and their understanding about CVD symptoms. Six (21%) women sought medical care immediately after experiencing symptoms; it was more common for women to wait days or weeks before seeking help, and three (10%) women experienced symptoms for years before seeking medical attention. Eighty-two-year-old Zena, who was 76 at the time of her diagnosis, has angina, high blood pressure and arrhythmia, and had been getting progressively weaker and more tired for 6 years before a debilitating episode motivated her to seek medical care.

I got to the point where I couldn't even take 4–5 steps that I didn't feel faint. And when I had that spell in the grocery store with the elephant, I call it the elephant sitting on my chest. I left my cart full of groceries and went to my car. I waited and waited for the pain to end, and then came home and decided I have to see somebody about this.

As Zena's comments illustrate, even when symptoms were debilitating, women did not seek immediate help by calling 911. Ten (34%) women waited for symptoms to pass, or consulted a family member or friend before deciding how to proceed. Only four (14%) women experienced pain, and in the absence of pain, the women attributed symptoms to other chronic conditions or old age. Seventy-five-year-old Clarissa experienced symptoms 2 years before her heart attack.

He [physician] told me fatigue, muscle cramps, tightness in the chest, and I related it all to age … I would ride my bicycle with my granddaughter, and I would get real tired, but I just thought it was part of growing older because I was 60.

Changes to Daily Life

Since recovery from the illness episode, 18 (62%) women experienced significant change (considered greater than 3 on a scale of 0–6) in one or more life domains (i.e., daily activities; family activities and relationships; and social engagement). Of the 11 women (38%) who did not rate change as significant in any of the domains, three women had vision problems, two had diabetes, and one had arthritis—all conditions that overshadowed CVD. Seventy-four-year-old Annette, who was blind and had diabetes and osteoporosis, said, “I can forget the heart until it bothers me, but I have to stay on this diabetes all the time.”

From the 18 women who reported change due to their heart disease, we found the most change in social engagement. The women's friendships were stable, with only three women (10%) reporting change. However, 13 (45%) of the women reported change in their ability to participate in recreational or social activities, and 11 (38%) reported change in their level of satisfaction when participating in those activities. Change in daily functioning was common, with 11 (38%) women reporting interference or change in their ability to complete daily activities. Family relationships were mostly stable, with 9 women (31%) reporting change in their marriage and/or their level of satisfaction with family-related activities.

Social engagement

The women described more change in their social activities than in any other domain. Thirteen women (45%) spoke generally about quitting, slowing down, or altering activities they enjoyed, such as gardening, going to church, or traveling. Seventy-year-old Ophelia was diagnosed with arrhythmia and high blood pressure 5 years ago. For 16 years, she had been the chairperson for her church's fundraising committee; despite her heart condition, she continued in that role but changed how she managed her responsibilities.

It [heart disease] slows you down in general and your meetings are not quite as long … I guess I will have to give it up one of these days, but they have to have somebody to get things done and so far, I have done a good job. They all call and need things done, and I can tell them what to do, but I don't do it. I just get somebody to do it for them.

Eleven women (38%) experienced change in their level of satisfaction with recreational or social activities. When the women considered satisfaction, their explanation for the change was not always specific to their heart condition. Seventy-two-year-old Dale, who had a pacemaker and lived in a remote rural location, had stopped driving. Her explanation for the change in her level of satisfaction involved her health as a whole.

I am usually too tired to be bothered and two-thirds of the time I don't want to be bothered. I have to depend on other people for things and I don't really like that.

For this group of women, what they could do, and how they participated in activities had changed, and for some, how they felt about what they were able to do changed, but the stability of their friendships was unwavering. For two of the three women whose friendships had changed, one woman had moved and could no longer walk with her friend, and the other was homebound and did not have friends or neighbors that visited with her. In contrast, 82-year-old Zena reported feeling “reborn” after getting a pacemaker. She began volunteering at a local health clinic where she made friends quickly and connected with a new social circle.

Daily functioning

Thirteen women (45%) experienced change in their daily functioning, with housework being the dominant daily activity. The women explained that housework tired them out, or they became short of breath while doing their chores. Feeling weak and experiencing pain also interfered with what and how much the women accomplished. Strategies they adopted for completing their work included turning to family or neighbors for assistance, changing the environment to make the chore easier, hiring help, or continuing to do the chore, but allowing themselves to rest. While the women were satisfied with their strategies, a few struggled with the quality of the work. For example, 89-year-old Justine lived alone in a large house and continued to do all of her housework, but she was dissatisfied.

