geriatric nurse

Cognition and Perception  CHAPTER 10 183 Box 10-2  Risk Factors Related to Cognition FIGURE 10-3  Nurses can use touch to calm a person with Alzheimer and Perception in Older Adults disease. (From Kostelnick C: Mosby’s textbook for long-term care nursing assistants, ed 7, 2015, St. Louis, Mosby.) • Vision problems (total blindness, presbyopia, macular degeneration, cataracts, hemianopsia, detached that the older individual can see the nurse, or the retina, diabetes, glaucoma, and significant refractive individual should be touched gently on the hand errors) before more personal contact is made. If the older adult is visually impaired, speak up and introduce • Hearing problems (presbycusis, otosclerosis, and yourself when entering the room. This lets the conductive sensorineural deafness) person know who is there, even if he or she cannot see a face clearly. • Dementia (including Alzheimer disease) 3. Determine the best methods for communicating • Disturbed cerebral circulation (stroke, aneurysm, and with older adults. Be patient and relaxed when working with older adults (Figure 10-3). When head injury) working with sensorially altered older persons, • Drugs that affect the sensorium (alcohol, narcotic keep messages as simple as possible, use easily understood words, and speak clearly. It may be analgesics, tranquilizers, sedatives, and hypnotics) necessary to reword a statement if the first attempt • Disturbed neurologic function resulting in decreased is not understood. Avoid overloading the older adult with information when explaining care or levels of consciousness treatments. When writing messages, make sure • Disturbed metabolic states (hypoglycemia and that the writing is clear and large enough to be seen easily. metabolic alkalosis) When working with hearing-impaired older adults, • Environments with either inadequate or excessive speak in a low tone of voice, because hearing sensory stimulation losses are usually in the higher frequencies of sound. Because many hearing-impaired people • Does the person turn the volume of the television compensate by lip reading, it is best to stand in or radio to a very loud level? good light while facing the person and to speak slowly but not unnaturally so. Do not chew gum • Does the person turn his or her head to hear? Wear or eat while talking. If one of the older person’s a hearing aid? ears is better than the other, speak into the good ear. Keep background noise from television or • Does the person respond appropriately or inappro­ radio to a minimum because it may distract older priately to questions? adults or interfere with verbal communication. Facial expressions, gestures, and other visual cues • Can the person follow directions? that are appropriate to the message should be Box 10-2 lists risk factors for problems related to cogni­ used. These cues can help the person understand tion and perception in older adults. what the nurse is talking about. For example, if the nurse’s intended message is “Please come NURSING DIAGNOSES with me,” hold out your hand and begin to walk. If it is time to groom someone’s hair, show the   person the brush and comb to help make the message clear. Risk for Injury related to altered sensory perception Impaired Verbal Communication related to distur­ bance in sensory input NURSING GOALS/OUTCOMES IDENTIFICATION   The nursing goals for older individuals with distur­ bances in sensory perception are to (1) remain free from injury; (2) demonstrate improved ability to detect changes in the environment; (3) interact appropriately with the environment; and (4) demonstrate the ability to compensate for deficits by using prosthetic devices and alternative senses. NURSING INTERVENTIONS/IMPLEMENTATION   The following nursing interventions should take place in hospitals or extended-care facilities: 1. Ensure that all caregivers are aware of the person’s sensory problems. The patient records should iden­ tify and prominently display any vision or hearing problems. Inform nursing assistants and ancillary personnel about sensory problems and appropriate methods of communication before assigning them to provide care for an older individual with sensory deficits. 2. Make appropriate sensory contact before begin- ning care. If the older adult is hard of hearing, avoid startling him or her. Approaches should be made so

184 UNIT III  Psychosocial Care of Older Adults FIGURE 10-4  Nurses should approach patients who have a FIGURE 10-5  A hearing aid in the ear canal is barely visible. left-sided hemiparesis from the right side. This older woman may (© iStock Photos.) not be able to see people to her left. (From Kostelnick C: Mosby’s textbook for long-term care nursing assistants, ed 7, 2015, Clean eyeglasses regularly. Fingerprints and other St. Louis, Mosby.) debris can distort vision and make the glasses useless. To be of benefit, eyeglasses must also fit the person Persons with hearing impairments are not likely to properly. Many eyeglass frames are too loose and slide understand messages spoken through the call down the nose; others are too snug and create uncom­ signal speakers that are used in most care set­ fortable pressure areas on the nose or ears. Often, older tings. Instead of using the intercom, respond adults wear eyeglasses with broken frames that are promptly and in person to calls from the sensori­ taped together. If the eyeglasses do not help vision or ally impaired. More information regarding com­ they are uncomfortable, older adults are likely to avoid munication with older adults is provided in wearing them. Nurses should arrange a consultation Chapter 5. with an eye specialist to correct such problems. 4. Modify the environment to reduce risks. Lighting Hearing aids are worn by many older people. These is important for older adults. Because it takes the devices do not duplicate normal hearing and are not aging eye longer to adjust to bright light, stairs beneficial for everyone. Hearing aids can be built in to and other hazardous areas should be designed to eyeglasses or inserted into the ear canal. Some of the prevent glare. When an older adult has a condition older units hang over the external ear; newer models in which a portion of the visual field is lost are almost invisible when worn (Figure 10-5). (hemianopsia), arrange the furniture to maximize the person’s ability to see (Figure 10-4). Place per­ Many people have difficulty adjusting to hearing sonal belongings toward the good side, and teach aids and complain that they are bothersome. When the person to turn his or her head and “sweep” the first fitted with a hearing aid, the person may be able environment to pick up more visual cues. to tolerate it only for a few minutes a day. As the person adjusts to the device, the amount of time it is 5. Verify that prostheses such as eyeglasses and worn should be gradually increased. Older people hearing aids are functional. Obtaining the proper who are adjusting to wearing a hearing aid often report corrective lenses is not a one-time requirement. As that it makes them nervous or jumpy to hear so many the eyes continue to change, a prescription that was sounds. They should be reassured that this is normal once adequate may lose its effectiveness. Simply and that the jumpiness will go away as they become because a person wears eyeglasses does not mean used to wearing the hearing aid. Many people who that he or she can see clearly, particularly if the wear hearing aids report that the sounds they hear are person has had the eyeglasses for some time. Eye “tinny” or “noisy” and that they hear feedback whis­ examinations should be performed regularly and tles or hums. These noises are usually caused by incor­ prescriptions changed whenever required. Many rect insertion or improper adjustment of the controls older adults suffer from multiple refractive errors on the device. and require bifocals or trifocals to achieve adequate focus. Bifocals and trifocals can present problems Hearing aids require a certain amount of care and because the wearers must move their heads to shift maintenance. Because they are fragile, be careful not the line of vision to the proper section, depending to drop them. Most are made of plastic and should be on what they wish to view. Some people find this so disturbing that they choose not to wear the correct prescription. Report these types of problems to the primary care provider so that an acceptable solution can be found.

Cognition and Perception  CHAPTER 10 185 (5) asking the speaker to repeat when informa­ kept away from very hot or very cold places. Before tion is not clear. being inserted into the ear, check the hearing aids for Many special devices are available for hearing- cracks or rough edges that could injure the ear. Clean impaired people. Local telephone companies can the ear mold regularly. Pay special attention to the provide special equipment, such as amplifiers or removal of cerumen, which may plug the canal and video display terminals, which enable older reduce the effectiveness of the device. Check and clean adults to maintain contact with others. Doorbells batteries regularly, because the hearing aid will not and mats that flash a light when someone is at work properly without a good power source. To the door are available. Alarm clocks that vibrate prolong battery life, shut the hearing aid off when it is rather than ring can be purchased from specialty not in use. Check batteries for corrosion and clean the shops or department stores. Hearing-impaired contacts, particularly if the device becomes wet. Storing individuals with adequate vision should be unused batteries in the refrigerator can prolong their made aware of closed-caption television broad­ life. Discard old batteries after a change so that they casts, which provide typed narration of news are not mistakenly saved and reused. and many entertainment programs. Most videos on the internet are also available closed cap­ Caregivers who are not familiar with hearing aids tioned; however, the accuracy of the captioning should receive special training in how to place them is variable and can be inaccurate if done by a in the ear canal properly. Hearing aids are useless computer. unless they are worn properly. Nurses should always Visually Impaired Persons. Telephone dials can be verify that a hearing aid has been applied to the correct modified with overlay rings that have large ear. If the person wears two aids, they should be numbers to assist in dialing. Most telephones can marked so that the correct device is placed in the be programmed with commonly used numbers correct ear. If the device still does not function prop­ so that the person needs to push only one button erly, nurses may need to consult with an audiologist to dial. Handheld or floor standing magnifying or speech therapist. If the older person is reluctant to devices help with reading or close work. Large- wear the hearing aid, do a thorough assessment to print books and magazines are available in most determine why he or she is refusing. A thorough public libraries; computer settings can be altered reevaluation of hearing may be necessary. for viewing large print. Written materials can be enlarged on photocopy machines to make reading The following interventions should take place in easier. Books on audiotape are also available in the home: stores and many libraries. Talking clocks that fit 1. Modify the home environment to compensate for in a pocket are available. sensory changes. Modifications in the home will NURSING PROCESS FOR CHRONIC CONFUSION help older adults cope with sensory changes. Increasing the amount of light is the least expensive   and most beneficial change. Lights should be posi­ tioned to avoid glare. Incandescent bulbs are better Anything that damages or interferes with the normal than fluorescent bulbs because they do not have a functioning of the cerebral cortex can result in cogni­ distracting flicker. Burned-out bulbs should be tive (i.e., thinking and judgment) problems. All changes replaced promptly. It is even better if light bulbs are in cognitive function must be given immediate atten­ replaced when they begin to dim rather than waiting tion. Prompt assessment of the type and severity of the until they burn out. disorder, along with identification of the cause or Use of contrasting colors helps older adults deter­ causes, enables the caregiver to plan the most appro­ priate interventions for each individual. Cognitive mine edges and borders. Apply contrasting strips function can be affected by sensory changes, physio­ to areas where there is a change in elevation, such logic factors, or emotional disorders. Cognitive prob­ as shower entrances and steps. Contrasting door lems can range from mild and reversible forms of frames, dishes, pillows, personal care items, and disorientation to severe and irreversible forms of toilet seats will help older adults distinguish dementia. Depression, hypothyroidism, and vitamin these items more easily. deficiencies are common treatable causes of pseudode­ 2. Assist sensorially impaired people in developing mentia (Box 10-3). techniques or acquiring devices that will help compensate for losses. Sensory changes can result in behaviors that mimic Hearing-Impaired People. Nurses should explain cognitive problems but actually are not. The two ways that hearing-impaired people can improve should not be confused. Sensory misperception should communications. These include (1) telling others be ruled out before further cognitive assessment is that they are hard of hearing; (2) focusing on performed. the speaker and paying attention to what is being said; (3) facing the speaker or asking the The term confusion is used to describe a wide range speaker to face them; (4) asking the speaker to of behaviors. Both lay people and professionals use speak slowly and clearly but not to shout; and

186 UNIT III  Psychosocial Care of Older Adults Table 10-1  Mnemonic Assessment for DELIRIUM COMPONENT CONSIDERATIONS Drug use Any recent change in medications, increase or decrease in dosage, change from specific brand to a generic. Pay special attention to sedative-hypnotics (including alcohol), antidepressants, opioids, antipsychotics, anticholinergics, anticonvulsants, antiparkinson medications, and H2 blocking medications Electrolyte imbalance Abnormal levels of calcium, sodium, or magnesium often related to malnutrition or dehydration Lack of drugs Missed medication doses Infection Check for urinary tract infection (UTI), signs of inflammation, respiratory congestion, etc., remembering that the signs may be subtle in the older adult Reduced sensory input Visual or hearing impairment, failure to use glasses or hearing aids, social isolation Intracranial problems Recent head injury, history of stroke, meningitis, history of seizure Urinary retention and/or Recent anesthesia, history of benign prostatic hyperplasia, recent catheter removal fecal impaction Myocardial problems Anginal symptoms, abnormal electrocardiogram (ECG), recent cardiac surgery Box 10-3  Types of Dementia thing you know you are restrained in bed, and a tube has been put in your bladder. If you could read the nurse’s note, Alzheimer disease you would see this statement: “Confused, agitated, and Vascular dementia combative. Restrained for protection. Catheter inserted for Dementia with Lewy bodies (DLB) incontinence.” Mixed dementia Parkinson disease dementia Acute confusion, often called delirium, is characterized Frontotemporal dementia by disturbances in cognition, attention, memory, and Creutzfeldt-Jakob disease perception. This type of confusion is usually caused Normal pressure hydrocephalus by a physiologic process that affects the autonomic Huntington disease nervous system. Conditions that can cause delirium Wernicke-Korsakoff syndrome include uncontrolled pain, infection, metabolic distur­ bances, vitamin deficiencies, uremia, hypoxia, hyper­ From Alzheimer’s Association. 2012 Alzheimer’s disease facts and figures. calcemia, endocrine imbalance, myocardial infarction, 2012. www.alz.org/downloads/facts_figures_2012.pdf. constipation, drug toxicity, and drug withdrawal. this term far too frequently, often incorrectly and A mnemonic tool used to focus an assessment is inappropriately. found in Table 10-1 (DELIRIUM). Confusion is defined as a mental state characterized Acute delirium has a sudden onset of hours to days. by disorientation regarding time, place, or person that It is characterized by rapid mood swings, disorganized leads to bewilderment, perplexity, lack of orderly sleep cycles, changes in psychomotor activity (hypoac­ thought, and the inability to choose or act decisively tivity, hyperactivity, or both), tremors or spasmodic and to perform activities of daily living. NANDA activity, rapid speech patterns, loss of attention, and a International identifies the following nursing diagno­ wide range of cognitive changes (Tables 10-2 and 10-3). ses that relate to confusion: acute confusion, chronic Older individuals with underlying emotional instabil­ confusion, ineffective impulse control, and impaired ity can exhibit a full-blown psychotic episode with memory (NANDA International, 2014). delusions and auditory or visual hallucinations. The severity of symptoms may vary throughout the day, Clinical Situation and symptoms are often worse at night. Because the cause of dementia is usually physiologic, acute confu­   sion does not respond well to behavioral approaches such as reorientation. Once the cause is identified and Cognition and Perception treated, the symptoms generally disappear. Failure to identify and correct underlying physiologic problems Imagine that you are an older adult hospitalized for chest pain. can result in serious physical harm or even death. You have trouble seeing (you cannot reach your eyeglasses in the drawer) and are hard of hearing (you are wearing your Confusion can sometimes be idiopathic, or from an hearing aid, but the batteries do not work). The medication you unknown cause. Idiopathic confusion does not have an took has made you a little lightheaded, and your bladder identifiable physiologic basis. It is most likely to occur seems to fill every 30 minutes. You send a call signal to go when there is a stressful disturbance in lifestyle or life to the bathroom, but no one comes and you feel desperate. patterns such as following the death of a loved one, You attempt to get up, but the rails are in your way and you depression, or relocation to a hospital or new living fall. Before anyone comes to help, you can wait no longer and void on the floor. By the time someone gets there, you are frightened and angry. You yell and slap the person. The next

Cognition and Perception  CHAPTER 10 187 Table 10-2  Differences Between Delirium and Dementia DEMENTIA Slower onset: months to years DELIRIUM No change in level of consciousness (initially) Stable over 24 hours Rapid onset: hours to days Impaired memory with loss of abstract Reduced level of consciousness thinking, judgment, language skills (aphasia), motor skills (apraxia), and ability Variable course over 24 hours to recognize familiar people or objects (agnosia) Increased or decreased psychomotor activity Disturbed sleep/wake patterns Generally not reversible Disorientation and perceptual disturbances, possible visual and auditory hallucinations Memory impairment Decreased attention span with disorganized thinking Generally reversible if underlying problem is identified and treated; may recur with acute illness Table 10-3  Nursing Interventions for Delirium and Dementia DEMENTIA Designed to maintain or maximize level of function DELIRIUM Designed to treat underlying pathologic condition and maintain Administration of medications (cholinesterase inhibitors); ensure that fluid and nutrition are maintained physiologic integrity Includes environment modification, activity-based Includes administration of fluids, nutrition, oxygen, antianxiety therapies, and communication strategies medications, and so on Designed to control environmental stressors, to protect safety, and to promote comfort Box 10-4  Facts About Alzheimer Disease • The first signs of Alzheimer disease are subtle changes in behavior. The disease affects each individual • Alzheimer disease is not a normal part of aging. It is a differently; the type and severity of symptoms, as well progressive, degenerative, irreversible form of dementia. as the order of their appearance, differ from person to person. • The disease was first identified in 1906 by Alois Alzheimer, a German neurologist. • People suffering from Alzheimer disease lose the ability to think, remember, understand, and make decisions. • Most cases of Alzheimer disease occur in people older Consequently, they are often unable to perform even the than 65 years of age, but it can occur as early as 30 most basic activities of daily living. The ability to control years of age. basic body functions such as elimination is also lost. • Alzheimer disease affects both men and women of all • People with Alzheimer disease suffer personality religions, races, and socioeconomic backgrounds. changes. They lose the ability to control moods and emotions, leading to unpredictable and often • The cause of the disease remains unknown, but inappropriate behavior. Unusual behaviors include genetic, chemical, viral, and environmental factors are wandering, pacing, hiding things, swearing, disturbed suspected. Family history and the presence of the sleep patterns, and repetitive actions. apolipoprotein E gene appear to indicate an increased risk for development of the disease. • There is no known cure for Alzheimer disease. A variety of medications are being tested for use with this • Alzheimer disease causes gradual changes such as disease, with varying degrees of success. plaques and tangles in the nerve cells of the brain that can be detected on autopsy. • Neurologic changes result in a loss of the ability to process information normally. quarters. The onset of symptoms is likely to correlate experiencing this form of confusion usually respond to specific occurrences or situations, although not well to reorientation interventions and approaches always. Idiopathic confusion tends to affect memory that reduce stress levels. Symptoms may be reversible and concentration. Affected older adults are often but may not disappear completely. depressed. Common symptoms of idiopathic confu­ sion include appetite changes, loss of interest in activi­ Dementia is a slow, insidious process that results ties, changes in sleep patterns, agitation, feelings of in progressive loss of cognitive function. Dementia worthlessness or guilt, fatigue, or other physiologic is caused by damage to the cerebral cortex that is complaints. The ability to perform routine activities of most commonly a result of disease conditions (e.g., daily living is not usually affected, but the willingness Alzheimer disease; Box 10-4), multiple infarcts of the to perform these activities might be. Individuals cerebrum secondary to stroke, or other pathologic con­ ditions of the brain. Drug intoxication, Huntington

188 UNIT III  Psychosocial Care of Older Adults Self-care deficits in eating, bathing, grooming, and toi­ leting are common. disease, Creutzfeldt-Jakob disease, Pick disease, cere­ bral hypoxia, hyperthyroidism, subdural hematoma, In the early stages of dementia, the family may be and brain tumors are less common causes. Recently able to provide adequate care at home. With advanced there has even come to light strong evidence linking stages, full-time supervision and total physical care are dementia with anticholinergic medication use in older often required. Dementia is likely to result in institu­ adults (e.g., diphenhydramine)—a category of medica­ tional placement. tions consumed by up to 20% of older people (Gray et al, 2015). Dementia is characterized by changes in Dementia affects up to 10% of adults older than age memory, judgment, language, mathematic calculation, 65 who live in the community. Approximately 5 million abstract reasoning, and problem-solving ability; impul­ older Americans suffer from Alzheimer disease, the sive behavior; stupor; confusion; and disorientation. most common type of dementia. The incidence of Changes related to dementia are progressive and irre­ dementia in those 85 years or older is estimated as high versible. In the early stages, many cases of dementia as 50%. are mistakenly considered a part of normal aging, which can result in delayed diagnosis and treatment. Critical Thinking The stages of dementia are listed in Box 10-5. Many older adults who suffer from the early stages of demen­   tia are able to recognize that something is wrong, but they do not know what it is. They may be rather cre­ Dementia ative in the types of excuses used to explain their prob­ lems. However, in the later stages, impaired cognitive What amount of personal connection have you had with a function is dramatic and obvious, even to a casual person who has Alzheimer disease or another form of demen- observer. tia? If possible, identify one specific individual whom you can recall well. Common behaviors seen with advanced dementia • In what context did you interact with this person (home, include wandering, excessively emotional reactions (catastrophic reactions), combative behaviors, suspi­ hospital, extended care)? ciousness, and hallucinations or delusions. These agi­ • How much continuous time did you spend with this tated behaviors, which are often worse late in the day, are referred to as the sundown syndrome or sundown- person? ing. Affected persons often do not recognize even their • What behaviors did you observe? closest family members and friends. These abnormal • How did you respond to these behaviors? behaviors are frightening to the family and anyone • Did you find interacting with this person to be stressful? who cares about the affected individual. Describe. People suffering from dementia are at increased risk Now imagine being a spouse or child caring for this individual for injury and personal neglect. They are unable to in a home setting. recognize or understand hazards in the environment. • How do you think this person’s experiences differ from Box 10-5  Stages of Alzheimer Disease yours? • What types of stressors do you think the person PRECLINICAL ALZHEIMER DISEASE • Measurable biologic changes (biomarkers); specific experiences? • What could you suggest to help this person cope? biomarkers include brain imaging studies and protein • What support services are available in your community? in spinal fluid • No obvious symptoms of memory loss or confusion ASSESSMENT/DATA COLLECTION • Occurs years to perhaps decades before the next stage   MILD COGNITIVE IMPAIRMENT (MCI) CAUSED BY • Does the person mention any changes in memory? ALZHEIMER DISEASE • Does the person’s family or significant others notice • Mild changes in memory, reasoning, and visual memory changes? perception • Does the person have difficulty remembering recent • Noticeable to person affected, friends, and family • Capability of carrying out everyday activities or remote events? • Can the person grasp new ideas, or does he or she DEMENTIA CAUSED BY ALZHEIMER DISEASE • Memory impairment have difficulty with this? • Behavioral symptoms • Can the person make appropriate, informed • Impaired ability to function in daily life decisions? From O’Neill: Common psychosocial care problems of the elderly. In de Wit • Does the person find it difficult to learn new and O’Neill: Fundamentals of nursing, ed 4, 2014, St. Louis, Elsevier Science. things? • What helps the person learn new things? • What is the person’s dominant language? • Does the person speak other languages? • What is the person’s language/vocabulary level? Education level? • How long is the person’s attention span? • Are there significant behavior changes, including hyperactivity (agitation, excitability, distractibility) or hypoactivity (lethargy, apathy, somnolence)?

