Life course

person aged 80+


Chronic conditions and / or social needs


Maria lives in a flat on the 3rd floor with no central heating and no lift with her daughter June and grandson Jon, who suffer from a chronic personality disorder and mild cognitive impairment respectively. Maria’s pension is little and her family is having serious financial difficulties. She has multiple chronic conditions and is prescribed many different medications. Due to her worsening eyesight she is having trouble identifying the correct medication and taking the prescribed doses correctly. Despite needing help in managing her own health, she rejects social services and does not want to go to a nursing home as she feels her family will be left unprotected without her. She has no interest in digital technology and feels isolated at home.

Internet usage

Mobile device skills

Affinity to new tech

Digital Health Literacy

Assistance (ICT use)

What's important to Maria

– Cooking and being in charge of her family
– Taking care of June and Jon
– Knitting, but less frequently due to worsening eyesight
– Watching soap operas on TV
– Feeding pigeons dry bread crumbs in the park.

Health concerns

Chronic conditions under control but with occasional relapses:
– Diabetes with complications (e.g. eyesight)
– Moderate chronic kidney disease (CKD)
– Heart-related: irregular heartbeat & moderate heart failure
– Chronic joint disease (Osteoarthritis)

Daily living

– Manages her personal hygiene and appearance poorly
– Less able to manage her household (e.g. cleaning, groceries)
– Not going out as much as she would like to
– Family meals are neither balanced nor healthy.

Health tests

Regular check of key parameters. Latest results:
– Heart rate: normal
– BMI: moderately overweight
– Blood glucose: slightly above normal
– Blood pressure: under control
– Cholesterol: fair levels

Events, issues & personal concerns

– She has problems managing her own health and adherence to treatment is poor. She was recently hospitalised for taking too much rapid insulin and suffered severe hypoglycaemia
– Has no one to rely on for help, no neighbourhood friends
– She is afraid she will be blind despite treatment.

Treatment: medications, therapies, etc.

– 1 insulin injection daily for glucose control
– 1 pill to prevent stomach ulcers
– 1 pill to prevent blood clots
– 1 pill to prevent water retention
– 2 pills to control blood pressure
– 1 pill to lower cholesterol
– Painkillers for occasional joint pain

Own resources & assets / support

– Primary health care team takes care of her illnesses. She visits the health centre at least once a month.
– In touch with her niece, who also visits Maria 2-3 times/year

Care professional concerns

– Some clinical parameters (BP, creatinine) have improved.
– Maria has been the carer of June and Jon since her husband’s death and they have become dependent on her.
– Good social services are available, but she rejects outside support (both for herself and for her family who also need it).


– Maria needs help with better adhering to her prescription and avoiding undesired adverse effects.
– Maria feels isolated. She needs help in managing her own health but she rejects outside support.
– Maria needs to take better care of herself, when it comes to personal and house hygiene. June and Jon do not participate much in her care due to their own conditions.
– Maria has difficulties doing the groceries as well as cooking meals (that are healthy and well-balanced) for her family by herself, and her family’s financial struggles make it harder to improve this situation.
– She has very low health and digital literacy levels.

Developed by

by Esteban de Manuel Keenoy , Kronikgune / Basque Country and Javier Urraca Madinabeitia, Basque Country