So far I have [done all of my housework]. Of course it's not kept the best in the world. I get tired even running the sweeper. I have got to do one room and then rest. I can't go on with my work like I normally should, you know. The age and the heart together just about puts you in the bed when you work an hour or so, if you do strenuous work.

After her second heart attack, 84-year-old Yvette hired someone to mow her lawn, but she was having a hard time accepting the situation.

I have a boy that comes and mows once a week, but he doesn't do a very good job. He says he does the trimming, but he doesn't get too close sometimes. You just have to kindly do as you can get done … and you have got to be satisfied with it, I guess.

Family activities and relationships

Nine women (31%) reported notable change in the family domain. Two themes emerged: Family members changed the way they treated the women; and changes in the women's functional status affected their satisfaction with family activities.

Four (14%) of the nine women experienced change in the way their family members treated them; three described positive change and one a negative change. The women reporting positive change shared the sentiment that heart disease had brought the family closer together. The women believed family members paid more attention, cherished them more, and were more protective. Katie, who had always been close with her family, explained, “I guess maybe we enjoy it more [family get-togethers] because you never know when it's going to be the last time.” Yvette was the only woman reporting negative change.

After my heart attacks they [children] didn't want me to do things, but after all I had to, you know, I couldn't give up. [The grandchildren] keep problems away from me and don't tell me things that they should. I think they should tell me, but they won't.

The tension this change created affected her level of satisfaction with family-related activities. Yvette told the interviewer that she was not going to join her family that summer for their annual family vacation because she did not appreciate them treating her as if she were fragile.

Seven (24%) of the nine women who reported change in the satisfaction they experienced from family-related activities, attributed the change to functional limitations (e.g., tired easily, could not walk long distances) and pain. They associated satisfaction with their level of comfort and their ability to do the activities and tasks they had done in the past. For example, 83-year-old Pearl, who was confined to a wheelchair following her stroke a year prior to the interview, did not feel part of the action any longer and found it difficult to accept.

I just can't do what I used to do. I used to get out and run and play ball, I can't do what I used to do. I used to participate in all of their games, and I can't do that no more.

Change in multiple domains

While themes and patterns in the data emerged within each separate domain, the story of living day-to-day with heart disease is more complex. Six women (21%) reported change in all three domains, six (21%) reported change in two of the three domains, and six (21%) reported change in just one domain. The women who rated significant change in one or more of the domains thought about their heart disease in the context of their overall lives. The manifestation of their multiple health conditions, along with significant life events, combined to influence the three life domains, and asking them to tease out the influence of their CVD was a difficult task. Eighty-seven-year-old Leanne, who had coronary heart disease, fibromyalgia, and arthritis, was able to articulate the role she believed her heart condition had played since her diagnosis 14 years ago.

My heart disease did not stop me from doing what I did before; it was the thought that nobody wanted me there because I couldn't do what I did before. The bottom line is me and my attitude. I don't think the heart disease curtailed my life half as much as the way I felt about having had a heart attack. It wasn't a physical thing, it was a mental thing.

Age, Time Since Diagnosis, and Presence of Other Health Conditions

We explored variation in the women's perceptions of change according to their age when interviewed, time since diagnosis, and the presence of other health conditions. Eight of the 18 women who attributed change in their lives to CVD also believed their age played a role. One of the women was told by her physician that age was influencing her heart condition, while three women independently questioned how much their age influenced the changes they were experiencing. Three other women were certain that their age interacted with their heart disease and other conditions to influence changes in their lives. Eighty-two-year-old Zena, who was able to do more activities daily, thanks to her pacemaker, was very clear that her age, not her heart condition, interfered with the way she could do certain tasks.

If I got down on my hands and knees to scrub that floor, within five minutes I would be so weak and so tired I couldn't do it. That is not from my pacemaker or my heart, that is from my whole body because it's old. I have lost all of my muscle.

Five of the 11 women who did not attribute significant change to their heart disease mentioned age as a contributing factor for experienced changes. Two of the younger women in this group viewed age as interacting with their other diseases, while all three of the oldest women in this group were adamant that age was the sole cause of changes they were experiencing.

Overall, younger women (aged 65–74) perceived age to have a limited effect on changes in their daily lives; about half of the older women (aged 75–84) perceived age to intersect with heart disease and other conditions; and age alone was the sole cause of change for half of the oldest old women (aged 85 and older). No discernible patterns emerged from the analysis of change based on time since diagnosis or presence of other heath conditions.