Cognition and Perception  CHAPTER 10 189 • Is the person restless, uncooperative, belligerent, to point out important events such as birthdays, angry, withdrawn, or threatening? holidays, and special activities. Remind the person of daily events; explain procedures before they • Has the person experienced any delusions or happen. If the person becomes combative, do not hallucinations? argue with him or her. Instead, focus on the feel­ ings that the person exhibits by using reflective • Are there particular times of day when behavior is statements such as, “I know that this isn’t what most noticeably different? you want to do right now, but it’s dinnertime and the food is here.” • Does the person have a history of stroke or other 4. Provide a structured environment that ensures brain disease? safety yet enables the person to keep active as long as possible. Provide an environment free • Have there been any recent changes in medication from hazards that could lead to falls. Individuals or dosage? who get up frequently might benefit from wearing shoes even when in bed so that they have better • Are there any signs of infection (urinary tract infec­ balance and footing when they get up. tion, pneumonia)? Some people suffering from dementia become • What is the level of hydration? less active; others demonstrate pacing or other • Is the person constipated? repetitive movements. To maintain strength and • What is the person’s oxygen saturation? joint mobility, encourage inactive persons to • What are the results of the Mini-Cog™? (See Chapter perform some physical activity that they enjoy each day. Identify specific activities and struc­ 8 for more details about this tool.) ture time into the care plan. Activity, occupa­ tional, and physical therapists can help develop NURSING DIAGNOSIS a plan to meet individual needs (Box 10-6). Allow individuals who pace to do so without   restraint. Encourage pacers to take rest periods during the day so that they do not exhaust Chronic Confusion themselves. Wanderers may need to be housed on a care unit NURSING GOALS/OUTCOMES IDENTIFICATION with controlled exits that set off alarms when anyone passes through the door. Staff can also   monitor wandering by use of an electronic The nursing goals for older individuals with chronic Box 10-6  General Approaches for Working confusion are to (1) remain free from injury; (2) assist With Confused Older Adults in activities of daily living to the highest level possible; and (3) seek assistance when needed. • Provide a calm, safe, and structured environment with a limited number of stimuli. NURSING INTERVENTIONS/IMPLEMENTATION • Use a calm, gentle, one-on-one approach.   • Speak normally and informally as though the person is The following nursing interventions should take place not confused. in hospitals or extended-care facilities: • Allow plenty of time; avoid hurrying. 1. Assess behavior on admission and at regular • Determine the confused person’s reality; avoid intervals. Correct identification of the type of cog­ confrontation or forced reorientation. nitive loss is important so that appropriate medical • Encourage reminiscence using family pictures, and nursing interventions can be planned and implemented. If a sudden change in behavior is common activities, or objects. observed in a person who has had normal cogni­ • Provide familiar clothing and personal items from tion, it is usually a physiologic problem that can be diagnosed and treated, not chronic confusion. home. However, for persons who already have a history • Redirect attention or use some other form of of cognitive changes, it is more difficult to identify these changes. Progression from mild acute confu­ distraction to reduce anxiety resulting from disturbing sion to chronic confusion can occur but may be thoughts. missed unless caregivers pay close attention to • Provide safe, repetitive activities within individual subtle changes in behavior. capabilities (e.g., winding yarn and folding towels). 2. Provide assistive sensory devices. Confusion is • Provide continuity of care with a limited group of worse when there is inadequate or inaccurate caregivers. sensory input. Nurses must ensure that older indi­ • Develop and maintain daily routines for care and viduals wear eyeglasses, hearing aids, dentures, activities. and other adaptive devices designed to maximize • Avoid sudden changes in routine, room, or caregivers. sensory perception when necessary. 3. Orient the person to person, place, and time, and provide any other important situational informa- tion, but do not force the issue, because it can lead to agitation. Address the person by the name he or she responds to best. This may be the first name, such as Audree or Fernando. Refer to calen­ dars and clocks to provide information regarding the day, week, and month. Calendars can be used

190 UNIT III  Psychosocial Care of Older Adults position a mattress on the floor next to the bed to reduce the risk for injury if the person does fall. bracelet that sounds an alarm when the wearer Current Omnibus Budget Reconciliation Act tries to leave the unit or building. In home or hospital settings where these controls are not (OBRA) legislation recognizes the problems practical, bed or chair alarms (weight sensitive involved with restraint and currently restricts pads that set off alarms when the person is off the use of chemical restraints to specific situa­ the pad) can be used to let nurses know that the tions. It is inappropriate to treat nonaggres­ person has gotten out of his or her bed or chair. sive behavior with psychotropic medication. Adequate lighting is important to reduce the Nonaggressive individuals are more likely to likelihood of falls and to reduce fear induced by respond to alter­native therapies such as music, misperception of shadows. dance, exercise, art, or other forms of activity therapy (see Complementary and Alternative Complementary and Alternative Therapies Therapies box). Verbal agitation is not typically responsive to medication. In 2008, the FDA   ordered that a “black box” warning (the stron­ gest advisory short of pulling a medication off Light Therapy the market) be placed on all antipsychotics Studies have shown that bright light therapy, also known as when used with dementia-related psychosis, phototherapy, may improve the length of sleep and decrease because they have been associated with some of the agitated behaviors commonly associated with increased risk of death (O’Neill, 2014). Even the sundown syndrome. In this therapy the patient sits or works newer atypical antipsychotic medications such near a light therapy box, and bright light indirectly enters the as risperidone have an increased risk of death eyes. It is important that the patient not look directly into the and carry a black box warning for cardiovascu­ therapy box, as directly looking into the light can be damaging. lar events (Riggs, 2013). Under the latest guide­ The therapy is prescribed for a specific amount of time, from lines, antipsychotics may be prescribed for 15 minutes to 2 hours in length, depending on the intensity of dementia, but only after “medical, physical, the light. functional, psychological, emotional psychiat­ ric, social and environmental causes [of behav­ 5. Provide continuity. Too many new faces or changes iors] have been identified and addressed” are frightening and disturbing to confused older (Center for Medicare and Medicaid Services adults. Whenever possible, assign care to a consis­ [CMS], 2013). If an antipsychotic is adminis­ tent group of caregivers who can develop a trust­ tered, monitor the patient closely. When psy­ ing relationship. The older adult should have chotropic medications are used, they should be access to familiar personal belongings such as pic­ administered at the lowest dose and for the tures or a blanket or purse. These can provide shortest possible time. comfort and help the person keep some contact with reality. Complementary and Alternative Therapies 6. Administer psychotherapeutic medications as   ordered. A few medications are available to aid in the treatment of cognitive disorders such as Music Therapy Alzheimer disease. These medications do not cure or reverse existing cognitive loss but are often Music therapy has been shown to be beneficial tool when beneficial in improving memory, alertness, and working with cognitively impaired older adults, including those social engagement. The most commonly prescribed suffering from dementia. It is hypothesized that musical stimuli medications include tacrine (Cognex), donepezil activate the creative right side of the brain, which, in turn, (Aricept), galantamine (Razadyne, formerly facilitates the entry of information to the logical left side of the known as Reminyl), and rivastigmine (Exelon). brain, thus enhancing cognitive function. Following are some behavioral responses to music: 7. Avoid use of physical and chemical restraints. • Improved mood Keeping confused persons restrained in beds or • Decreased depression chairs tends to increase their level of confusion. • Muscle relaxation Using physical and chemical restraints can be • Diminished fear and apprehension harmful and can actually make the behavior worse. • Improved physical movement during therapy Restraints are a form of imprisonment, and using them without a valid medical reason can be 8. Structure participation in activities of daily grounds for legal action. Restraints were tradition­ living. If affected people are able to perform any ally used to protect people from falls or other of their own physical care, encourage them to do injury. Too often, however, they were used so that so, particularly in the early stages of dementia. nursing staff did not have to take time to ade­ This helps maintain physical strength and range of quately meet the older person’s needs. Rather than motion, and promotes self-esteem for those who protecting older adults, restraints can cause harm are aware that they are losing functional ability. and lead to physical deterioration. It may be more appropriate to keep the bed in low position or

Cognition and Perception  CHAPTER 10 191 FIGURE 10-6  The nurse offers simple clothing choices to the patient. trigger catastrophic reactions or delusional behav­ (From Kostelnick C: Mosby’s textbook for long-term care nursing ior. Making decisions and responding to questions assistants, ed 7, 2015, St. Louis, Mosby.) are stressful to those suffering from dementia and should be avoided. Certain actions on the part Keep routines simple. Individualize the care plan of nurses will help the person regain control. for each person and have all caregivers follow it Distractions such as a walk or a cup of tea can be consistently. Provide simple step-by-step direc­ used to divert the person’s attention. If this does tions. Keep choices to a minimum because they not work, it may be necessary to take the person tend to increase anxiety and agitation (Figure to his or her room or a quiet place free from the 10-6). Keep clothing simple; modify clothing stimuli that caused the upset. Simple touch and to make dressing and undressing easy, thereby reassurance, even sitting quietly with the person, reducing frustration. Hair should be styled so may be enough to reestablish control. that care is quick and easy. Shorter styles make shampooing and grooming easier and less time- Clinical Situation consuming. Keep mealtimes as pleasant as possi­ ble. Finger foods are more easily managed than are   foods that require the use of silverware. Serve soup or beverages in cups with handles that are easier Keep Calm and Carry On to control. To prevent burns, pay careful attention It is essential to remain calm when confused individuals act to the temperature of hot beverages or soups. out. It is not easy for nurses to deal with repeated irritating Prepare trays before serving to minimize delay or hostile behaviors, but they must remember that anger, and frustration. Cut meat into easily digested arguments, and explanations only confuse the person and pieces because the person may forget to chew make the situation worse. Even if nurses do not say anything before swallowing. Reminders to swallow are nec­ negative to the person, body language may communicate a essary in some cases. Toileting schedules can help lack of acceptance. Frustration can be perceived by older reduce episodes of incontinence. Many confused persons, despite their confusion. If nurses are unable to control older adults become increasingly agitated when their personal behavior, it may be necessary to leave the situ- they need to eliminate, even if they do not recog­ ation and seek support from other staff members to regain nize the sensation. self-control. 9. Structure the environment to minimize disrup- tion; avoid sudden changes of room or environ- 11. Use effective communication skills. Using effec­ ment. Frequent change of staff, large numbers of tive communication techniques can promote strange people, excessive noise, and excessive positive interactions with confused older adults. amounts of activity can be overly stimulating to Smiles, eye contact, and gentle touch should be those who suffer from dementia; therefore, keep used. Express genuine interest and warmth and them to a minimum. Sudden changes of room or listen to the confused person, even if the words do even rearrangement of the furniture and belong­ not make sense. Allow the person adequate time ings can cause increased confusion, apprehension, to express himself or herself. When giving infor­ and agitation. Whenever possible, avoid room mation, keep the messages short and simple, using changes. If it is necessary, the new room should be words that are familiar to the person, and speak in as similar to the old one as possible. Do not move a calm, natural tone of voice. personal effects unless necessary for safety. 10. Develop a plan to deal with “acting out” behav- 12. Consult with family and the multidisciplinary iors. Excessive stimulation and stress are likely to team. The family may be able to provide valuable information regarding the older person’s likes, dislikes, routines, and fears. When they have been providing care in the home, families may also be able to provide suggestions for approaches that have worked in the past. Care of confused older adults requires cooperation and coordina­ tion between various departments so that continu­ ity can be maintained. Regular “staffings” that include all relevant departments and disciplines provide an opportunity to review the person’s current status and revise the plan of care. The following interventions should take place in the home: 1. Help the family accept the diagnosis. The diagno­ sis of dementia is difficult for loved ones to accept. They must be allowed opportunities to verbalize concerns and express feelings of anger, frustration, or helplessness.

192 UNIT III  Psychosocial Care of Older Adults family often needs assistance in making contact with these facilities or with a social worker who can 2. Help the family adjust to the demands of provid- help them with the planning. In addition to helping ing care for a cognitively impaired older person. with the planning, nurses should provide emotional People with severely altered thought processes support to the family. The decision to move a loved cannot be left alone. It is challenging to devise a one to a long-term care facility is exceedingly stress­ plan that enables families to supervise impaired ful, and the family is likely to experience feelings of older adults while also allowing them to continue helplessness or guilt. with their own lives. Nurses can do several things 6. Encourage families to plan for end-of-life deci- to help families cope with this situation. Nurses can sions. The family needs to discuss issues such as a explain and demonstrate the types of behaviors, guardianship or health care decision maker. They actions, and communication techniques that are should be encouraged to seek advice from the likely to be effective. They can help families make primary caregiver and a lawyer before severe modifications in the home environment that will mental deterioration occurs. In some cases, a hospice provide optimal safety yet maintain some sem­ referral is appropriate and can provide valuable blance of a normal home. Nurses can also recom­ care services for physical care needs of the Alzheimer mend books and pamphlets that provide families disease patient. with more detailed and specific information. Several 7. Use any appropriate interventions that are used in good books on the care of patients with Alzheimer the institutional setting (Nursing Care Plan 10-1). disease are available in bookstores. The Alzheimer’s Association has many good reference books and NURSING PROCESS FOR IMPAIRED pamphlets, including a handbook titled Home Care of the Alzheimer Patient.   Community Considerations VERBAL COMMUNICATION   The ability to communicate by using words or lan­ guage is a uniquely human skill. It is so much a part Silver Alert of our daily lives that we do not even consider the Many states have recently enacted “Silver Alert” programs possibility of losing it. Yet many people are forced to whereby local police have the authority to request the state live without the ability to speak or communicate highway patrol to send out electronic bulletins to the public, through words. Individuals who experience cognitive news media, and broader law enforcement when an older or sensory changes commonly lose the ability to use adult, usually with Alzheimer disease or another dementia, is words to communicate effectively. reported missing and believed to be in danger. More than 30 states have enacted Silver Alert or similar programs, leading Speech is the term used to refer to spoken language. to the safe return of many older adults to their homes. Speech requires coordinated functioning of the brain, cranial nerves, pharynx, larynx, and lungs. The normal 3. Provide emotional support and help the family physiologic changes of aging affect the quality of identify coping strategies. Coping with the day- speech. Normal speech in older adults tends to be to-day responsibilities of caring for a cognitively slower, softer, less fluent, less rhythmic, and breathier impaired older person is highly stressful. Regular than in younger individuals, and it often has a tremu­ visits to assess how the family is coping, as well lous quality. Patients who suffer from neurologic as time spent listening to concerns, help family damage affecting muscle control may experience members deal with their fears and anxieties. more than usual difficulty with speech articulation, a condition called dysarthria. Speech is only a part of 4. Identify community resources. Support groups for language. the families of Alzheimer disease or other dementia sufferers are available in many communities. Nurses Language is a broad term that includes all modes should keep abreast of support groups that are of spoken or symbolic communication. Language available in each community so that they can supply allows us to send and receive messages from other this information to concerned family members. humans. We use language to convey our ideas and Nurses should encourage family members to par­ to make our wishes known to others. Without the ticipate in these groups. Respite care programs are ability to communicate, we are isolated from the world also available in many communities. These pro­ around us. People who lose the ability to use language grams provide supervised care for a few hours, and or to speak are likely to experience problems. Older even for days at a time, so that the family members adults with impaired verbal communication skills can spend time doing the things they need or want often become depressed, agitated, and frustrated; they to do without worrying about care responsibilities. feel excluded from normal social interactions. 5. Help families make arrangements for institutional Language is a complex and not completely under­ placement, if necessary. If the demands of caring stood function of the brain. Both hemispheres of the for the impaired person become physically or psy­ cerebral cortex contribute to the process of encoding chologically excessive for the spouse or family, and decoding language, but two regions of the brain nursing home placement may be necessary. The

Cognition and Perception  CHAPTER 10 193   Nursing Care Plan  10-1  Chronic Confusion Mr. Quick has a history of organic brain syndrome. He is not oriented to person, place, time, or situation. He often cannot remember whether he has eaten or what he should be doing at any given time. His behaviors are sometimes socially inap­ propriate; for example, he wanders into rooms and takes the belongings of other residents. He has a very short attention span and is unable to follow most directions. He likes to wander the halls and often laughs to himself. He sometimes sits in the dayroom if the radio is playing and taps his foot to the music. NURSING DIAGNOSIS Chronic Confusion DEFINING CHARACTERISTICS • Longstanding cognitive impairment • Altered response to stimuli • Altered personality • Altered interpretation • Impaired memory • Impaired socialization PATIENT GOALS/OUTCOMES IDENTIFICATION Mr. Quick will sustain no harm. NURSING INTERVENTIONS/IMPLEMENTATION 1. Address Mr. Quick by name. 2. Make eye contact before attempting to communicate. 3. Use pictures and familiar objects to orient him to his own room. Place a recognizable picture or other device at the door. 4. Provide a simple calendar or clock to help orient him to time. 5. Use simple language and short sentences. 6. Use concrete objects or other visual cues to explain things. 7. Allow adequate time for social interaction and communication. 8. Encourage participation in music therapy sessions. 9. Assess for changes in mental processes. 10. Notify the primary care provider of significant changes in mental status. EVALUATION Mr. Quick is still not oriented to person, place, time, or situation. He continues to wander the halls on the unit when not distracted. He will sit still to fold and unfold towels or other repetitive tasks. He sings and claps along during music therapy sessions. You will continue the plan of care. CRITICAL THINKING QUESTIONS 1. What other activities can you identify that would be appropriate for Mr. Quick? 2. What safety precautions are needed if he continues to wander in the halls? play key roles in language and speech: Broca’s area, language; and global aphasia, in which the person which is located in the posterior frontal lobe, and loses the ability both to understand language and to Wernicke’s area, which is located in the posterior tem­ express himself or herself using language. Each of poral lobe. If either of these areas is damaged by these categories has several subclassifications. trauma or oxygen deprivation for prolonged periods of time from occlusion or hemorrhage, serious lan­ Receptive aphasia is not the same as deafness. guage problems can occur. The most common lan­ Communication problems in deaf people are caused guage problem seen in older adults is called aphasia by mechanical or neurologic defects that do not allow (or dysphasia). sounds to enter the nervous system. People suffering from receptive aphasia hear sounds normally but Dysphasia should not be confused with dysphagia, are unable to give these sounds meaning. In some which is difficulty in swallowing. Stroke or head cases, this loss is complete; in others, only specific trauma can cause both problems. Speech pathologists language reception is lost. Some people cannot are an excellent resource for information about speech understand spoken words but can understand written problems and swallowing disorders. words. Others can repeat the spoken words but cannot give any meaning to them. Still others can Aphasia has been classified in several different understand single words but not sentences or word ways. The most common classification includes recep- combinations. tive aphasia, in which the person has difficulty under­ standing language; expressive aphasia, in which the Like receptive aphasia, expressive aphasia comes in person is unable to express himself or herself using more than one form. Broca aphasia is a common form

194 UNIT III  Psychosocial Care of Older Adults Table 10-4  Comparison of Common Types of Aphasia NURSING GOALS/OUTCOMES IDENTIFICATION BROCA APHASIA WERNICKE APHASIA   Lesion in frontal lobe Lesion in temporal lobe The nursing goals for older individuals with impaired Expressive or motor Receptive or sensory verbal communication are to (1) communicate needs with minimal frustration; (2) demonstrate an increased Speech is slow, labored, Speech is rapid, fluent, ability to communicate needs and feelings; and (3) hesitant, nonfluent, poorly normal in tone, clearly express satisfaction with or acceptance of alternative articulated articulated, and long methods of communication. and rambling NURSING INTERVENTIONS/IMPLEMENTATION Short sentences with little May follow stereotyped grammatical structure patterns   Nonsense or jargon speech The following interventions should take place in hos­ indicates noncomprehension pitals, in extended-care facilities, and at home: 1. Assess the older adult’s communication problems in which the person is able to understand verbal and written language but is unable to speak words fluently. and abilities. Communication problems and abili­ The area of the brain that coordinates the muscles of ties differ from person to person. It is important to speech is damaged. This form of aphasia is particularly understand the specific problems and capabilities of frustrating because the person knows what he or she each older adult so that the plan of care can be wants to say but cannot get the words out. In Wernicke individualized to best meet the individual’s needs. aphasia, the person is able to speak, but the words 2. Identify specific approaches that are effective for produced may be nonsensical or have little connection each person. Many techniques can facilitate com­ with reality (Table 10-4). munication; try a variety of these to determine which are most effective. When working with an The term global aphasia is used when receptive and older adult with impaired verbal communication, expressive language skills are lost. People suffering use the following approaches: (1) face the person from global aphasia are profoundly affected. If any when speaking, and establish eye contact; (2) speak communication ability remains, it is in the form of a slowly and clearly and in a low tone of voice; (3) single sound that may be repeated with a variety of speak in a normal tone of voice, and avoid shouting; pitches, rhythms, and emphasis. (4) allow adequate time for communication (do not hurry the communication); (5) pace communi­ When an older person loses the ability to talk with cation to avoid fatigue; (6) keep messages simple others, he or she finds it difficult, if not impossible, to with one- or two-word phrases; and (7) use touch maintain normal roles and relationships. Even those therapeutically. who fully retain their intellectual function and under­ 3. Document in the care plan the selected techniques standing are viewed differently if they cannot speak that facilitate communication. The specific ap­ clearly. Once the ability to communicate has been proaches or techniques that are effective should be damaged, these older people find they are no longer clearly documented in the plan of care so that all treated as capable, competent adults, but are instead caregivers can use them consistently. This will treated as though they were deaf or mentally impaired. reduce the frustration of both the affected person Friends, family, and even health care professionals are and the staff. increasingly likely to avoid people with impaired com­ 4. Explain effective communication techniques to munication skills. This voidance is rarely deliberate; family members and friends. Explain communica­ it occurs out of anxiety or ignorance. Avoidance by tion techniques to visitors, including family, friends, others increases the likelihood of frustration, depres­ and clergy. This promotes positive interactions and sion, social isolation, and loss of self-worth in older enables both the affected person and his or her visi­ adults. tors to have a good experience. If interactions are ASSESSMENT/DATA COLLECTION positive, there is a greater likelihood of regular visits and interaction with the affected individual.   This enables the older adult to maintain a some­ what more normal pattern of social interaction. It is • Does the person have any sensory limitations? (See wise to avoid large groups of visitors, which might the assessment of disturbed sensory perception on interfere with the person’s concentration and result pages 182-183.) in confusion, frustration, and fatigue. 5. Teach verbally impaired older adults methods for • Has the person experienced any injury or surgery their specific communicating needs. If the older that altered the normal speech mechanisms? adult is unable to communicate verbally, provide flash cards, pads, pencils, picture boards, or magic • Does the person have a history of stroke or cerebro­ slates. If he or she is unable to use these, encourage vascular disease? the use of gestures. Open-ended statements such as NURSING DIAGNOSIS   Impaired verbal communication

Cognition and Perception  CHAPTER 10 195   Nursing Care Plan  10-2  Impaired Verbal Communication Mr. White, age 68, suffers from Alzheimer disease. He is able to understand simple commands and follow them. His speech is brief, hesitant, and garbled. It takes a long time for him to say anything. He often shakes his head and pauses when trying to think of words. He often repeats the phrase “Help me, help me.” At times, he becomes very frustrated when he cannot make his wishes known to his family or the staff. He spends much of his time alone in his room and has been observed crying after a particularly frustrating visit with his family. NURSING DIAGNOSIS Impaired verbal communication DEFINING CHARACTERISTICS • Garbled speech • Difficulty expressing thoughts verbally • Difficulty finding words • Difficulty forming sentences PATIENT GOALS/OUTCOMES IDENTIFICATION Mr. White will maintain the optimal level of interaction with family and staff. NURSING INTERVENTIONS/IMPLEMENTATION 1. Ask yes/no questions whenever possible. 2. Observe nonverbal communication. 3. Use touch to communicate empathy. 4. Speak slowly using short, simple sentences. 5. Repeat, rephrase, and restate messages. 6. Decrease environmental distractions. 7. Establish eye contact before starting communication. 8. Provide visual cues whenever possible. 9. Use pictures of familiar items. 10. Allow ample time for responses. 11. Explain basic communication techniques to family. 12. Consult with speech therapist regarding other communication techniques that may benefit Mr. White. EVALUATION Mr. White follows some simple one- or two-word directions once his attention is obtained. He points to common objects on a picture board and occasionally leads caregivers to an object when told to “Show me.” He continues to have episodes of crying and pleas of “Help me.” His family states that he “seems less upset” when they sit with him in a quiet area or when they look at a family picture album. You will continue the plan of care. CRITICAL THINKING QUESTIONS 1. What other approaches could the nurse use to decrease Mr. White’s frustration? 2. What intervention might help the family deal with Mr. White’s diminishing communication ability? “Show me what you would do with (the item in is. Everyone experiences pain in a unique way. Because question)” may help the individual describe his or no two people mean exactly the same thing when her needs. they say they have pain, nurses must attempt to detect 6. Consult with a speech therapist/pathologist to and determine the severity of another person’s pain determine the most effective communication through careful assessment. strategies. Speech therapists are specially trained to identify and treat communication disorders. Nurses can neither see pain nor measure pain with Whenever possible, consult with speech therapists a meter, but they can detect its presence by careful as soon as a communication problem is suspected. listening and observation. Much information regard­ The recommendations should be incorporated into ing the severity, quality, and location of pain can be the plan of care and supported by all caregivers gained from listening to how the person describes his (Nursing Care Plan 10-2). or her pain; observing the individual’s level of activity; and watching body language for subtle cues such as NURSING PROCESS FOR PAIN grimacing, guarding of a body part, or drawing away when a body part is touched. Various visual pain scales   (Figure 10-7) can help determine the severity of pain. The origin of some stimuli, such as pain, is within the Response to pain differs from person to person. body. Either physiologic damage or psychological dis­ Culture, sex, spiritual beliefs, and age all play a role in tress can result in the sensation we call pain. Pain is a what a person considers painful and how he or she subjective perception. It is what the person tells you it responds to it. Some people believe that pain and

196 UNIT III  Psychosocial Care of Older Adults Pain as bad Visual Analog Scale (VAS) as it could possibly be No pain A B FIGURE 10-7  A, Visual analog scale. B, Wong FACES Pain Rating Scale. (A, From Pasero C, McCaffery M: Pain assessment and pharmacologic management, p. 55, St. Louis, Mosby © 2011, Pasero C, McCaffery M. The scale is in the public domain. May be duplicated for use in clinical practice. B, From Hockenberry MJ, Wilson D: Wong’s nursing care of infants and children, ed 10, 2015, St. Louis, Mosby. Used with permission. © Mosby.) suffering are punishments or ways to atone for wrongs relief from the pain as quickly as possible. Nurses they have done in their lives. Others believe that pain coming from one cultural perspective may be totally is a test of their faith. puzzled when confronted by patients from another. Nurses who think that a person who is quiet cannot be Some cultures teach that a person should be stoic or in pain often fail to look for pain in quiet patients. uncomplaining or that pain should be hidden and tol­ Nurses who are silent sufferers themselves often erated with a minimal amount of intervention. Other become upset with the dramatic behavior of more cultures teach that it is acceptable to express pain by demonstrative people. crying, moaning, and yelling. These individuals expect

Cognition and Perception  CHAPTER 10 197 Older adults are at increased risk for pain because and (3) demonstrate techniques that provide relief of the higher incidence of disease conditions with from pain. aging. Some older adults have a decreased ability to NURSING INTERVENTIONS/IMPLEMENTATION sense pain, whereas others are highly sensitive to painful stimuli. There is no proof that pain decreases   with aging. Pain influences the way older adults feel about themselves and how they interact with others. The following nursing interventions should take place Chronic or unrelieved pain can lead to behavior in hospitals or extended-care facilities: changes. Older persons who demonstrate anger, 1. Thoroughly assess the nature and severity of the depression, or isolation from others should be evalu­ ated for pain. pain. Not all pain is the same. It is easy to miss significant changes in an older adult’s condition, Many older adults deny pain because they fear they particularly someone who suffers from chronic will be avoided or they will lose their independence. pain. A thorough assessment should be done to They live with pain because they think that it is a determine whether current pain is similar to pre­ normal part of growing old. It is not. Others may deny vious pain or is different in degree, location, pain out of fear of becoming “addicted” to pain medi­ or severity. The mnemonic PQRST (provokes, cations. Most patients who take pain medications as quality, radiates, severity, time) provides an orga­ directed, however, do not become addicted (Hitti, nized plan so that all relevant areas are considered 2011). Pain is an indicator that something is wrong in (Table 10-5). the body. It does not have to be tolerated simply If the person is cognitively impaired or noncom­ because the sufferer is old. municative, it is particularly important to watch Determining the presence of pain in confused older nonverbal cues. A close family member who adults is difficult. If pain is not recognized and knows the person’s normal responses can help assessed, serious harm may result. Failure to recognize nurses interpret the person’s behavior. An excel­ pain can cause delays in the treatment of serious lent tool, used internationally, to assess pain in a medical conditions and delays in response to a change patient with dementia is the PAINAD (pain in condition. assessment in advanced dementia) scale. With this scale, the observer scores five different areas: Confused older adults have difficulty interpreting breathing independent of vocalization, negative painful stimuli, identifying the location, and com­ vocalization (such as moaning or calling out), municating the nature of their distress to caregivers. facial expression, body language, and consolabil­ They do not always respond to pain in expected ity (Table 10-6). Do not, however, assume that a ways. Changes in body language, vital signs, and level cognitively impaired person cannot report pain. of orientation are possible indicators of pain. The pres­ Using the PAINAD scale should augment, not ence of pain is likely to result in agitation; increased replace, a patient’s self-reporting of pain. pulse, respiratory rate, and blood pressure; and an 2. Provide comfort measures. Often, simple comfort increased level of confusion. measures (e.g., repositioning, giving a backrub, and ASSESSMENT/DATA COLLECTION toileting) can reduce pain. Fear and anxiety can increase pain. Listening to older adults and provid­   ing emotional support often help reduce pain. 3. Avoid actions that increase pain. Simple actions • Does the person complain of pain? such as jarring the bed or moving an individual too • Is the pain constant or intermittent? When did rapidly can increase pain. Because movement may increase pain, care should be used when moving, it start? transferring, or otherwise touching people in pain. • Where is the pain? Is it generalized or localized? A simple touch, an explanation of what to expect, • How does the person describe the pain (e.g., or acknowledgment of the pain can demonstrate sensitivity to the older adult’s feelings. burning, stabbing, radiating, and gnawing)? 4. Anticipate situations likely to cause pain. Because • Does the pain interfere with activities of daily confused people are unable to report pain accu­ rately, nurses need to anticipate activities or proce­ living? With sleep? dures that are likely to cause pain and institute • What helps control the pain? measures to prevent or reduce it. • Does the person take any medication for the pain? 5. Teach nonpharmacologic approaches to pain control. Many nonpharmacologic approaches are What medication, and how often? available for pain control. Biofeedback, meditation, NURSING DIAGNOSES hypnosis, and imagery are all useful in pain control. These techniques often are not attempted with   older adults because caregivers think that they will not accept or understand the techniques. Many • Acute Pain • Chronic Pain NURSING GOALS/OUTCOMES IDENTIFICATION   The nursing goals for acute or chronic pain are to (1) report an improved comfort level or decrease in pain; (2) verbalize the ability to cope with pain;

198 UNIT III  Psychosocial Care of Older Adults Table 10-5  PQRST Method for Pain Assessment COMPONENT ASSESSMENT QUESTIONS EXAMPLES Pain occurs only when stomach is empty. Provocation What activities or circumstances precede or cause the pain? or Palliation Did the pain occur suddenly or gradually? Pain occurs after exercise. What makes the pain better or worse? Pain builds from mild to severe. Pain decreases with rest. Quality What does the pain feel like? (Describe using patient’s own words.) Dull, aching, sharp, burning, crushing, stabbing, tearing, cramping, throbbing, Region, Where is the pain located? Can the patient touch the specific grinding. Radiation, area? or Referral Pain localized in temporal region of skull. Does the pain remain localized to a small area or does it Entire abdomen hurts. Severity involve a larger area of the body? Pain in pelvic area and region of the Timing Is pain present in one or more areas of the body? scapula. Does the pain begin in one area and then move to another Pain starts in chest and radiates down Additional questions area? If so, where does the pain move to? left arm. How severe is the pain on a scale of 1 to 10? Pain reported at level 7. Which illustration best represents pain? (Use a picture board Pain first noted at 7 a.m. ranging from a happy face to a face with a frown and tears.) Pain has been present for 6 hours. Pain “comes and goes.” When did the pain start? Pain noticed only during evening. How long does the pain last? Is the pain continuous or intermittent? History of intermittent headaches. Does the pain occur only at certain times of the day? Current headache much more severe than Has the patient experienced any pain like this in the past? ever experienced previously. Is the current pain similar or different than previous episodes? Acetaminophen reduces, but does not Did the patient take any medication for pain? Has the medication been effective at relieving pain? How eliminate, the discomfort for 2 to 3 hours. effective? How long was it effective? Table 10-6  Pain Assessment in Advanced Dementia (PAINAD) Scale ITEMS* 0 1 2 SCORE Normal Breathing Occasional labored breathing. Noisy labored breathing. Long independent of Short period of period of hyperventilation. vocalization hyperventilation. Cheyne-Stokes respirations Negative None Occasional moan or groans. Low Repeated troubled calling out. Vocalization level speech with a negative or Loud moaning or groaning. disapproving quality. Crying. Facial Expression Smiling or inexpressive Sad. Frightened. Frown. Facial grimacing. Body Language Relaxed Tense. Distressed pacing. Rigid. Fists clenched. Knees Fidgeting. pulled up. Pulling or pushing away. Striking out. Consolability No need to console Distracted or reassured by voice or touch. Unable to console, distract or reassure. Total† *Five-item observation tool (see the description of each item below). †Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0 = “no pain” to 10 = “severe pain”). Reprinted from Journal of the American Medical Directors Association, 4(1):9–15. Warden V, Hurley AC, Volicer L: Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. © 2003, with permission from the American Medical Directors Association. older adults are not only capable of learning these suffering than necessary. Nurses are often afraid techniques, but they are pleased to have some that administering medication will lead to addic­ control in the relief of pain. tion or dependence. In fact, timely administration 6. Administer medications as ordered. Studies have of medication before pain becomes severe actually shown that nurses tend to underestimate rather decreases the total amount of medication used. than overestimate pain in others. This leads to more Administer pain medications before activities or

Cognition and Perception  CHAPTER 10 199 procedures likely to result in pain. The types and the affected person and his or her loved ones. dosages of medications used to control pain in older Nurses should help those living at home to develop adults are highly individualized and may differ a plan built on the interventions that are most effec­ from those used with younger adults. tive for them. Older adults and their families should be shown how to incorporate these pain-relief mea­ The following interventions should take place in sures into daily activities so that pain is kept to a the home: minimum and the person is able to lead as normal 1. Help older adults and their families develop a a lifestyle as possible. 2. Use any appropriate interventions that are used in plan to cope with pain. Pain, particularly the the institutional setting. chronic pain endured by many older persons, can be physically and psychologically exhausting for Get Ready for the NCLEX® Examination! 2. Why should the nurse use care when assessing pain level in older adults? (Select all that apply.) Key Points 1. Chronic pain is more common with aging. 2. Older people are able to tolerate more severe pain • Perceptual changes are among the most common than younger persons. problems experienced by older adults. 3. Older people have increased sensory perception of pain. • Disturbed vision and hearing present multiple concerns 4. Cognitive changes may alter the ability to report and related to safety and lifestyle. describe pain. 5. There is no useful pain assessment tool for an older • Pain, although not a routine problem of aging, can adult with Alzheimer disease. interfere with the older person’s ability to lead a 6. Behavioral changes may be indicators of pain. fulfilling life. Assessment of the older adults using a pain scale can be useful; the PAINAD scale is useful 3. Which condition which is least likely to be reversible? with cognitively impaired older adults. 1. Dementia 2. Delirium • Nurses must be alert to cognitive and perceptual 3. Confusion changes and identify ways to support as normal a 4. Depression lifestyle as possible. 4. The nurse explains to a family member that the most • Delirium has a rapid onset (hours to days) and is appropriate environment for a person suffering from generally reversible; dementia has a slower onset dementia is one that has: and generally is not reversible. 1. Lots of color and textures 2. Subdued lighting and soft music • Providing care for older adults who are experiencing 3. Bright lights and a TV for stimulation severe cognitive changes, particularly those with 4. Common and familiar objects dementia, challenges the skills and capabilities of nurses, families, and all health care providers. 5. What is the most appropriate intervention for an older adult with dementia resisting efforts to reposition or • Ongoing assessment of perceptual and cognitive ambulate? functioning is necessary to detect subtle but potentially 1. Try again in five minutes dangerous changes. 2. Try to convince the person to perform the activity, explaining the therapeutic benefit • Prompt recognition of problems and careful selection of 3. Call the primary care provider and ask for an appropriate interventions will allow the aging person to antianxiety medication maintain the highest level of function possible. 4. Assess the person using the PAINAD scale Additional Learning Resources   Go to your Evolve website at http://evolve.elsevier .com/Williams/geriatric for the additional online resources. Review Questions for the NCLEX® Examination 1. Hearing aids are worn by many older people. Which statement regarding hearing aids is false? 1. Batteries should be stored in the refrigerator. 2. Ear molds should be cleaned regularly. 3. Most people easily adjust to hearing aid use. 4. Hearing aids are fragile.