DISCUSSION

Heart disease was seldom the lone attribution for change in any of the life domains. The persistent explanation for change was the women's energy level. Women felt tired and, with varied certainty, expressed that their heart condition in combination with other health problems, pain, and advancing age were all to blame (Penrod et al., 2003; Williamson & Fried, 1996). The women who perceive their heart condition as not affecting their daily life remained vigilant about not aggravating their heart. Overall, despite their energy level, the women pushed themselves in their daily lives until they were tired and then rested. As a group, they were adamant that they knew their bodies best and knew what, and how much, they could or could not do.

Years after the diagnosis, 11 women (38%) did not perceive their heart disease as interfering in their daily lives. These women were either not bothered by their heart condition, had other health conditions that overshadowed their heart disease, or attributed changes to their age, not heart disease. The 18 women (62%) who experienced significant change in their daily lives perceived the most change in social engagement, followed by daily functioning, and then family relationships. With limited energy, the women were cognizant about how they chose to spend their time. Generally, they curtailed their social engagements first and then housework. Most women continued to do their own housework, but completed heavier chores by resting frequently or turning to social network members for help; however, not all of the women were satisfied with their situation. When the women's standards for “a job well done” were incongruent with the perceived quality of the job, they expressed remorse about not being able to do the work themselves. Family relationships were mostly stable, and for all but one woman, families responded to the women's changing health in ways they perceived as positive. Changes in satisfaction with family events were a result of how the women felt about themselves in light of their functional limitations. As noted by others studying chronic disease, a negative sense of self interfered with how much the women enjoyed family-related activities (Roberto, Gold, & Yorgason, 2004; Hooker, 1999).

Variations in health-related characteristics—chronological age, length of time with CVD, and the number of other health conditions present—did not consistently influence the types of changes the women perceived in their lives since CVD diagnosis. The primary differentiation across all groups was a sense of congruence between their self-perception, or their self-imposed standards, and the quality of, or experience with, the tasks they wanted to accomplish. Women who recognized significant change reflected on the past in comparison with the present, and reported either a sense of gratitude for the change (e.g., improved family relationships) or disappointment that they could not accomplish a chosen and important activity in the same way they had before (e.g., unable to mow lawn). This suggests the women were grappling with tension around their sense of self and the loss of, or change in, skills or abilities (Baltes & Carstensen, 1996; Hooker, 1999). The key difference among the women was their location in the process of reconciling those losses or changes. Strategies the women used to help them let go of unsatisfactory feelings included accepting life changes and not dwelling on negative situations.

Our approach to exploring how women adapted to life with CVD revealed an important methodological insight. Despite priming the women to think only about their heart disease (and reinforcing this throughout the interview), they tended to think about their health in general and, infrequently, other major life events that influenced the domain in question. Consistent with findings that women tend to think about their health in totality, and that older adults generally have more than one health condition (Penrod et al., 2003; Roberto et al., 2005), researchers focusing on single diseases should interpret their findings cautiously. The manifestation of multiple illnesses in later life is complex. Older adults are not always clear about which disease is causing which symptom, or if it is their disease that is causing change. Thus, the presence of multiple chronic conditions has important effects on prognosis, disability, and quality of life.

Study limitations include a retrospective account of their experiences with CVD. Longitudinal research is needed to further understanding of how this chronic condition manifests and changes over time. In addition, the study sample was drawn from a relatively small geographic rural area that lacks racial and ethnic diversity. It is important to note, however, that in qualitative research, generalizability is not assumed beyond the participants in the study. Instead, emphasis is placed on the transferability of findings, or the extent to which another researcher is able to reconstruct a study in which similar contexts and populations are examined (Creswell, 2003). Applying the principles of effective data analysis for qualitative designs (Anfara, Brown, & Mangione, 2002), we developed rich descriptions of the women's experiences through the analysis of the transcript data, and established dependability by pursuing researcher triangulation in support of the confirmability aspect of trustworthiness.

In conclusion, it is important to understand that how women react to and interpret immediate symptoms of heart disease is strongly influenced by the women's physical symptoms, the presence of other health conditions, their individual health beliefs, and their social network members. Health care providers and public health educators need to reinforce the importance of these factors as vital information for the recognition and response to illness episodes. Further, care providers need to consider the influence of coping strategies, personal resources (e.g., family, education), and past life experiences when providing long-term care for older women with heart disease. These complex and individual factors shape the ways in which older women react to, and then manage, or mismanage, their heart disease.

ACKNOWLEDGMENT

This research is dedicated in memory of Louise Sparks, and was supported in part by the Cooperative State Research, Education, and Extension Service, U.S. Department of Agriculture under Project No. VA-135688 of the Virginia Agricultural Experiment Station.