chapter 11  Self-Perception and Self-Concept http://evolve.elsevier.com/Williams/geriatric 6. Describe methods of assessing changes in self- perception and self-concept. Objectives 1. Discuss the concepts of self-perception and 7. Identify older adults who are most at risk for problems related to self-perception and self-concept. self-concept. 2. Describe how aging can affect self-perception and 8. Recognize selected nursing diagnoses related to self- perception or self-concept problems. self-concept. 3. Discuss the effects of disease processes on self- 9. Describe nursing interventions related to self-perception and self-concept of older adults. perception and self-concept. 4. Identify signs of later-life depression. helplessness  (p. 201) 5. Identify suicide risk in older adults. hopelessness  (p. 201) powerlessness  (p. 201) Key Terms reminiscence  (p. 206) anxiety  (p. 201) self-esteem  (p. 200) body image  (p. 204) depression  (p. 201) fear  (p. 201) feedback  (p. 200) NORMAL SELF-PERCEPTION AND SELF-CONCEPT idealized. Anyone who does not meet these superficial and artificial standards is somehow judged inferior The attitudes and perceptions people have about and thus is viewed negatively by our society. Few themselves, their abilities, and their self-worth make people are able to meet all of the idealized criteria. up what is often called self-identity. People form This results in a large number of people (of all ages) their self-identities from their values, life experiences, in contemporary society who suffer from negative and interactions with others. People with good self-esteem. self-worth and high self-esteem share certain charac- teristics. They have strong personal values and In trying to meet external standards, people are believe they have the ability to control their lives. They likely to lose themselves and their internal values. The have had positive life experiences and have received more we look to the external forces, the less likely we positive feedback from others. People with poor are to have high self-esteem. The more we look inter- self-worth and low self-esteem tend to have weak nally for our self-worth, the more satisfied we will be personal values and think they have little control in the long run. Shakespeare summed it up nicely in over their lives. They have had primarily negative Hamlet: “This above all: to thine own self be true/And life experiences and have received negative feedback it must follow, as the night the day, thou canst not then from others. be false to any man” (I, iii, 75). We form our self-identities by comparing ourselves It is easy to say that people should draw on internal and our experiences with some ideal. This can be an ideals to maintain self-esteem, but this is difficult in internal ideal drawn from our personal values or an light of external pressures and feedback. In today’s external ideal drawn from the society around us. Many society, people usually have more negative experi- people experience problems with self-worth because ences than positive ones. Therefore, problems relating they always measure themselves against external stan- to self-perception and self-esteem are common in dards. Contemporary standards are communicated people of all ages. Problems relating to self-esteem are repeatedly by advertising and the media. People who particularly common among the poor, those who are young, thin, rich, successful, and attractive are are weak and frail because of chronic disease, and 200 older adults. Studies have shown that women tend

Self-Perception and Self-Concept  CHAPTER 11 201 to have lower self-esteem than men until they reach Health Promotion their eighties or nineties. Not surprisingly, it was also found that health and wealth have positive effects on   self-esteem. Six Ways Older Adults Can Improve Self-Esteem Clinical Situation by Taking Control   1. Take control of your attitude. Health is not the best measure of successful aging, attitude is. A positive Actions That Caregivers Can Use to Promote Self-Esteem attitude is the starting point to taking control of other • Help older adults find interests, activities, or hobbies, areas of life. Have a “can do” frame of mind. Seek out small changes at first, ones that you can make easily. A even learn a new skill. success will increase your positive attitude and enhance • Encourage volunteering, social interaction (including online your motivation to keep trying. communication and social media), and participation in 2. Take control of your health. See your primary care social gatherings. provider and dentist regularly. Follow a regular exercise • Seek guidance or mentoring from older adults and listen plan. Eat balanced meals. Get enough sleep. to their advice. • Avoid “talking down” to older adults. 3. Take control of your appearance. Stand up straight • Keep older adults informed, and encourage them to and hold your head high. Take time to dress up, have maintain control of their health. your hair styled, wear makeup, get a manicure, shave, or buy some new clothes (or use some that are hiding in Feedback from others affects our perception of our- your closet or drawers). selves. People who have caring friends and families tend to have a higher self-esteem and a strong 4. Take control of your time. Be as active as you can. self-identity. Strong families and friends provide Establish a schedule that gets you up and moving. Plan support for one another. They help one another keep to get out for visits, shopping, or activities, or just a walk things in perspective by providing positive feedback several times a week. Better still, at least once a day. and buffering one another from an often negative world. A good family and good friends play an impor- 5. Take control of your social life and relationships. tant part in building and maintaining our self-esteem. Call friends and family; do not wait for them to call you. People who lack supportive family and friends are Go to church or a social gathering, join a book club, join likely to have a poor perception of self and low self- an online community, or do anything you enjoy where esteem. Those who come from dysfunctional families you may meet new people and form new friendships. or who are separated from loved ones run a high risk for poor self-perception and low self-esteem. These 6. Take interest in both old and new activities. people are more likely to suffer from negative feedback Recognize your physical limitations but do not use them because they lack the necessary support to provide as an excuse for inactivity. Take up old hobbies or find balance. new ones. Find out what classes are offered at the senior center, library, or community college. Find a part-time job, A real or perceived ability to make choices plays or volunteer. an important role in self-perception and self-esteem. People who feel capable of controlling what happens Problems related to self-perception and self-esteem are perceive things far differently from those who perceive not as obvious as are physical problems. By their very no control over their lives. Our sense of self-control nature, self-perception and self-concept are subjective. starts with our bodies. Adults are used to having Many people find it difficult to talk about their feel- control of their bodies and bodily functions. Control of ings, often finding themselves unable or unwilling to the movement of body parts and of elimination are so put their feelings into words. More often, our percep- basic we do not even think of them; at least not until tions of self-worth and self-esteem are exhibited to we lose control of them for some reason. Consider others through behavior. Significant behaviors include how you would feel if tomorrow you woke up and the amount of attention paid to personal hygiene and could not move or could not control your bladder grooming, the type and frequency of emotions exhib- or bowels. Would your sense of self-worth and self- ited, body posture, the amount and type of eye contact, esteem change? Adults are also used to having control and voice and speech patterns. People with very high and making choices regarding their activities. Choices self-esteem appear to be very much in control of them- regarding activities of daily living (e.g., hygiene prac- selves and their lives. They are usually well groomed, tices, amount and type of clothing, amount and type maintain an erect body posture, make eye contact with of food, and amount and type of exercise and sleep) others, speak clearly in a normal tone of voice, and are determined by and are reflections of an adult’s self- exhibit emotions appropriate to a given situation. perception and level of self-esteem. Loss of control results in depression, powerlessness, helplessness, People with very low self-esteem often appear hopelessness, fear, and anxiety. Loss of control destroys disinterested and out of control. They often appear self-esteem. (See Health Promotion box.) unkempt or disheveled. They may slump or slouch, and there seems to be little purpose to their movement. Eye contact is infrequent. The amount of communica- tion with others is reduced, is negative in nature, and is often mumbled or abrupt. Emotions can vary from expressions of sadness to full-blown anger.

202 UNIT III  Psychosocial Care of Older Adults attitudes toward aging will be and how they will Most people’s self-esteem and behavior fall between change as Baby Boomers move into old age. these two extremes. As long as behavior falls within Older people who accept the negative societal per- the accepted range of normal, people tend to disregard ceptions are likely to suffer more than those older or overlook what is going on inside other people. Only adults who refuse to accept these stereotypes. when behaviors move outside of the normal range do Unfortunately, those who start with the poorest self- we seriously attempt to understand what is happening concept are the ones who are most likely to accept the inside the person to cause those behaviors. negatives and are particularly vulnerable to loss of self-worth. Physical, social, and economic changes that SELF-PERCEPTION/SELF-CONCEPT AND AGING occur with aging result in changes in the way older adults perceive themselves and their bodies. The Erikson has identified the major task of late life as greater the amount of change, the more likely the maintenance of ego integrity (the sense of self-worth) person is to experience problems related to self- versus despair. Attitudes toward aging, the level of concept. Small changes in appearance or function (e.g., self-esteem throughout life, the extent of physical wrinkles or aches and pains) nibble at the edges of change caused by aging and illness, the presence or self-worth. Serious illnesses (particularly those that absence of emotional support systems, and the ability result in obvious disfigurement or major loss of func- to maintain a degree of control; all of these have an tion, such as strokes) take a large toll on the aging impact on whether or not older adults will be success- person’s perception of self. ful in accomplishing this task. Frequent and significant losses (including decreas- Aging individuals develop their own perceptions of ing physical health; decreasing mental agility; loss of aging. It is difficult to see oneself getting old. Many significant others; loss of pride in appearance, roles, or older adults express dismay with the realization and possessions; and loss of independence) threaten the can even identify a particular moment when they per- perception of control that is important to most adults. ceived themselves as old. One older woman recently These losses can result in a variety of problems, which attended her fiftieth high school reunion. She reported often increase in severity if left unchecked. having a good time but wondered what she was doing with all of these “old people.” A subtle but real change Institutional placement further damages self-worth in her self-perception occurred after that incident. by stripping older adults of many of the personal Before then, she did not feel old; afterward, she was belongings that make up the visible part of their iden- more aware of her age. Successful aging is not so much tity. Facilities that are able to accommodate more than a matter of years lived or health status, but rather a a small amount of clothing and a few mementos of a matter of perception and attitude. Successful aging has lifetime are rare. A lifetime of 80 years is often reduced sometimes been described as “mind over matter.” If to a small closet and bedside stand. you don’t mind, it doesn’t matter. Although losses of physical and functional abilities Poor self-concept, depression, and other negative are damaging to self-worth, loss of the emotional feelings can be seen in the older population. Studies support of loved ones is even more devastating. Death have shown that quality of life and life satisfaction is an increasingly common visitor to older adults. This may be linked to personality and mental health factors. does not make it less frightening; rather it is a reminder Older adults who have had a poor self-concept of one’s own mortality. The friends and loved ones throughout their lives are unlikely to gain self-esteem who made life worthwhile slip away, one by one. The with aging. Older adults who had a healthy level of positive messages that a person is worthwhile, lovable, self-esteem during their younger days may experience and loved become less frequent, and the reasons for some problems during aging, but these are most often living disappear. Losses resulting from death or sepa- a result of societal attitudes. ration from friends and family can leave older adults without those sources of positive feedback that nourish Ageism is still prevalent in our youth-oriented self-worth. society, which far too often portrays older adults as physically and mentally inept, nonproductive, and We cannot prevent loss resulting from death, but dependent. Considering these negative images of loss resulting from separation is another matter. Older aging, it is easy to understand why many people do adults who are separated from their families and sig- all within their power to avoid the physical signs of nificant others are at increased risk for experiencing aging. It is difficult for some younger people to under- diminished self-worth. Breakdown of the extended stand how radically the changes of age or illness can family and increased geographic mobility may result destroy self-image and self-esteem. Many younger in isolation of older adults. Although a large percent- people feel that measures such as hair transplants or age of older adults do not reside with family members, cosmetic surgery look absurd. They mock older adults, they often live alone by choice. A majority of older further lowering the aging person’s self-worth. It will adults report that they continue to have regular and be interesting to see what these insensitive people frequent contact with grown children either in person do as they age. One can only wonder what societal or by telephone.

Self-Perception and Self-Concept  CHAPTER 11 203 Separation from family is often associated with • Agitation and irritability placement in an institutional setting. In spite of the fact • Suspiciousness or unjustified fears that institutional placement is usually the last choice • Mood swings after all other alternatives have failed, older adults • Isolation and withdrawal often feel rejected and isolated when nursing home • Increased use of alcohol or mood-altering drugs placement is necessary. It is a natural response for • Unexplained injuries older adults to feel they have been “put away” because • Verbalization of worthlessness they have little value or worth. These individuals often • Verbalization of suicidal thoughts feel unimportant, unloved, and unwanted. Even if this SUICIDE AND AGING is completely untrue, the perception greatly decreases Older adults comprise about 12% of the total U.S. pop- their sense of self-worth. If family and friends visit ulation, but they account for 16% of the suicides. Older often and show positive concern, self-esteem can be adults at risk for suicide because of depression often maintained. Unfortunately, this is not always the case. present themselves to health care professionals with a It is in institutional settings, where nobody really variety of physical complaints. Many times, an older knows or cares about the inner person, that many adult has been seen by a health professional shortly older adults lose their remaining sense of self-esteem before committing suicide (20% the same day, 40% and self-worth. It is vital that we, the caregivers of the within a week, 70% within a month), but the real sig- older adult, make an effort to know and understand nificance of the complaints was missed. Older women the person behind the aging body: the retired nurse are more likely to experience depression but depressed who married her childhood sweetheart—who later older men and older adults with a history of affective became her caregiver as her memories slipped away— disorders are most at risk for committing suicide. but unfortunately outlived her husband and some of Severe emotional or physical pain, a recent loss, or a their children, for example. Care for each older adult stressful event (such as the diagnosis of a terminal as you would want your mother or father cared for. disease) is present in a large percentage of those who DEPRESSION AND AGING attempt suicide. Depression is more common in the aging population than often suspected or recognized. Studies indicate Older adults have a higher rate of successful sui- the magnitude of the problem. It is estimated that cides than do other age groups. They tend to use more among people over age 65, depression is a problem for violent methods to end their lives. Firearms (71%), as many as 1% to 5% of community-dwelling older overdose, and suffocation are common methods used. adults, 14% of older adults receiving home care, 29% Seniors are less likely to communicate their intentions, to 52% or more of long-term care residents, and 12% although statements regarding helplessness or hope- of hospitalized older adults. Research estimates that lessness, sudden interest in firearms, sudden revision only 1 in 10 older adults who suffer from depression of a will, or verbalization about suicide should never is recognized and treated. Depression is more difficult be ignored. Family members and health care profes- to recognize because typical indicators may be similar sionals can help by being aware of warning signs and to those seen with a variety of medical disorders. For risk factors. Prompt referral to a mental health profes- example, weight changes, changes in sleep patterns, sional is wise if problems are suspected. decreased energy, and changes in psychomotor activ- ity are not only signs of depression, but also signs of NURSING PROCESS FOR DISTURBED numerous other medical problems. Sudden behavioral or personality changes are not a normal part of aging.   Depression may be related to a wide range of factors, including loss of independence or loved ones or SELF-PERCEPTION AND SELF-CONCEPT increased medical problems such as hypothyroidism, anemia, and diabetes. Use of medications to treat When an older adult has a poor self-concept, fear and disease such as antihypertensives, antiarr­ hythmics, anxiety increases. As control over one’s life decreases, anticholesterolemics, cardiac glycosides, analgesics, self-esteem plummets even lower, and older adults fall and hormones, such as corticosteroids and progester- victim to feelings of hopelessness and powerlessness, one, are all associated with increased incidence of which lead to depression. Depression leads to isolation depression. Careful assessment is necessary to recog- from others, further decreasing the sense of self-worth. nize problems with depression before they result in ASSESSMENT other, even more serious problems. Some changes that warrant further investigation include the following:   • Stopping normal routines • Neglected self-care • Does the person verbalize fears or concerns? • Unwillingness to talk • Are these fears of a known or an unknown source? • Does the person verbalize loss of control over his or her life? • Has the individual recently experienced significant losses? • Has the person recently moved or been separated from significant others?

204 UNIT III  Psychosocial Care of Older Adults change has occurred and act as though nothing has happened. Many persons who suffer with this problem • What is the person’s general appearance and are unwilling to discuss their concerns with others for posture? fear that they will be rejected or made to feel different. If they are willing to verbalize their concerns, they may • Does the individual make or avoid eye contact? speak of themselves in a disembodied way, as though • Does the person verbalize concerns regarding the deformity or change is not really happening to them. They may speak of themselves negatively or changes in appearance? with a great deal of disgust that they are no longer who • Does the person make negative comments regard- they once were. They may become preoccupied with their body function and excessively concerned about ing himself or herself? every minor change. They may need reassurance that • Does the person avoid looking in the mirror or at nothing else will happen to them. Many people with altered body image refuse to participate in their own altered body parts? care and resist any plans for rehabilitation. They are • Does the person question his or her worth? likely to verbalize feelings of worthlessness and • Are there verbalizations of failure? Hopelessness? powerlessness. ASSESSMENT/DATA COLLECTION Despair? • Does the person spend most of the time alone, or   does he or she interact with others? See the assessment for disturbed self-perception and • Does the individual accept directions from care­ self-concept starting on p. 203. NURSING DIAGNOSIS givers passively, or does the person express the desire to make his or her own decisions?   • Are there signs of aggression, anger, or demanding behaviors? Disturbed body image • Are there any signs of autonomic nervous system NURSING GOALS/OUTCOMES IDENTIFICATION stimulation (e.g., increased pulse or respiratory rate, elevated blood pressure, diaphoresis)?   • Does the person manifest any behaviors typical of emotional upset (e.g., pacing, hand wringing, The nursing goals for older adults with disturbed body crying, repetitive motions, tics, aggressiveness)? image are to (1) verbalize concerns regarding changes • Are there changes in vocal quality (e.g., quivering)? in body appearance or function (2) identify personal • Does the person complain of headaches? strengths; (3) acknowledge and look at the actual • Does the person have difficulty focusing on activi- changes in body appearance; (4) verbalize willingness ties, remembering things, or making decisions? to modify lifestyle to accommodate physical changes; • Have there been changes in eating or sleeping and (5) demonstrate readiness to participate in therapy patterns? and to use necessary assistive devices. • Has the person started to give away treasured NURSING INTERVENTIONS/IMPLEMENTATION possessions? • Does the person use alcohol or other mood-altering   drugs? Which drugs? How much? How often? • Does the person verbalize the desire to end his or The following interventions should take place in hos- her life? pitals, in extended-care facilities, and at home: Box 11-1 provides a list of risk factors for altered self- 1. Assess the older adult’s perceptions of self, includ- perception and self-concept in older adults. ing strengths and support systems. Even with NURSING PROCESS FOR DISTURBED BODY IMAGE serious impairment, older adults can have strengths that will help them cope with change. Identify the   unique strengths of each person so that these can be drawn on when planning care. People experiencing body image disturbance are likely 2. Establish a trusting relationship. To help older to refuse to look at or touch the affected body parts. In adults work through and accept physical changes severe disturbances, the individual may deny that the or deformities, demonstrate acceptance both ver- bally and nonverbally. Actively listening to con- Box 11-1  Risk Factors Related to Self-Perception cerns and planning care to include opportunities for and Self-Concept in Older Adults the patient to verbalize his or her feelings can help build trust. • Conditions that result in change of body appearance 3. Provide care in a nonjudgmental manner. Because (burns, obesity, skin lesions, chemotherapy, disfiguring nurses are the people most likely to actually see any endocrine disorders such as acromegaly or Cushing deformity, it is particularly important to show no disease, surgical removal of body parts) sign of revulsion or disgust when providing care. Take particular care not to show even subtle body • Inability to control bodily functions language or facial expressions that could be per- • Significant losses (of significant others, possessions, ceived by older adults as a sign of nonacceptance. social roles, financial status) • Recent relocation (particularly if involuntarily) • Chronic pain

Self-Perception and Self-Concept  CHAPTER 11 205 4. Encourage the older adult to look at and touch facial expression is one of sadness; and they usually affected body areas. Nurses are so used to seeing avoid eye contact. These individuals are likely to speak physical deformities (e.g., stomas and amputations) of themselves in negative terms. Statements such as that they may not be aware of just how frightening “Don’t waste your time on me” or “I can’t do anything these are to the affected person. Many people need right” are indicative of low self-esteem. The speech of time and encouragement to even look at the affected individuals with low self-esteem is full of statements body part. Some depersonalize the change and refer of sadness, loss, depression, anxiety, and anger. They to “it” as though the deformity was something can see little that is positive about their lives and tend apart from themselves. Looking at and touching the to focus on negative experiences. People with low self- deformity will help the person accept the change. esteem pay little attention to hygiene or grooming. Until he or she is able to do this, the individual will They tend to be very passive, letting caregivers control not be ready for teaching or self-care. all facets of their lives. They may demonstrate extreme dependence on others, even if they are capable of 5. Focus on abilities, not disabilities. To become doing things for themselves. They are unlikely to initi- motivated, a person must feel that he or she is ate activities, and if they do, they are likely to leave capable of doing the activity. Most older adults, activities unfinished. They are resistant to positive even those with severe deformities, are capable of feedback and may argue or become angry with anyone doing something. Focusing on what can be done attempting to give it. Older adults with low self-esteem instead of on what cannot be done promotes feel- are likely to avoid social contact; if forced to be in ings of self-worth. contact with others, they tend to avoid interaction and stay at the edges of the group or activity. 6. Assist in selecting clothing and/or dressing older adults in a manner that deemphasizes body ASSESSMENT/DATA COLLECTION changes. Clothing that draws attention away from obvious deformities helps maintain body image.   Sweaters, lap robes, and properly fitted clothing can be used to make deformities less obvious. See the assessment for disturbed self-perception and self-concept on p. 203. 7. Ensure that the older adult is carefully groomed. Change soiled clothing promptly. Always keep the NURSING DIAGNOSIS face and hands clean and free from food or other debris. Little things such as neatly combed or styled   hair, a shave, or the application of a tasteful amount of makeup can make the person feel better about his Risk for situational low self-esteem or her appearance. How a person looks makes a difference in how that person feels. Remember, NURSING GOALS/OUTCOMES IDENTIFICATION though, that an older person should never be made to look “cute.” Always groom older adults appro-   priately for their age. The nursing goals for older adults with self-esteem 8. Coordinate rehabilitative care with other depart- disturbances are to (1) identify personal strengths; (2) ments. Physical therapy, occupational therapy, express feelings and concerns; and (3) practice behav- speech therapy, pharmacy, and other departments iors that promote self-confidence. may be involved in the care of individuals who have experienced significant changes in body func- NURSING INTERVENTIONS/IMPLEMENTATION tion. Nurses spend the most time with these indi- viduals and are most aware of the total effect of   various therapies. Coordinate these activities in the care plan to ensure that all groups are working The following nursing interventions should take place toward the same goals. Monitor and document the in hospitals, in extended-care facilities, and at home: patients’ responses to the therapy and their ability 1. Explore feelings and concerns. To plan effective to tolerate the effort required in therapy. interventions that will improve feelings of self- NURSING PROCESS FOR RISK FOR SITUATIONAL worth, nurses must be aware of the unique concerns and feelings of each older adult.   2. Demonstrate acceptance of older adults as people with value and self-worth by responding to con- LOW SELF-ESTEEM cerns, encouraging them to make choices, follow- ing through with their requests, and including Older adults are at risk for losing self-esteem for many them in care planning. Taking time to actually reasons. Those who have low self-esteem are likely to listen and respond to the needs communicated by display certain characteristic behaviors. Body lan- older adults is the best way of demonstrating accep- guage of people with low self-esteem is similar to that tance. Too often, the nurses “listen” and then do of depressed individuals. They are often observed something completely different from what the older with their head slumped on the chest or shoulder; the person requested. This is a subtle way of indicating that the person does not matter. If nurses are unable to comply with the older adult’s requests, an expla- nation should be given so that the individual under- stands the reasons. 3. Encourage participation in self-care activities. Participation in self-care activities allows older

206 UNIT III  Psychosocial Care of Older Adults meet the challenges of the present, and it is a way to prepare for death. FIGURE 11-1  Choosing her own clothes, this long-term resident is Older adults who have completed a life review, actively participating in her own care and is able to retain her sense either on their own or with assistance, seem to of self-worth. (From Kostelnick C: Mosby’s textbook for long-term have a certain serenity. They accept that, although care nursing assistants, ed 7, 2015, St. Louis, Mosby.) not perfect, their lives have been worthwhile. Some find areas of discontent that they are still adults to retain a sense of self-worth. Even small able to correct: They can still find lost friends, acts such as washing one’s own face or eating a finish incomplete personal business, and make piece of toast can help make the older adult feel amends. Life review is a healthy process. It is a some control over her own life (Figure 11-1). normal and necessary way that all individuals, 4. Provide opportunities for reminiscence. Reminis­ particularly older adults, can maintain mental cence, sometimes called life review, is a phenome- health. non that is especially important to older adults. Reminiscing can be done individually or in groups. Nurses tend to focus on the present. Because there Older adults who reminisce alone (as many do) is so much to do, we may not take time to listen to are often highly critical of themselves, feeling old stories. We are so busy making sure that older that they did not make the right choices and adults are oriented to the present that we tend to do the right things. By reminiscing with others, forget about their past. Some nurses think that the true value and merit of life often become talking about all of the “old stuff” is downright clearer. Group sharing tends to be less intense boring. Some even make the mistake of thinking than one-on-one communication. In addition, that participating in these often sentimental and the memories of one person often trigger similar nostalgic conversations is inappropriate, unneces- recollections among other group members. sary, and not a part of nursing care at all. These Different perspectives on situations can help errors can result in missing important information older adults see themselves and their responses regarding the mental health and self-esteem of the in a different light. aging person. When working with a group of older adults, nurses All people, particularly older adults, need to feel should ensure that the group is not too large, or some individuals will not have an opportunity to that their existence has made a difference. As participate. Five to eight people can effectively death approaches, older adults need to feel participate in a group at one time. It is essential that their lives have had purpose and meaning. to remain open and actively listen to all partici- Absence of self-worth leads to despair and hope- pants. Reminiscence therapy may even be bene­ lessness. Erikson stressed the importance of ficial to individuals suffering from Alzheimer seeing value in the life stories of older adults. disease by stimulating remnants of long-term People of all ages reminisce (i.e., think back to earlier memory. times in their lives). This process helps people Various devices can be used to stimulate reminis- work through previous problems and recognize cences. Items such as picture albums and old previous successes. It helps resolve conflicts and movies, magazines, newspapers, or songs can be enables older adults to cope with the present and used to start the conversation. Activities such as future and to go on with life and living. Life writing poems, assembling picture albums, review is not just looking back at the good old making collages, or writing an autobiography times; rather it is a process of determining that may be helpful. Open statements such as “Tell one’s life has had value and merit. It is a way to me about when you started your family or tell me about your job” can be helpful as well. 5. Encourage the family to participate in reminis- cence by providing pictures or items that bring back memories of happy times (Figure 11-2). Encourage families to take the opportunity to share in the memories of their older members. Many families find boxes of old pictures among the older person’s belongings. Sometimes the people and events are familiar; other times they include many unknown and unfamiliar individuals. A review of these pictures often helps trigger memories in older adults and enables them to show a side of them- selves that their adult children and grandchildren never knew anything about. Pictures of a smiling

Self-Perception and Self-Concept  CHAPTER 11 207 FIGURE 11-2  Reminiscing with the patient about his family history Box 11-2  Technology to Enhance Communication promotes self-esteem in older adults. (From Sorrentino SA: Mosby’s textbook for nursing assistants, ed 6, 2004, St. Louis, Mosby.) Technology and computer use among older adults lags behind that of younger generations, but it has been shown to have many benefits when introduced and encouraged. The following are some benefits that have been identified by research: • Enhanced self-esteem • Increased sense of productivity • Decreased depression • Improved social interaction • Improved mental stimulation The most common types of computer activities studied included word and board-type games, computer art activi- ties, and e-mail communications. To mediate some age-related changes in vision, hearing, and mobility, computer manufacturers are constantly improving their technology, including features such as touch screens and voice-activated commands. Social media such as Facebook is becoming a more popular method of keeping up with family photos and events. Technology such as Skype and FaceTime allow older adults to communicate face to face with loved ones who may live far away. FIGURE 11-3  Bringing young and old together is an important part prevent these regrets is to say and do these things of the self-esteem of older adults. (© 2010 Photos.com, a division of when the older person is still alive. It means a lot to Getty Images. All rights reserved.) all of us to hear that we are appreciated and loved. It means even more to older adults, who may be young couple kissing, dancing, taking their children questioning whether their lives have had any to the park, or taking part in any number of other meaning. Young family members are often hesitant activities can help the older person remember better to say positive things face to face because they times. It can also help the family realize that, like assume that the older person knows how they feel themselves, their parents really were young once, or because they just feel awkward saying them. It is facing the same dreams and challenges. This knowl- interesting to observe how many people have no edge can help them grow closer and more aware trouble saying something negative but seem unable of the continuity of family and can provide an to put something positive into words. It is no opening for older people and their families to share wonder that so many people, particularly older feelings that they might otherwise feel uncomfort- adults, have an altered sense of self-worth. able addressing (Figure 11-3). The greeting card industry has capitalized on this fact 6. Encourage families to communicate positive feel- by mass-producing cards to help people convey feel- ings to the older person. Too often, especially at ings they cannot verbalize. Many older adults treasure funerals, grief-stricken family members are heard to greeting cards they receive from family because this is say, “I wish I had told my mother (or father) how the closest they get to true communication of feelings much she (or he) meant to me.” The best way to from family members. Sometimes families need to be reminded and encouraged to meet the need for posi- tive support. Anything nurses can do to help families recognize the importance of positive communication will help older adults (Box 11-2). NURSING PROCESS FOR FEAR   Fear is a feeling of dread or apprehension regarding an identified source. Fear is not unique to older adults, but as functional abilities decrease, fears may become more obvious. The most common fears identified in older adults include fears of change and disruption in their lives or routines, crime and victimization, loss of loved ones, disease, injury, pain and suffering, loss of

208 UNIT III  Psychosocial Care of Older Adults who require assistance in transfers, particularly transfers that involve hydraulic devices. This fear independence, financial destitution, and loneliness. It can be reduced by ensuring that there is adequate is interesting to note that death was not the most feared help and by providing ongoing reassurance during item; in fact, many older people express less fear of the transfer. death than do younger persons. They may state that 3. Provide explanations for all care procedures. Fear they fear the unknown, but not death itself. Many even of the unknown is common at all ages. Many activi- view death as a release from fears and an opportunity ties and treatments that are familiar to nurses are to rejoin loved ones. extremely strange and frightening to older adults, who may fear that the procedure will cause bodily Fear is closely related to anxiety. Individuals with harm or pain. Take care to explain why the proce- known fears usually also experience anxiety, although dure must be done, what will happen, and what the anxiety can occur without a known fear. People person can do to help. Explanations do not always respond to fear in different ways. Some might verbal- remove the fear, but they usually do reduce it. ize feelings of helplessness, others might withdraw from contact with other people, and still others might NURSING PROCESS FOR ANXIETY respond aggressively. Aggressive responses to fear are often misinterpreted by caregivers as anger. Fear can   also result in physiologic symptoms resulting from stimulation of the sympathetic nervous system. Such Anxiety is an unsettled or uneasy feeling caused by a symptoms include dilated pupils, dry mouth, trem- vague or unidentified threat. Anxiety can be mild, bling, elevated blood pressure, increased pulse and moderate, or severe; in extreme cases, it can reach the respiratory rate, palpitations, diaphoresis, diarrhea, level of panic. Anxiety can be acute or chronic. Anxiety and urinary frequency. Physiologic stimulation caused is more prevalent among older adults than among any by high-level anxiety can be dangerous to aging indi- other age group, with studies revealing that as many viduals who are already compromised by endocrine, as 20% of older adults report chronic, often debilitat- respiratory, cardiovascular, or neurologic disease. ing, forms of anxiety. Mild anxiety can actually be ASSESSMENT/DATA COLLECTION good for people, even older adults. A little anxiety keeps people vigilant for potential hazards. A little   anxiety provides the motivation for positive actions such as seeking health care. Those who have never See the assessment for disturbed self-perception and experienced anxiety would have little reason to plan self-concept on p. 203. ahead or take precautions in life. However, persistent NURSING DIAGNOSIS or high-level anxiety can interfere with a person’s ability to perceive situations accurately and to respond   to them appropriately. In addition to behavioral changes of anxiety, stimulation of the sympathetic Fear nervous system can result, with physiologic changes NURSING GOALS/OUTCOMES IDENTIFICATION identical to those seen with fear. ASSESSMENT/DATA COLLECTION     The nursing goals for fearful individuals are to (1) identify specific fears; (2) identify coping strategies See the assessment of disturbed self-perception and that were helpful in the past and use these when fears self-concept on p. 203. arise; and (3) use strategies that help control fear. NURSING DIAGNOSIS NURSING INTERVENTIONS/IMPLEMENTATION     Anxiety The following interventions should take place in hos- NURSING GOALS/OUTCOMES IDENTIFICATION pitals, in extended-care facilities, and at home: 1. Provide opportunities for older adults to express   their fears. Fear is debilitating. It stops people from The nursing goals for older adults diagnosed with being able to take positive actions. Identifying fears anxiety are to (1) identify methods that help reduce is the first step in dealing with them. If older adults anxiety and (2) experience fewer episodes of anxiety. demonstrate signs of fear during care, stop the NURSING INTERVENTIONS/IMPLEMENTATION activity and give the individual the opportunity to express his or her fears. These fears should then be   taken into account when planning a strategy to reduce or eliminate them. Do not minimize or deny The following nursing interventions should take place the person’s fears. Avoid using clichés such as in hospitals, in extended-care facilities, and at home: “Don’t worry, we know what we’re doing,” because 1. Encourage older adults to verbalize their thoughts such statements convey the idea that the person’s feelings are not valid. and feelings. Once thoughts and feelings are put 2. Remove or reduce the most common sources of into words, individuals are often more able to rec- fear. Each of us fears different things. Fear of falling ognize the causes of their anxiety. Once the causes and fear of loud noises are common from the time are recognized, strategies can be designed to help of birth. Falling is a very real fear to older adults

Self-Perception and Self-Concept  CHAPTER 11 209 FIGURE 11-4  Crafts such as knitting may help lessen anxiety and is that of despondency. In most cases, these persons maintain activeness in older adults. (© 2010 Photos.com, a division display few emotions (although some respond with of Getty Images. All rights reserved.) anger). Self-destructive behaviors are common among hopeless older adults. Signs of hopelessness include the person cope with anxiety. Other people (e.g., failure to eat, failure to take prescribed medication, nurses) can often see patterns in the verbalized and failure to follow up with medical care. In extreme thoughts and feelings of anxious people. This per- cases, hopeless individuals may become suicidal. The spective is more objective and often helps the person suicide rate in older adults is higher than that in any with anxiety gain a better understanding of himself other age group, and the numbers appear to be rising. or herself. Allowing the older person to verbalize Any older person who demonstrates severe signs of anger and irritation or to cry may enable the person hopelessness should be watched closely. Hopeless to calm down. older adults who abuse alcohol or other depressant 2. Provide a quiet environment and reduce exces­ medications are at higher-than-average risk for suicide. sive stimulation. Excessive noise or activity usually ASSESSMENT/DATA COLLECTION increases anxiety. A quiet room with minimal contact and stimulation may help calm older adults.   Reassurance with gentle touch and empathetic communication may also help. Stimulating bever- See the assessment of disturbed self-perception and ages such as coffee should be avoided. self-concept on p. 203. 3. Provide distraction or diversion. Moderate anxiety NURSING DIAGNOSIS may decrease if the individual becomes involved in another activity that he or she finds pleasant. Quiet   activities such as listening to music, watching tele- vision, or working on a craft are soothing to many Hopelessness older adults (Figure 11-4). NURSING GOALS/OUTCOMES IDENTIFICATION NURSING PROCESS FOR HOPELESSNESS     The nursing goal for older adults diagnosed with hopelessness is to identify activities or interventions Hopelessness is a subjective state in which people feel that promote hopefulness. unable to solve problems or establish goals. They feel NURSING INTERVENTIONS/IMPLEMENTATION that they have no alternatives or choices, even when they can actually control what occurs. Hopeless people   express feelings of complete apathy in response to problems. They are often heard making statements The following interventions should take place in hos- such as “What’s the use in trying; nothing will go right pitals, in extended-care facilities, and at home: anyway” or “Nothing ever goes right for me.” Because 1. Visit older adults frequently and spend time hopeless people cannot see any possible solutions, they tend to be passive and uninterested. They find it exploring the factors that contribute to feelings of difficult, if not impossible, to solve problems or make hopelessness. It is necessary to spend time with decisions. The body language of hopeless individuals older adults to develop enough trust for them to share their concerns. Regular visits that are not related to direct physical care show that nurses are concerned with the person. It is important to get the person to verbalize his or her feelings. Unless nurses know the specific concerns, it is impossible to design approaches that will help a particular aging indi- vidual. Hopelessness is often related to other problems, particularly spiritual distress, grief, and depression. 2. Assess the potential for self-destructive behaviors or suicide. Take seriously any verbalization in older adults of the wish to harm themselves or to commit suicide. Depressed older adults and those who have recently experienced significant loss are at highest risk for suicidal thought. Older adults who live alone are more likely to try to take their own lives. Some commit suicide passively by refus- ing to eat, refusing medical care, or failing to comply with medical treatments such as taking medica- tions. Other older adults choose a very active form of suicide such as drug overdose, shooting, or hanging. Frail older adults are more likely to attempt passive forms; the stronger person is more likely to choose an actively destructive method (Boxes 11-3 and 11-4).

210 UNIT III  Psychosocial Care of Older Adults Box 11-3  Suicide and Older Adults • At least 6000 people aged 65 years or older commit suicide each year. • White men over age 85 are six times more likely to commit suicide compared with the general population. • Medical illness is a major contributing factor to suicide. • Social isolation, serious depression, and a history of self-destructive behaviors increase the risk for suicide. • Life events such as loss of a loved one, uncontrollable pain, and major life changes such as retirement increase the risk for suicide. Box 11-4  Interventions Related to Suicide FIGURE 11-5  Assertiveness. (© 2010 Photos.com, a division of Getty Images. All rights reserved.) ASSESS FOR SIGNS OF DEPRESSION • Changes in appetite or sleep patterns attempt self-care. Individual dignity and control are • Unexplained fatigue too often sacrificed to efficiency. This is particularly • Apathy or loss of interest in life true of older adults who require more time to accom- • Trouble concentrating or indecisiveness plish tasks. It is easier for the staff to do something for • Social withdrawal from family and/or friends older adults than to wait for them to do it. • Loss of interest in normal activities or hobbies • Loss of interest in personal appearance Life in an institutional setting tends to be regi- • Crying for no apparent reason mented and restrictive. In an attempt to meet the needs of many people, it is easy to lose track of the unique- ASSESS FOR OTHER BEHAVIOR CHANGES ness of the individuals. The needs of the institution • Giving away treasured possessions often take priority over the desires of the individual. • Talking about death or suicide If the importance of older adults is not recognized by • Taking unusual or unnecessary risks caregivers, the institution will completely control the • Increased consumption of alcohol or drugs lives of each individual. • Failure to follow through with prescribed medication Persons who are acquiescent and relinquish control or diet of their lives to others without question are often • Purchase of a weapon viewed as the “good” or adjusted residents. Those who protest and demand their own way are viewed as DEMONSTRATE INTEREST AND BECOME INVOLVED WITH the “bad” or maladjusted residents (Figure 11-5). These THE PERSON are mistaken notions. Persons who give up control are • Take clues of suicide seriously; do not ignore them. more at risk for low self-esteem, hopelessness, power- • Ask the person whether he or she is considering lessness, and social isolation than are those who manipulate, argue, or complain to maintain some suicide. control over their lives. • Avoid judgmental statements. ASSESSMENT/DATA COLLECTION • Offer hope and help the person seek alternatives. • Promote a safe environment by removing easy suicide   methods. See the assessment of disturbed self-perception and • Seek help from persons or agencies that specialize in self-concept on p. 203. NURSING DIAGNOSIS suicide prevention.   NURSING PROCESS FOR POWERLESSNESS Powerlessness   Powerlessness occurs when older adults feel they have lost control of what happens to them. Such feelings may result from the loss of control of physical func- tions or body parts or from loss of a body part. Powerlessness is common with hospitalization or placement in an extended-care facility. Nurses often contribute to feelings of powerlessness by taking over or taking charge of older adults. Doing too much for a person is perhaps more damaging than doing too little. By their very competence, caregivers can intimidate older adults and destroy any initiative for them to even

Self-Perception and Self-Concept  CHAPTER 11 211 older person becomes angry and tells the caregiver NURSING GOALS/OUTCOMES IDENTIFICATION to leave him or her alone, or the older person gives up and lets the caregiver do everything. In the first   case, the person may not get help when he or she really needs it. In the latter, the person is likely to The nursing goals for older adults diagnosed with experience a rapid loss of ability. The best approach powerlessness are to (1) identify actions in which they is a balanced one in which caregivers support and can exert control and (2) make decisions and have encourage older adults to perform as much for input in the plan of care. themselves as is safely possible. Unless the situation NURSING INTERVENTIONS/IMPLEMENTATION is harmful, nurses may have to learn to accept less than perfection and avoid redoing what the person   has done for himself or herself. Redoing what has already been done can strip away the older person’s The following interventions should take place in hos- dignity and make him or her feel impotent and pitals, in extended-care facilities, and at home: childlike. Therefore, provide help only when it is 1. Allow older adults to make choices whenever needed and only to the extent it is needed. possible. Even in institutional settings, choices 6. Respect older adults’ right to refuse. The ultimate should be made by older adults as often as possible. power held by patients is the right to refuse care. Menus can be planned to include options such as Older adults who are in control of their mental fac- sandwiches for people who do not like the menu ulties retain this right, and nurses cannot force them items. Display a variety of suitable clothing before to do anything against their wishes. When a person dressing so that individuals can select the articles refuses food, care, or medication, nurses should they desire. Make enough activities available so first determine the reasons for the refusal. Once the that the person can find one that interests him reasons are known, develop a plan to reduce or or her. remove the objections. Unless the reasons for refusal 2. Encourage older adults to do as much as possible are known, any approaches are likely to be unsuc- for themselves. When people perform their own cessful. A good explanation of the importance of the care, they feel more in control. Such control of treatment or medication often can overcome objec- simple things can help maintain a sense of being tions and relieve conflict. In other cases, minor able to influence what happens. modifications such as changing the method or 3. Adapt the environment to encourage independent timing of medications will work. For some indi- activity. Evaluate the environment, taking into con- viduals, consultation with the dietitian, primary sideration the strengths and limitations of older care provider, or other specialist is needed to solve adults. Many older adults lose their sense of power the problem. If alert older persons continue to refuse because things in the environment are outside of care despite attempts to gain acceptance, accept the their control. When older adults must always ask refusal. This does not mean that further attempts to for things or call on nurses for help, the nurses gain compliance cannot or should not be made in control the situation. Modifying the environment so the future. When a person refuses some or all parts that all necessary or desired items (e.g., walkers) are of his or her care, document all of the facts of the close at hand gives control back to older adults. situation, as well as all interventions that were tried. Elevated toilets can reduce the need to call for assis- tance. Providing snacks and beverages in a readily If older adults are unable to make judgments because accessible place such as a lounge provides control. of impaired cognitive function, a different situation 4. Explain the reasons for any changes in the plan of exists. In these cases, actively involve the families or care. At times, the plan of care may need to be guardians in planning care. These individuals may be changed. When this is necessary, inform older able to suggest ways to get the person to cooperate. adults as soon as the change is known. Explain the People who hold legal guardianship can speak for reasons for the change so that the person under- patients in determining what should be done. Nurses stands that the change occurred because of certain should also discuss these concerns and problems with circumstances and not simply because the nurses the primary care provider. Changes in the medical are assuming control of the patient’s right to make plan can often eliminate problems (Nursing Care choices. Plan 11-1). 5. Avoid being overprotective or directive. Nurses and other caregivers often do not allow older adults to use their abilities. In the name of concern and caring, caregivers do too much for older adults. This can lead to one of two possible outcomes: either the

212 UNIT III  Psychosocial Care of Older Adults   Nursing Care Plan  11-1  Powerlessness Mrs. Green, age 90, was living independently until recently, when she suffered a fall that resulted in a broken hip. Her family is unable to provide the ongoing care she requires because they, too, are getting old and they live in a different state. Mrs. Green is a new resident of Golden Grove Nursing Home. She is very passive and allows the staff to do everything for her, despite the fact that she is capable of doing many things for herself. She does not express any feelings or preferences about her care, meals, or anything else. When asked about her perceptions, she says, “It doesn’t matter. You’ll do whatever you want anyway.” She prefers to remain in her room. NURSING DIAGNOSIS Powerlessness DEFINING CHARACTERISTICS • Passive behavior • Dependence on others • Apathetic responses • Verbalization of lack of control • Nonparticipation in care PATIENT GOALS/OUTCOMES IDENTIFICATION Mrs. Green will participate in decision making regarding her care and identify actions within her control. NURSING INTERVENTIONS/IMPLEMENTATION 1. Visit daily for 10 to 15 minutes to allow Mrs. Green to verbalize her feelings and concerns. 2. Respect Mrs. Green’s right to private space. Allow her to choose what belongings she wants and where she wants them. 3. Actively include her in care planning, present her with options, and then follow through with her choices. 4. Explain the reasons for any changes that must be made. 5. Keep the call signal handy and respond promptly when called. 6. Meet her requests promptly. 7. Encourage participation in personal care. 8. Assist her in identifying areas in which she can retain control. EVALUATION The nursing assistant reports that Mrs. Green is demonstrating more assertive behaviors, such as insisting on choosing her own clothing and stating preferences about meals. She has been heard saying, “I will do that later when I am ready.” You will continue the plan of care. CRITICAL THINKING QUESTIONS As her hip has healed, Mrs. Green’s behavior has changed, and she is now described by the staff as being demanding and critical of the staff. 1. What do you think has caused the change in behavior? 2. How could you assess and validate your conclusions? Get Ready for the NCLEX® Examination! • Nurses should pay close attention to what older adults have to say about themselves. Key Points • Measures should be taken to provide emotional • Both age-related and disease-related changes affect support, enhance personal control, and promote older adults’ self-images; societal values and life self-esteem in older adults. experiences also play a role. Additional Learning Resources • Self-concept is closely related to the older person’s values, beliefs, roles, and relationships.   Go to your Evolve website at http://evolve.elsevier .com/Williams/geriatric for the additional online resources. • When older adults suffer losses in any important area of life, self-concept is threatened.   Internet Resources • If older adults are able to maintain a sense of self-worth • Evidence-Based Practices KIT: Depression and Older and personal value, few problems occur. Adults: www.aipc.net.au/articles/what-causes -depression-in-the-elderly/ • If older adults believe that they are of little value, serious problems, including fear, anxiety, hopelessness, and powerlessness, will result. • Disturbances in self-concept and self-esteem can significantly affect the older adult’s response to care.

Self-Perception and Self-Concept  CHAPTER 11 213 Review Questions for the NCLEX® Examination 4. Which is a verbal clue of an older adult experiencing low self-esteem? 1. How is positive self-esteem promoted in older adults? 1. “I need help now.” (Select all that apply.) 2. “I can’t do anything right anymore.” 1. Strong personal values 3. “I wish I were young again.” 2. Supportive family that takes care of everything for 4. “I can’t do things like I used to.” the older adult 3. An external ideal goal drawn from society 5. When assessing an older adult’s risk for self-esteem 4. The ability to find motivation through negative problems, which nursing diagnosis is NOT appropriate? feedback from friends and family (Select all that apply.): 5. Good health and wealth 1. Anxiety 2. Fear 2. The nurse should assess for changes in behavior 3. Hopelessness that are likely to indicate depression such as: 4. Reminiscence (Select all that apply.) 5. Powerlessness 1. Increased alcohol consumption 2. Changes in daily routines 6. The nurse should recognize what signs of suicide risk 3. Agitation and irritability in older adults? (Select all that apply.) 4. Isolation and withdrawal 1. Loss of a spouse or a close loved one 5. More frequent calls to family 2. Obsession with clothes and appearance 6. Complaints of palpitations, trembling, and dry mouth 3. Frequent complaints of physical ailments 4. Giving away possessions to friends and family 3. Which is true of suicide risk in the older adult? 5. Dependence on others to care for them 1. It is lower and less violent compared to other age 6. A new interest in firearms groups. 2. It is highest in white women over 80 years old with a chronic illness. 3. It is increasing, because only 42% of seniors seek treatment for depression. 4. It is often triggered by pain, a recent loss, or a stressful life event.

chapter 12  Roles and Relationships http://evolve.elsevier.com/Williams/geriatric 5. Describe how grief and complicated grief can affect the older adult who has experienced losses. Objectives 1. Describe normal roles and relationships. 6. Select appropriate nursing diagnoses related to role or 2. Discuss how patterns of roles and relationships change relationship problems. with aging. 7. Describe nursing interventions that are appropriate for 3. Describe methods of assessing changes in roles and older adults experiencing problems related to changing roles and relationships. relationships. 4. Identify older adults who are most at risk for experiencing relationships  (p. 214) role  (p. 214) problems related to changes in roles and relationships. social isolation  (p. 219) Key Terms complicated grief  (p. 218) grief  (p. 217) heterogeneous  (p. 215) homogeneous  (p. 215) NORMAL ROLES AND RELATIONSHIPS Cultural Considerations A role is a socially accepted behavior pattern. People   tend to establish their identities and to describe them- selves based on their roles in life. Man, woman, Asian and Pacific Islanders husband, wife, adult, senior citizen, parent, child, son, daughter, student, teacher, doctor, nurse, worker, and • Asian and Pacific Islanders include more than 20 distinct housewife are some common roles. People play many ethnic groups. roles over a lifetime and often must attempt to play several roles simultaneously. • Many of these groups are influenced by the teachings of Confucius, which dictate the importance of the family Roles are identified, defined, and given value by the over the individual. society in which a person lives. Each member of society learns the status of various roles and learns to expect • In keeping with this, children are expected to exhibit “filial certain behaviors, symbols, and relationships that are piety,” a concept from Confucianism that emphasizes acceptable for each role. These behaviors, symbols, obedience and devotion to one’s parents and ancestors, and relationship patterns can differ widely, depend- including honoring and caring for aging parents in the ing on the values and norms of the society in which home. the individual lives. The value assigned by society indicates the status of each role. Those in high-status • Belief in this concept may cause a great deal of conflict roles generally possess more privileges and receive and guilt for younger family members who have become more rewards. For example, modern society gives Americanized in their lifestyles. bosses higher status than employees; teachers higher status than students; employed persons higher status Relationships are connections formed by the dynamic than unemployed persons; and younger, more produc- interaction of individuals who play interrelated roles. tive members of society higher status than older, Studies have shown that social relationships are retired members. associated with improved quality of life, including 214 improved health (Avoilo et al, 2013). Most people develop a wide range of relationships within their families, at work, and during day-to-day social activi- ties. The way individuals occupying each role interact with each other describes their relationships. Rela­ tionships can be short-term or long-term, personal or

Roles and Relationships  CHAPTER 12 215 impersonal, intimate or superficial. Relationships individuals and finds it difficult to establish close rela- change over time and are affected by the role changes tionships with people from different cultural back- of the people involved. grounds. Furthermore, it explains why people of different ages may have difficulty understanding each Each culture and subculture sets standards for des- other. The diversity of the population contributes to ignated roles and relationships. People in various roles the prevalence of role and relationship problems in or relationships are expected to behave in accord with contemporary American society. accepted standards, which include things such as the amount and type of clothing or jewelry that are appro- However, this is not the only role or relationship priate. Standards specify the type of housing, the issue people face. In addition to the interpersonal con- means of transportation, and even the type and amount flict or confusion seen in modern society, individuals of food consumed. Standards specify how individuals can also experience internal role conflict and confu- in the culture relate to each other in social and work sion. Problems occur when the demands of multiple situations. For example, the role perception for a roles and relationships must be met at the same time, middle-class American businessman is that he is particularly when the expectations of one role conflict expected to wear a suit and tie with minimal jewelry, with those of another. For example, a woman today is live in an apartment or house in the suburbs, drive often expected to be wife, mother, and employee. She a conventional car, eat healthful meals, show up for may be expected to keep up the home, prepare meals, work on time, and show respect to the boss. If this supervise the children, be active in school or commu- businessman showed up late for work in jeans and a nity programs, be a social and sexual companion to her sweatshirt, wearing an earring and riding a motorcy- spouse, and be a productive worker, capable of doing cle, and then later eating a hamburger and telling the everything, while working with everyone, and always boss not to “bug” him, most people would be shocked. arriving on time with a smile on her face. Unless Yet this same behavior is not considered atypical for a today’s woman is superwoman, she is bound to fall college student, even one who is studying to be a short of someone’s expectations. businessman. Because people form their self-image based on their A simple, or homogeneous, society is one in which roles and relationships, they are likely to have diffi- all members share a common historical and cultural culty accepting changes in either. Our identity and experience. There is little confusion or conflict in a sense of self are threatened when roles are lost and the homogeneous social system because the symbols, relationships associated with those roles change. The behaviors, and relationships are perceived in the same longer the role was held and the more intense way by all members of the society. Everyone knows the relationships, the greater the grief will be. When the accepted roles and how people in each role are someone experiences role change, symbols and indica- expected to relate to each other. Therefore, there is little tors of that role and status also change. Loss of symbols question and few problems with regard to role or rela- or status is often as painful as the loss of the role. tionship expectations. People may grieve a change of role or loss of relation- ship as much as they grieve the loss of a loved one. A more complex, or heterogeneous, society is one in which the members of many diverse subcultures ROLES, RELATIONSHIPS, AND AGING with different historical and cultural experiences must interact. These subcultures may have their origin in The longer a person occupies a particular role, the race, religion, ethnic heritage, or age. Because subcul- more familiar and, consequently, more comfortable the tures do not share the same experiences, their symbols, person becomes with it. The more comfortable people behaviors, roles, and relationships are not perceived in are in their roles and relationships, the harder it is to the same way by all members of the larger society. adjust to changes. Roles and role expectations are not always clear, and this lack of shared perceptions often leads to mis­ Older adults must adjust to many predictable role understandings, confusion, and conflict. and relationship changes associated with aging, includ- ing retirement, altered relationships with adult chil- The American culture is very heterogeneous and dren, changes in housing, loss of valued possessions, is becoming even more so. Problems are likely to loss of friends resulting from relocation or death, loss occur when people with different role and relationship of a spouse to death, loss of health, and loss of inde- perceptions are required to interact with each other. pendence. All of these changes and losses are poten- The greater the differences in role perceptions, role tially traumatic to older adults. symbols, and role relationships, the greater the likeli- hood that cross-cultural misunderstandings will occur. Some older adults resent the fact that society forces This explains the confusion or stress many people them to retire. Age 65 was once the typical retirement experience when they interact with individuals of age, but that is no longer the case. This change has different ages or from different cultural backgrounds. occurred partially because of financial reasons, but It also explains why a person who was raised in also because many older people do not want to retire. a specific culture is more comfortable with similar Many of these people feel that they would lose too

216 UNIT III  Psychosocial Care of Older Adults There are some roles from which a person cannot officially “retire.” Homemaker is one such role. Older much of their identity if they retired. They say, “I don’t persons who have spent the largest part of their lives know what I would do if I couldn’t work.” Older managing a home, doing the cooking, cleaning, sewing, adults who do retire may adjust well or poorly, depend- and other duties required of a homemaker, may feel ing on the adequacy of their other roles to keep them lost when they are forced by circumstances of ill health satisfied. In general, the more roles and relationships or finances to give up the home. Many older adult a person develops at younger ages, the better his or homemakers (primarily women) have few other roles her ability to adjust will be when some of those roles and feel a great sense of loss when institutionalized. and relationships are lost. Those who took the time to develop hobbies or social interests and relationships outside of the home tend to When an occupational role no longer exists, the adapt better than do those who had no interests other individual often grieves its loss. Many people look than their homes. forward to retirement, but once retired find that they miss both the status that role gave them and the inter- Older adults do not give up the role of parent just action with other people. They often resent the fact that because their children are adults. The role of parent is they are no longer viewed as productive, contributing usually identified as being someone who is self- members of society. They are no longer lawyers, sufficient and in control. Role conflict and altered plumbers, nurses, or teachers; they are just retired family relationships are likely to occur when older people. adults attempt to continue to direct their children’s behavior long after the children are adults or when the The Baby Boomer generation may revise this view parents lose the ability to function independently and of roles and retirement. Perhaps the fact that many are forced to become dependent on their children. have changed jobs and even careers several times Successful adjustment to changes in the parenting role during their working years has given them a different is difficult and requires a great deal of patience, tact, perspective on what they can do with the rest of their and accommodation on the part of all family members. lives. Either from desire or necessity, 83% of this cohort Families who have a history of altered parenting or plans to keep working after retirement. Some need to poorly developed family relationships are likely to continue to work because of loss of pensions or retire- have serious problems, often leading to abuse or isola- ment investments because of downturn in the economy. tion of the older person from his or her family. Others want to work and “try something new” or “stay active and engaged.” Many expect to never fully In addition to being the parent of adult children, retire and plan to work as long as their health permits. many older adults are grandparents. The role of grand- Many people who are not interested in employment parent is often described as being much more pleasant make plans to volunteer, travel, or seek other outlets than that of being a parent. As one grandmother said, for their energy. “I can have all of the fun and enjoyment of children without the responsibility.” Another grandmother Did You Know? replied, “Yes, it’s nice when they come to visit, but it’s also nice when you can send them home.”   Grandparenting allows older adults to share their Early Baby Boomers seem to be having less difficulty adjusting wisdom and experiences with a new, young genera- to retirement than those who preceded them. Many report tion. Because grandparents are often under less daily being highly satisfied with their lives and are in many cases stress and are not the primary disciplinarians of the developing new roles and forming new relationships. A children, they are usually more relaxed and have more common comment heard from this group is, “I don’t know how time to spend on nonessential activities such as con- I ever had time to work full-time. I’ve got too many things to versation and play (Figure 12-1). It is common for do.” This is more likely to be the case for those who have retired grandparents with time on their hands to enter- entered retirement in good health and with substantial eco- tain children with stories or teach the grandchildren nomic resources. Only time will tell if this pattern continues. skills, hobbies, or games that they learned as children. When positive interactions take place between grand- To maintain a connection with those who are still parents and grandchildren, a close bond is often employed, many retired older adults continue to think formed that benefits both parties (Figure 12-2). Mobil­ of themselves as a part of their occupation. A nurse ity and the resulting separation of family members remains a nurse throughout life, a plumber remains often make it difficult for this relationship to develop. a plumber, and so on. Even if they have not worked Divorce or separation of the child’s parents can in the occupation for years, older adults typically also impede the grandparent-grandchild relationship continue to identify with their previous occupational from fully developing. Whether the challenges are roles. This may be particularly obvious in older adult geographic or because of disruption of the family, professionals (e.g., physicians, lawyers, professors, it is vitally important for families to make the extra and ministers) who never stop using their titles. effort to foster this special grandparent-grandchild Many expect to retain the same status level and respect as was paid to them when they were actively employed and are highly insulted if this respect is not forthcoming.

Roles and Relationships  CHAPTER 12 217 Many activities require more than one person to be FIGURE 12-1  Grandparenting. (From Hockenberry M, Wilson D: fun. Many older adults have formed friendships or Nursing care of infants and children, ed 10, 2015, St. Louis, Mosby.) social groups over the years. As more and more of the members move away or die, the older person is likely FIGURE 12-2  An older man reads with his grandchild. (From to become increasingly socially isolated. Older people Kostelnick C: Mosby’s textbook for long-term care nursing who outlive their families and friends often feel that assistants, ed 7, 2015, St. Louis, Mosby.) their lives are without purpose. relationship. If not, both parties are usually worse off when they cannot have the opportunity to know one Many older adults change housing arrangements another. out of choice or necessity. The house may be too big, too expensive, or too difficult to maintain. This is par- Many older people have occupied the role of spouse ticularly true when the health of one or both occupants for 30, 40, or 50 or more years. With the death of a fails or when a widow is unable to keep up the home partner, these people are deprived of a significant role after loss of the spouse. Moving to smaller accommo- and relationship. Marriage is one of the most personal dations commonly necessitates the sale or distribution and intimate relationships. A successful long-term of personal possessions accumulated over a lifetime. marriage requires a great deal of effort; the loss of this This loss of possessions makes the process of moving intensely personal relationship triggers a high level of even more traumatic for older adults. In some ways, emotional distress. Many widowed older adults expe- they are “giving away” their lives. rience severe grief and social isolation as a result of the loss. They describe themselves as feeling as though a Loss of health and independence are probably the part of them is missing, of feeling half-alive. Many most traumatic losses because they involve changes in widows and widowers find their grief so overwhelm- the very essence of who people are. When older adults ing that they cannot even continue to perform normal lose health and independence, they lose control over activities of daily living. their own destiny. They are at the mercy of others (either family or strangers) for care and sustenance. The loss of friends because of relocation or death also results in changed social roles and relationships. As previously discussed, societies establish and define the boundaries of various roles. Individuals are judged by how well they understand and comply with their assigned roles. “Old person” is a role that has many connotations and expected behaviors. In con- temporary American society, an ageist definition of the role of older adults would include adjectives such as helpless, infirm, cranky, and useless. Some older adults accept this stereotype and act the part. However, many older adults are continuing in productive roles and maintaining successful relationships well into their eighties and nineties. Indeed, it is expected that the Baby Boomer generation will try to reinvent aging and break the old stereotypes. Just as they have challenged societal norms from early youth, Baby Boomers are likely to redefine the meaning and intent of life’s later years. NURSING PROCESS FOR COMPLICATED GRIEVING   Grief is a strong emotion. It is a combination of sorrow, loss, and confusion that comes when someone or something of value is lost. This reaction can come in response to the loss of a person, role, relationship, health, or independence. Grief affects thoughts, emotions, and behavior and creates a wide range of physical sensations. The normal grief response follows a somewhat predictable pattern, although the exact amount of time any given indi- vidual needs to work through a loss differs (Table 12-1). Dr. Elisabeth Kübler-Ross also recognizes a five- stage grief process that dying patients may experience. This grief process has also been applied to survivors who have lost loved ones. The five stages are: Denial,

218 UNIT III  Psychosocial Care of Older Adults Table 12-1  Phases of Grieving Behaviors: Crying, searching, sighing, loss of appetite, sleep disturbance, limited concentration, muscle weakness, inability to Shock and Numbness (First 2 Weeks) make decisions, emotional outbursts Feelings: Disbelief, denial, anger, guilt Behaviors: Restlessness, poor memory, impatience, lack of Searching and Yearning (2 Weeks to 4 Months) concentration, crying, social isolation, loss of energy Feelings: Despair, apathy, depression, anger, guilt, Behaviors: Resistance to seeking help or reaching out to others, hopelessness, self-doubt trying to live as if nothing happened, restlessness, irritability Disorientation (4 to 7 Months) Feelings: Depression, guilt, disorganization Behaviors: Renewed energy, reorganization of eating and sleeping habits, improved judgment, renewed interest in activities and goals Reorganization (Up to 18 to 24 Months) for the future Feelings: Sense of release, decreased sense of obsession with loss, renewed hope and optimism Data from Davidson G: Processing sudden loss, 1999, Available at http://www.workroom10.com/content/index.php?id=210 Box 12-1  Normal Loss/Grief Reactions support systems and feel a profound sense of detach- ment. They may lose interest in all activities and even PHYSICAL • Sadness fail to perform the basic activities of daily living. • Persistent fatigue • Guilt ASSESSMENT/DATA COLLECTION • Tightness in chest • Shock • Muscle weakness • Helplessness   • Shortness of breath • Apathy • Susceptibility to minor • What is the person’s marital status (i.e., single, COGNITIVE married, widowed, divorced)? illnesses • Confusion • Hypersensitivity to • Forgetfulness • If the individual has lost a spouse or significant • Disorientation other, how long ago did this occur? noise • Disbelief • Dry mouth • Preoccupation • Does the person live alone or with others? • Headaches • Decreased attention • If the person lives with others, who are they, and • Grinding teeth • Inability to concentrate • Tension how are they related? What is the family • Nausea BEHAVIORAL structure? • Hyperacidity • Absentmindedness • How does the person describe relationships within • Dizziness • Crying the family? • Decreased motivation • What family interactions have you or others EMOTIONAL • Restlessness observed? • Anger • Social isolation • Does the person belong to any social groups? • Anxiety • Inconsistency • Does the person have close relationships with • Ambivalence • Irritability friends? • Depression • Diminished • Is the individual employed? What are the relation- • Fear ships at work? • Irritability productivity • Has the person retired from work? How long ago? • Loneliness • Sleep disturbances What are his or her feelings regarding retirement? • Numbness • Appetite disturbances What does the person do to occupy his or her time? • Panic • Does the person feel a sense of belonging in the community or neighborhood? Anger, Bargaining, Depression, and Acceptance. (See • If in a long-term care setting, has the person estab- Chapter 15 for further discussion.) lished relationships with other residents? • Has the person recently relocated? From home to an Grief is normal after the loss of a significant role or acute-care setting? From home to an extended-care relationship (Box 12-1). Grieving becomes complicated facility? From one unit or room to another? when the person has an exaggerated or prolonged • Does the person spend a great deal of time alone? period of grief. Continued sadness, anger, or denial is • Does the person speak excessively with others or indicative of poorly resolved grief. Often, grief is so remain silent? severe that it prevents the person from functioning • Does the person exhibit signs of withdrawal, anger, normally. Older people experiencing complicated grief depression, sorrow, fear, or shock? may completely shut themselves off from normal • Has the person verbalized concerns regarding losses of persons, jobs, or abilities?

Roles and Relationships  CHAPTER 12 219 Box 12-2  Risk Factors Related to Changes in Roles complex and personal emotion. Because most and Relationships in Older Adults people find it difficult to deal with grief, they avoid grieving persons and avoid discussing anything • Recent loss of a spouse, child, close friend, significant that approaches the source of the grief. These be- other, or cherished pet haviors leave the problem unresolved. To help with grief, it is essential that the grieving person identify • Recent loss of lifelong or valuable roles and confront the loss. Nurses can help by spending • Recent major adjustment in his or her living situation time with grieving individuals and by allowing • Inability to perform familiar roles owing to loss of them the opportunity to verbalize their grief. Once older adults are able to verbalize and acknowledge functional abilities their grief, nurses can use problem-solving methods to help them develop coping strategies. Box 12-3  Actions That Promote Trust 3. Encourage older adults to participate in activities of daily living. Grieving individuals are often • Spend time with the person. totally preoccupied with their loss. Although this • Actively listen to what the person says. preoccupation is understandable, it is incompatible • Address the person by name. with normal living. The more a grieving person is • Smile. able to maintain contact with day-to-day activities, • Use a warm, friendly voice. the sooner he or she will be able to go on with • Make appropriate eye contact. life. Nurses can help by providing structure to • Respond honestly to questions. the day. A plan of care that allows for preferences • Provide consistency of care. while setting limits helps provide this structure. A • Respect confidentiality. daily schedule that is well planned and predictable • Follow through on commitments. often enables grieving older adults to regain some control and to cope with the changes. Provide • Has the person’s sleep or eating patterns changed? encouragement and positive feedback for partici­ • Has the person’s ability to concentrate changed? pation in daily activities to help motivate positive Box 12-2 provides a list of risk factors for problems behaviors. related to changes in roles and relationships in older 4. Identify sources of support. Although nurses can adults. provide some support to grieving older persons, many others can also help. Family, friends, spiritual NURSING DIAGNOSIS advisers, counselors, therapists, and support groups are all valuable sources. Many pamphlets, books,   and other materials are available to help people who are experiencing grief. Many can be found in Complicated grieving libraries, physician’s offices, or other locations where older adults congregate. NURSING GOALS/OUTCOMES IDENTIFICATION NURSING PROCESS FOR SOCIAL ISOLATION     The nursing goals for older individuals with compli- cated grieving are to (1) verbalize their grief; (2) use AND IMPAIRED SOCIAL INTERACTION available support systems; and (3) participate in activi- ties of daily living. Social isolation, the sense of being alone, is a common problem among older adults. It is estimated that NURSING INTERVENTIONS/IMPLEMENTATION between 10% and 43% of older adults in the commu- nity experience social isolation. They are likely to be   uncommunicative and withdrawn and to have few visitors or other social interactions. Social isolation is The following nursing interventions should take place a result of many factors and can be unintentional or in hospitals, in extended-care facilities, and at home: intentional. The more people are separated from family 1. Establish a trusting relationship to encourage ver- and friends, the greater the likelihood of social isola- tion will be. balization of feelings regarding the change or loss. Before sharing their true feelings, older adults must Most social isolation is unintentional. Separation develop trust in their nurses. Trust comes only resulting from death is a common and unavoidable when they believe that the nurses truly care about part of aging. Many older people simply outlive their them as unique human beings and that the nurses families and friends. These people are likely to become will be understanding and sensitive to their feel- isolated unless they establish new social outlets. ings. It takes time and effort to develop trust. Separation resulting from relocation is also common. Trust cannot be forced. It may take days, weeks, or Today, it is unusual for family members to remain in a even months for a grieving person to share his or her deepest feelings. Although trust cannot be forced, nurses can take actions to promote its development. These actions are summarized in Box 12-3. 2. Assess the source and acknowledge the reality of the grief. Grief is very much like pain. It is a

220 UNIT III  Psychosocial Care of Older Adults FIGURE 12-3  A resident maintaining social contact by using the telephone. (From Kostelnick C: Mosby’s textbook for long-term single community. Young family members move to care nursing assistants, ed 7, 2015, St. Louis, Mosby.) find job opportunities; older adult family members move to retirement communities. Information about all activities in a facility should be well communicated to older adult residents. Decreased physical mobility and limited finances Offer encouragement to those who are reluctant can result in social isolation. Physical changes can to participate in activities. restrict an older person’s ability to move about and make social contacts. Financial limitations can lead to Careful planning is needed to prevent social isola- separation from others because of the lack of adequate tion in older individuals with restricted physical money to buy appropriate clothing or transportation mobility. Schedule care activities to allow for to social activities. adequate time for social interaction. Provide for any needed assistance to enable participation in Intentional isolation is less common and is most social activities. likely to occur when older adults fear not being accepted by others. Those who suffer from grief may 3. Spend one-on-one time with the isolated person. be too upset or absorbed in their own problems Those who cannot or will not participate in social to interact with others. Older adults experiencing interaction need extra attention from the nursing changes in body image from procedures such as ampu- staff. One-on-one interaction, even for brief inter- tation or colostomy are also likely to isolate themselves vals during the day, helps isolated people maintain from others. Older people who have cognitive or per- some social contact. Over time, nurses can attempt ceptual problems may isolate themselves because they to motivate these individuals to try other forms of do not understand what is going on around them. social contact. ASSESSMENT/DATA COLLECTION 4. Initiate referrals. Often, the social worker, chaplain,   or activities department can help socially isolated older adults identify acceptable social activities. See the assessment for complicated grieving earlier in the chapter. NURSING PROCESS FOR INTERRUPTED NURSING DIAGNOSIS     FAMILY PROCESSES Impaired social interaction NURSING GOALS/OUTCOMES IDENTIFICATION Normal changes in family processes were discussed in Chapter 1. When older adults or their families verbal-   ize concern or confusion related to a change in roles or relationships, family dynamics should be assessed. The nursing goals for older individuals with impaired Alterations in family processes can occur at any age social interaction are to (1) demonstrate increased par- but are most common when an aging family member ticipation in social activities and (2) identify actions or becomes dependent. resources that will help reduce social isolation. ASSESSMENT/DATA COLLECTION NURSING INTERVENTIONS/IMPLEMENTATION     See the assessment for complicated grieving earlier in The following nursing interventions should take place the chapter. in hospitals, in extended-care facilities, and at home: 1. Assess the reason or reasons for the social isola- tion. Because many factors can lead to social isola- tion, nurses should identify those that affect each individual. Tailor nursing interventions toward solving specific problems. 2. Promote social contact and interaction. Telephone calls and mail can be used to maintain contact with family and friends. Those with computers may stay in touch using e-mail, social media, or internet communication tools. Make telephones readily available and located so that older adults can have privacy yet comfort when using them (Figure 12-3). Equip telephones with amplifiers for those who are hard of hearing. Deliver mail promptly. Offer help to visually impaired older adults in reading mail. Adjust computer screens to display large font characters if needed. Social rooms and lounges should be available for older adults to use for visits. If the individual is confined to bed, provide privacy to conduct visits in the room.

Roles and Relationships  CHAPTER 12 221 feel useless or unnecessary. Some family members NURSING DIAGNOSIS feel that their presence is not desired by the nursing staff. Nurses should recognize that family members   are able to relate to older adults in unique and special ways. Rather than make the family uncom- Interrupted family processes fortable, the nursing staff should do everything pos- NURSING GOALS/OUTCOMES IDENTIFICATION sible to make them feel welcome and at ease. Greet family members by name to help forge bonds of   mutual caring. Respond promptly to requests and show small considerations (e.g., offering the family The nursing goals for older individuals with inter- members a cup of coffee) to make the family feel rupted family processes are to (1) express their feelings valued. regarding changes in roles and relationships and 5. Encourage the family members to assist in older (2) work with family members to develop strategies adult care. Family members are often able and for coping with changing roles and relationships. willing to help the nursing staff care for aging loved NURSING INTERVENTIONS/IMPLEMENTATION ones. Assisting with care provides the family with the opportunity to show their concern for the aging   person. Do not expect or demand that the family assist with care, but encourage it if the family The following nursing interventions should take appears willing. The amount of involvement will place in hospitals, in extended-care facilities, and differ from family to family. Some family members at home: may desire to perform a great deal of the care, even 1. Assess interactions between older adults and bathing and feeding. Others are more comfortable helping with less technical things such as hair their families. Spend time sitting in when family grooming or shaving. Nurses can help families by members visit their aging relatives. Be alert for providing all necessary equipment, by teaching signs of destructive emotions such as anger or frus- families safe and effective ways to perform tasks, tration. If these are evident, suggest a rest time or and by providing positive comments for a job coffee break to reduce the tension and allow the well done. family members a chance to calm down. When they 6. Assist families in identifying factors that are inter- have been separated, attempt to explore their feel- fering with normal interactions. Normal physio- ings individually and suggest coping strategies. logic changes, illness, disability, side effects of 2. Encourage all family members to verbalize their medication, decreased finances, and other events feelings. It is best to explore the feelings of family can affect the behavior of older adults and interfere members independently. People of all ages are with normal family interactions. Perform a thor- afraid to express their real feelings in the presence ough assessment to determine the factors at play of other involved parties. Spend time with older in any given situation. Once the causative factors adults and individual family members in private are identified, work with older adults and their settings. During this time, convey to concerned families to develop a plan that eliminates or reduces family members that all feelings, including those the problems and thereby facilitates more normal of anger and frustration, are acceptable and will interactions. be held in confidence. Expressing the negative 7. Explore community resources. If the family dynam- emotions that are triggered by the stress of coping ics are severely altered, nurses may be unable to with changing roles and relationships is not easy meet the family’s needs. Special assistance in the for most people and will take time. Once feelings form of support groups, geriatric social workers, or are identified, positive coping strategies can be geropsychiatric clinics are available in many com- developed. munities. Be knowledgeable about available com- 3. Assist family members in identifying personal munity resources and inform the family members and family strengths. Each person and each family (Nursing Care Plan 12-1). has weaknesses and strengths. The key to maintain- ing or repairing family dynamics is identification of the strengths. Love, concern, and shared spiri- tual values can be used as a basis for positive relationships. 4. Encourage family members to visit regularly. When an aging family member is hospitalized or resides in an institutional setting, the family may

222 UNIT III  Psychosocial Care of Older Adults   Nursing Care Plan  12-1  Social Isolation Mrs. Hixton is an alert, generally healthy 77-year-old widow who lives alone in the home she and her husband shared until his death from cancer last year. Her daughter lives several hundred miles away and calls occasionally. The home hospice nurse who visited regularly during her husband’s illness stops by as part of her routine follow-up and finds that Mrs. Hixton spends most of her time in the house with the shades drawn and goes out only to buy groceries and other necessary items. She drives to church weekly but does not speak to other church members. She speaks hesitantly to the nurse and makes little eye contact during the conversation. With tears in her eyes, she states that “Nobody cares about me anymore; they all have somebody, but I have nobody.” NURSING DIAGNOSIS Social isolation DEFINING CHARACTERISTICS • Feelings of rejection and being alone • Absence of supportive family or friends • Withdrawal from contact with others • Sad, dull affect • Lack of eye contact • Preoccupation with own thoughts PATIENT GOALS/OUTCOMES IDENTIFICATION Mrs. Hixton will demonstrate increased participation in social activities and identify actions or resources that will help reduce social isolation. NURSING INTERVENTIONS 1. Allow Mrs. Hixton time to verbalize feelings of sadness or depression relating to the loss of her spouse. 2. Encourage her to develop a list of family members and friends with whom she previously socialized. 3. Encourage her to make contact with her daughter by telephone on a weekly basis. 4. Identify social activities that were previously of interest to her. 5. Encourage participation in a grief counseling group. 6. Consult with minister regarding visitations. EVALUATION Mrs. Hixton hesitantly expressed willingness to attend one session of grief counseling. During this session, she sat quietly and listened to others explain what they were going through. At the next home visit she told the nurse, “I think I’ll go to another session. There was another woman there who’s having the same problems I am. She offered to have coffee with me.” You will continue the plan of care. CRITICAL THINKING QUESTIONS 1. What could the nurse do to help Mrs. Hixton prepare for her next grief counseling session? 2. What could the nurse do if Mrs. Hixton had a negative experience at the group counseling session? 3. What are possible interventions the nurse could use if Mrs. Hixton refused to attend further sessions? Get Ready for the NCLEX® Examination! • Social isolation may result from ineffective methods of coping with grief or from impaired family dynamics. Key Points • Roles and relationships are maintained through • People play many roles and have many integral communication with others. relationships over a lifetime. • If the ability to communicate with others is impaired (as • When aging results in loss of these roles and changes is the case with many of the common disorders of in relationships, grief is a normal response. aging such as stroke or dementia), the ability to maintain relationships is affected. • Grieving people are often unwilling to participate even in normal daily care or activities. In complicated grief, • Older adults with impaired communication are likely to the older person may lose all interest in life. feel isolated from family and friends and from normal social interactions. • To break through grief, nurses must attempt to build a trusting relationship in which the older person can work • Nurses who work with older adults should understand through the loss and grief. It is hoped that this will the effects of changes in roles and relationships. enable the person to find new meaning in life and to build new relationships. • An understanding of the significance of these losses enables nurses to assess the behavior of older adults • Older adults may become isolated from social more effectively and to plan interventions that will be of interaction. benefit.

Roles and Relationships  CHAPTER 12 223 Additional Learning Resources 4. What is the most appropriate intervention to use for an older adult who always stays in his or her room?   Go to your Evolve website at http://evolve.elsevier 1. Tell the older adult, “It’s time to go out and see .com/Williams/geriatric for the additional online resources. people.” 2. Use a wheelchair to transport the older adult to the Review Questions for the NCLEX® Examination activity room. 3. Spend one-on-one time discussing the older adult’s 1. An older woman was widowed about a year ago. What concerns. would normal expected behavior at this stage of 4. Call the family and request that they visit more often. grieving include? 1. Loss of appetite, sleep changes, and difficulty 5. Which person is most likely to experience relationship making decisions issues? 2. Improved energy, interest in new activities and goals 1. One who has a large pool of family and friends 3. Restlessness, poor memory, and irritability 2. One who has few interests 4. Crying, social isolation, lack of concentration 3. One who likes solitary activities and states, “I like to be left alone” 2. How do roles change as a person ages? (Select all 4. One who has multiple chronic illnesses that apply.) 1. Communication becomes less important as older 6. What interventions should nurses consider when an adults become more dependent on others for care. older adult is grieving the loss of a role or relationship? 2. Relocation to new environment may separate (Select all that apply.) friends/family and possessions. 1. Encourage communication with friends and family 3. Loss of roles with death of spouse or family members. members. 2. Build a trusting relationship. 4. Isolation is a common expected outcome with aging. 3. Assist with all day-to-day activities until grieving is 5. Retirement brings loss of previous profession/roles improved. or status. 4. Introduce a variety of new experiences each day to encourage social interaction. 3. What characteristics place an older adult at increased 5. Be available to discuss loss without stirring up deep risk for social isolation? (Select all that apply.) emotions or feelings. 1. Sensory changes 6. Identify support groups, counselors, spiritual 2. Decreased physical mobility advisors, and family members who can provide 3. Advanced age additional support. 4. Limited financial resources 5. Incontinence 6. Physical deformity 7. Belongs to an ethnic minority group

chapter 13  Coping and Stress http://evolve.elsevier.com/Williams/geriatric 6. Identify older adults who are most at risk for experiencing stress-related problems. Objectives 1. Explain the concepts of stress and coping. 7. Choose selected nursing diagnoses related to stress- 2. Compare the physical, emotional, and behavioral signs related problems. of stress. 8. Describe nursing interventions that are appropriate for 3. Describe methods for reducing stress. older adults who are experiencing problems related to 4. Discuss changes in stress and coping that occur with stress and coping. aging. meditation  (p. 231) 5. Discuss methods of coping with stress and depression. proactive  (p. 228) reactive  (p. 228) Key Terms relaxation  (p. 228) coping  (p. 228) self-hypnosis  (p. 230) distress  (p. 224) eustress  (Ū-stress, p. 224) imaging  (ĬM-ĭ-jĭng, p. 230) mantra  (MĂN-tră, p. 231) NORMAL STRESS AND COPING muscle pain is a stressor to most people but not to an athlete who views it as a measure of training. Public Stress is a normal part of life. No one lives without it. speaking is highly stressful to most people, but not to Stress occurs when a person is faced with a real or a politician who does it every day. perceived threat or experiences a significant or life- altering change. Stressors include external physical Various rating scales have been developed to quan- threats such as extreme heat or cold, noise, or physical tify the amount of stress caused by common social and trauma; internal or psychological threats such as thoughts psychological occurrences in the lives of older people and feelings; and external social threats such as job pres- (Table 13-1). In these rating scales, various events are sures or changeable social relationships. Stress often based on the proportional amount of stress involved. results from a combination of these factors. The more These scales are general guides to attempt to measure stressors a person faces, the greater the level of stress the amount of stress caused by a particular event. will be: it all adds up. Stress occurs whether the threat Stress is cumulative, and a combination of several or change is positive or negative. Stress can be an smaller stressors can have the same effects as a major exciting or positive change like getting married or stressor. The more stressors a person faces at a time, starting a new career. Dr. Hans Selye described this the greater the likelihood will be of physical, cognitive, positive stress as eustress, whereas the negative stress and behavioral changes, such as weight gain, insom- is distress. nia, and heart disease. Chronic stress has even been linked to Alzheimer disease (Bengtsson, 2013). Each of us faces a steady stream of life events with which we must cope. Some are temporary or minor When confronted with stressful events, the body events, such as taking a test or giving a speech, which undergoes predictable physiologic responses that may cause mild distress for a short period. Major life prepare it to withstand the threat and to maintain events such as the death of a spouse, serious injury, homeostasis. The general adaptation syndrome, birth of a child, or marriage are likely to cause signifi- described by Selye, describes the collective responses cant stress that lasts for a longer period. People expe- of the body to stress. According to this theory, stress riencing high levels of stress feel exhausted, anxious, activates both the sympathetic and parasympathetic and vulnerable. components of the autonomic nervous system, initiat- ing a series of physiologic responses (Gabriel, 2013). Different experiences are stressful to different people. Perception plays an important role in deter- The general alarm reaction, often called the fight- mining what constitutes a stressor. For example, or-flight response, occurs first. In this stage, the 224 body undergoes a predictable range of responses or

Coping and Stress  CHAPTER 13 225 Table 13-1  Stokes/Gordon Stress Scale: Selected Items RANK EVENT OR SITUATION WEIGHT 1 Death of a son or daughter (unexpected) 100 99 2 Decreasing eyesight 99 97 2 Death of a grandchild 96 96 3 Death of spouse (unexpected) 93 93 4 Loss of ability to get around 92 90 4 Death of a son or daughter (expected, anticipated) 90 90 5 Fear of your home being invaded or robbed 89 89 5 Constant or recurring pain or discomfort 89 87 6 Illness or injury of close relative 86 86 7 Death of spouse (expected, anticipated) 85 84 7 Moving in with children or other family 84 84 7 Moving to an institution 84 82 8 Minor or major car accident 82 80 8 Needing to rely on a cane, wheelchair, walker, or hearing aids 79 78 8 Change in ability to perform personal care 77 77 10 Loneliness or aloneness 76 76 11 Having an unexpected debt 76 75 11 Your own hospitalization (unplanned) 73 71 12 Decreasing hearing 69 69 13 Fear of abuse from others 67 64 13 Being judged legally incompetent 63 59 13 Not feeling needed or having a purpose in life 14 Decreasing mental abilities 15 Giving up long-cherished possessions 15 Wishing parts of your life had been different 16 Using your savings for living expenses 17 Change in behavior of a family member 18 Taking a relative or friend into your home to live 19 Concern about elimination 19 Illness in public places 20 Feeling of remaining time being short 20 Giving up or losing driver’s license 20 Change in sleeping habits 21 Difficulty using public transportation 23 Uncertainty about the future 25 Fear of your own or your spouse’s driving 27 Concern for completing required forms 27 Death of a loved pet 29 Reaching a milestone year 32 Outstanding personal achievement 33 Retirement 35 Change in your sexual activity Modified from Stokes SA, Gordon SE: User’s Manual, 1988, SGSS, Pleasantville, NY, Pace University.

226 UNIT III  Psychosocial Care of Older Adults Table 13-2  Physical Signs of Stress BODY SYSTEM CHANGES SEEN WITH STRESS Cardiovascular Sensation of racing or pounding heart. Elevated pulse rate. Increased BP. Cold, clammy hands and feet. Increased blood glucose level. Respiratory Increased respiratory rate and depth. Possible hyperventilation with a tingling sensation in the extremities, faintness, dizziness, and even seizures if the acid-base balance is seriously altered. Musculoskeletal Increased blood glucose level to provide energy for muscles. Increased muscle tension in the back, neck, and head. Complaint of tension headaches, teeth grinding, and backaches. Gastrointestinal Decreased production of digestive enzymes. Loss of appetite, nausea, abdominal distention, vomiting, and heartburn. May contribute to development of gastric or duodenal ulcers. Decreased peristalsis resulting in excess intestinal gas and constipation, but diarrhea is also quite common. Urinary Decreased urine production but increased urinary frequency. physiologic changes that are designed to overcome problems that they have little capability for or interest the threat. If these physiologic responses are effective, in interacting with others. When stress becomes severe, the body enters a stage of resistance during which it people may experience signs of major depressive dis- returns to normal functioning. If the responses are not order or even verbalize suicidal thoughts. effective, the body depletes its energy reserves and enters the stage of exhaustion, similar to aging, caused Depression is not easily identified or diagnosed. by wear and tear. In the most severe cases, this exhaus- Depression is often missed because it occurs in con- tion can result in death. junction with the numerous physical and social changes that occur with aging. Depression is more PHYSICAL SIGNS OF STRESS than the down moods that everyone temporarily expe- Physical signs of stress are similar in both the young riences. For depression to be diagnosed, the symptoms and older adults. These are summarized in Table 13-2. must occur most of the day, nearly every day, for at least 2 weeks. Depression is a whole-body syndrome COGNITIVE SIGNS OF STRESS that causes physiologic, emotional, and cognitive In addition to physiologic changes, stress affects the changes in older adults. The notion of mental illness is way we think, feel, and act. Although some stress is unsettling to many older people, who feel that seeking normal and necessary, even beneficial, high stress help for mental problems is a sign of a weakness that levels can be physically and mentally exhausting. they should be able to overcome alone. Symptoms such as chronic pain, appetite loss, sleeplessness, Mild stress results in an increased state of alert­ loss of interest, and even dementia-like behavior ness. Individuals experiencing mild stress are able are often attributed to other problems, and the to pay attention to details, to learn, and to solve underlying depression is missed. This is unfortunate, problems. With increased stress levels, these abilities because 80% to 90% of the identified cases of depres- decrease rapidly. sion are treatable (National Alliance on Mental Illness [NAMI], 2014). Persons experiencing severe stress are likely to miss obvious details and might forget even basic Depression, although common, is not a normal part information. Problem-solving ability is severely of aging. In fact, studies have shown that the majority affected. Under stress, people are likely to develop of older people are satisfied with their lives. It appears tunnel vision, focusing narrowly on one aspect of a that working through the stressors of a lifetime has problem and ignoring other important facts. These enabled many older people to develop a high level of individuals are likely to act irrationally or impulsively self-knowledge and strong coping skills. Depression and make poor choices. Some become completely appears to be most common when older adults are indecisive. Some research even indicates that stress can under physiologic stress. Depression is also likely to cause physiologic changes in the brain that have an occur when older adults perceive that they have lost adverse effect on memory. control of a situation, that they lack the support of significant others, or that their normal coping mecha- Emotional Signs nisms have been overwhelmed by the number or People experiencing high levels of stress are likely severity of stressors (Boxes 13-1 and 13-2). to complain of fatigue, tension, and anxiety. They often report a feeling that something is wrong. They Behavioral Signs may appear distracted, irritable, short-tempered, even People attempt to cope with stress in different ways. angry. People living with high-level stress often ver- Some avoid all interactions or tasks that might increase balize feelings of poor self-worth or low self-esteem. their stress level, whereas others take on additional They may appear to be so wrapped up in their own duties in an attempt to block out the source of their

Coping and Stress  CHAPTER 13 227 Box 13-1  Symptoms of Depression directions given on a prescription. They alter doses and frequency to suit themselves, increasing their risk • Persistent sad, anxious, or “empty” feelings for tolerance and dependence. Because the use of • Feelings of hopelessness or pessimism alcohol is legal, socially acceptable, and readily avail- • Feelings of guilt, worthlessness, or helplessness able, it is most often an abused substance. • Irritability, restlessness • Loss of interest in activities or hobbies once Alcohol tolerance changes as a result of altered physiology. Decreased lean muscle mass, changes in pleasurable, including sex liver enzyme function, and increased nervous system • Fatigue and decreased energy sensitivity to alcohol decrease the safe level of intake • Difficulty concentrating, remembering details, and for older adults. Older adults who have abused alcohol for many years consume larger amounts and more making decisions often than those who start abusing alcohol later in life. • Insomnia, early-morning wakefulness, or excessive Long-time abusers are more likely to have classic symptoms of alcoholism, experience disturbed family sleeping or social relationships, and experience withdrawal • Overeating, or appetite loss when alcohol consumption is stopped suddenly. Late- • Thoughts of suicide, suicide attempts life abusers are more likely to drink in response to • Aches or pains, headaches, cramps, or digestive stressful events. They suffer fewer physical symptoms, are less likely to experience withdrawal, and are more problems that do not ease even with treatment likely to have intact relationships. Both groups are likely to drink alone, at home, and in response to Source: National Institute of Mental Health. www.nimh.nih.gov/health/topics/ stressful or negative emotional perceptions. depression/index.shtml#part3 Most health care providers overlook alcohol prob- Box 13-2  Goals of Treatment for Depression lems in older adults. Signs of alcohol and drug abuse are sometimes missed because they mimic age-related • Decreased symptoms of depression changes such as bone density changes, urinary incon- • Reduced risk for relapse and recurrence tinence, altered sleep patterns, unsteadiness, hyperten- • Improved quality of life sion, stomach complaints, and falls. Substance abuse • Improved medical health status should be evaluated even though it seems unlikely. Although greater numbers of older men have sub- distress. In either case, performance is likely to suffer. stance abuse problems, older widows who live alone People under stress tend to be disorganized, make are also a high-risk group. more errors, and leave tasks incomplete. They may appear and even sound muddled. Mental health resources and support groups are available in many communities to help with substance The thoughts, statements, and actions of stressed abuse. Many are tailored to meet the specific needs of people often jump around in a scattered or discon- older adults. nected manner. They may pace, hum, or perform other STRESS AND ILLNESS ritualistic actions such as finger drumming, key jan- Stress and illness are closely linked. Research has gling, or toe tapping. Temper tantrums, shouting, and shown that both mental and physical illness results in other aggressive behaviors can occur without warning. stress and that stress increases the risk for both mental and physical illness. A physically ill person is less able Self-medicating is one response to dealing with to cope with additional physical or psychological depression and other situational problems. It is cer- stressors, which take energy away from the already tainly not a recommended method, but one that is all depleted reserves and decrease the ability to cope. too common among all age groups, including older Stress can interfere with the ability to learn, function, adults. The substances most commonly abused include and follow through with the plan of care. Decreasing tobacco, alcohol, and prescription drugs. Some older the number of stressors or the level of stress can prevent adults also abuse illicit street drugs (a number expected illness or improve a person’s ability to cope with exist- to climb as Baby Boomers get older). The majority of ing illnesses. older adults are aware that tobacco has harmful effects and continue to use the substance in spite of warnings. Stress has been shown to have negative effects on Although it is physically damaging, tobacco does not many body systems. Because stress activates the sym- have the same effects on the mind and behavior, as do pathetic nervous system (fight-or-flight response), the alcohol and drugs. older adult under high levels of stress is at increased risk for angina, heart rhythm abnormalities, and even Although some people have abused substances heart attack. Stress is associated with hypertension and from early in life onward, as many as 40% of addic- may increase the risk for stroke. The immune system tions occur later in life. Drugs such as anxiolytics, tran- is affected, because of secretion of the stress hormone quilizers, analgesics, and other mood-altering drugs are among the most common prescriptions given to older adults. Many times an older person receives pre- scriptions from several care providers, thus increasing the availability and potential for abuse. As discussed in Chapter 7, many older adults do not adhere to the

228 UNIT III  Psychosocial Care of Older Adults strategy used depends on the personal significance of the event and the perceived ability to alter the Box 13-3  Common Coping or Defense Mechanisms outcomes. • Repression: The removal of anxiety-producing One effective way of reducing stress is to avoid or thoughts or experiences from conscious awareness escape the stressor(s). When an event has little per- sonal significance or when there is little likelihood of • Denial: Refusing to acknowledge some painful aspect having an impact on the outcome of an event, avoid- of external reality that is obvious to others ance may be the best choice. When people know that certain events are likely to increase their stress level, • Rationalization: Creating an acceptable reason for the best alternative may be to avoid these situations unacceptable thoughts or actions whenever possible. It is often simpler and wiser to avoid stress than to endure it. When facing a major • Intellectualization: Making generalizations to avoid stressor, it is wise to eliminate as many smaller stress- disturbing thoughts or feelings ors as possible so that energy is available to cope with the major problem. • Displacement: Transferring emotions about one situation or person onto another When stressors cannot be avoided, when their per- sonal significance is high, or when the person believes • Suppression: Avoiding thinking about distressing he or she can affect the outcome, other methods can be situations used. Confrontational, cognitive, and problem-solving methods are effective means of dealing with these • Projection: Attributing one’s own feelings to another types of stressful situations. • Sublimation: Channeling negative energy into socially To use a problem-solving method, a person must acceptable behaviors first identify and examine his or her stressors. Once • Substitution: Keeping so busy with activities that there the stressors are identified, the individual can deter- mine their importance. Only then can one explore is no time to think about stressors alternative actions to reduce the stress. For example, the individual can continue to face the stressor (e.g., cortisol, increasing susceptibility to infections and an annoying co-worker) and live with the conse- potentially impairing an older adult’s response to quences (confrontational), change jobs (escape), immunizations such as the pneumonia vaccine. Gas­ decrease contact with the stressor (avoidance), or con- trointestinal problems such as ulcer, GERD, and irri- sciously work to change one’s attitude toward the table bowel disease are more likely to occur or worsen annoying person (emotional distancing). The choice when an older adult is under stress. Stress can exacer- made is based on a deliberate decision. This method bate sleep problems and often triggers painful head- of taking a proactive stance (choosing an active aches or muscle spasms. response to control the situation), as opposed to being reactive (reacting to the situation), gives the person a People differ in their abilities to cope with stress. sense of control and empowerment. The mere fact that Those who do not cope effectively with normal day- the person retains control and makes a choice helps to-day stressors cannot function normally when the reduce the stress level. stress level is high and are at risk for becoming physi- cally or mentally ill. Those who do learn good coping Many people need to be taught how to use the strategies can maintain their ability to function despite problem-solving method for coping with stress in their high-level stress. Many different coping or defense lives. Learning to use this process with small or minor mechanisms are used as part of day-to-day living (Box stressors can help people learn to cope with major 13-3). People who are able to cope effectively usually stressors. Some find that physical activity helps them rely on several of these mechanisms. Coping mecha- cope with stress. Exercise may reduce excessive levels nisms are neither good nor bad; they become dysfunc- of stress-related hormones and may allow the body to tional only when used excessively or inappropriately regain homeostasis. The particular physical activity as a way of avoiding dealing with the stressors. chosen should be one that the stressed individual enjoys and participates in willingly. Physical activity STRESS AND LIFE EVENTS should be carried out in moderation, not to a level of Although stress can cause physical illness, physical exhaustion where it becomes another form of stress. illness also increases stress. An older adult suffering from numerous chronic and acute conditions is under Relaxation techniques can be used to help people greater stress than one who is healthier. Stress can cope with stress. The most common forms of relax- increase as a result of loss; the loss of friends, family ation techniques include progressive relaxation, medi- members, and, particularly, a spouse can be highly tation, imaging, biofeedback, and self-hypnosis. In stressful. Other life events, such as a change in resi- addition to these techniques, the support of friends dence or financial worries, can also cause stress. and family benefits most people. Talking through problems and stresses can facilitate problem solving. STRESS-REDUCTION AND COPING STRATEGIES There are two basic categories of coping style: problem- focused strategies and emotion-focused strategies. Problem-focused coping strategies attempt to change or eliminate the stressful event or threat. Emotion- focused strategies attempt to change the person’s response to the stressful event or threat. The type of

Coping and Stress  CHAPTER 13 229 If the level of stress is too severe for routine stress- age. Many of the stressors of older adults involve reduction techniques, professional help from counsel- losses. Loss of a spouse or child, home, vision, or ors, ministers, or mental health professionals may be driver’s license can result in the loss of a purpose in necessary. life and may place a severe strain on the coping abili- ties of older adults. Too many or too frequent stressors Complementary and Alternative Therapies can overwhelm older adults, particularly those already under physiologic stress because of physical illness.   The ability to cope with stress differs widely among Geriatric Massage older adults. In general, those who have learned good coping strategies and have used them throughout a • Geriatric massage is a modification of standard massage lifetime will continue to do so into old age. Those who designed to meet the needs of older adults. did not learn at a younger age how to cope with stress will only continue to experience problems. • Benefits of massage include improved circulation, relief of pain, increased range of motion, decreased anxiety or Because of the unchanging nature of the many depression, improved sleep, and enhanced sense of stressors seen with aging, older adults are more likely well-being. These services can be provided by certified to emotionally distance themselves from situations therapists available in many communities. they cannot change. They are increasingly likely to seek support in spiritual or philosophic beliefs that • Massage treatments are not covered by Medicare or help them cope with these uncontrollable situations. Medicaid, but they may be covered by private insurance programs. NURSING PROCESS FOR INEFFECTIVE COPING • A typical session lasts no more than 30 minutes to   decrease the risk for fatigue. Ineffective coping occurs when a person cannot form • Gentle motions designed to stimulate circulation and relax a valid appraisal of stressors, chooses an inadequate muscles are used over most of the body. Passive response, or does not use available resources (NANDA, movement and gentle stretching with occasional stronger 2014). The individual cannot solve problems or adapt movements are used on larger joints in the shoulders, to the stressors in his or her life. People experiencing legs, and hips to improve joint mobility and flexibility. ineffective coping often verbalize feelings of anxiety, anger, or sadness and can often be heard using phrases • Smaller joints in the hands and feet are gently massaged such as “I just can’t cope anymore.” In addition, they to relieve pain and improve mobility. may complain of changes in physical function as a result of stress. Loss of appetite, nausea, altered bowel • Massage is not a replacement for physical therapy or or bladder elimination patterns, and sleep pattern dis- exercise. turbances are common complaints. Older adults who are having problems coping often demonstrate inad- • Not all older adults are candidates for full body massage. equate problem solving. In severe cases, the person Use of this technique should be discussed with the may engage in destructive behavior or may withdraw physician before initiation. from contact with others. If these individuals live inde- pendently, they may abuse tobacco, alcohol, or drugs Complementary and Alternative Therapies in an attempt to cope with their stress (Box 13-4 and Figure 13-1).   ASSESSMENT/DATA COLLECTION Stress Reduction   • Concentration meditation: A variety of activities focusing • Does the person verbalize feelings of tension, stress, on breathing, body sensation, or mantras may divert the frustration, or sadness? mind from worries and concerns that increase stress. • Are there verbalized complaints of changes in eating • Movement meditation: Activities such as yoga, tai chi, habits? Sleeping patterns? Qigong, walking, or dancing use motion and focused attention to reduce both mental and physical stress. • Does the person complain of changes in bladder or bowel elimination patterns? • Prayer and reflection: Prayers and reflection on sacred verses or poems, performed alone or in a group setting, • Does the individual have difficulty making deci- can be calming and reduce stress. sions or solving problems? • Massage: Focused manipulation of muscles reduces • Does the person appear agitated, aggressive, angry, tension, decreases pain, and promotes a bond of caring, or hostile? all of which reduce stress. • Does the person seem sad or withdrawn? • Reiki: This Japanese technique for stress reduction and • Does the person smoke or consume alcohol relaxation also promotes healing. It is administered by “laying on hands” to increase an unseen “life force excessively? energy” that causes us to be alive. When this energy is • Has there been an increased frequency of illness or low, we are more likely to feel stress; when it is high, we are more capable of being happy and healthy. accidents? Stress is as much a fact of life for older adults as it is for the younger population. However, the amount and types of stressors do seem to change with aging (see Table 13-1). Many negative life events have been iden- tified as stressors in older adults; however, there can be fewer positive life events that produce stress as we

230 UNIT III  Psychosocial Care of Older Adults FIGURE 13-1  Loneliness and hopelessness can be manifestations NURSING INTERVENTIONS/IMPLEMENTATION of alcohol abuse. (© 2014 Photos.com, a division of Getty Images. All rights reserved.)   Box 13-4  Alcohol-Related Problems in Older Adults The following nursing interventions should take place in hospitals or extended-care facilities: • As many as 17% of people over age 65 have alcohol 1. Maintain continuity of care to develop a stable, abuse problems. trusting relationship. Before older adults will ver- • Five million older adults are expected to require balize their concerns, they must develop trust in treatment for substance abuse problems by 2020. their caregiver(s). Gain this trust by keeping the number of caregivers to a minimum. Develop a plan • Alcohol-related problems often go undetected in older of care with the individual. To reduce stress, follow adults because symptoms are often mistaken for this plan with minimal changes. dementia or medical problems. For example, 2. Encourage older adults to verbalize their feelings. gastrointestinal problems are more likely to be Verbalization provides older adults with an oppor- correlated to antiinflammatory medications than to tunity to express their concerns and solve problems. alcohol consumption. Merely putting feelings into words often reduces the stress that comes from holding back anxious • Alcohol use in the older adult population contributes thoughts. Nurses should be careful to remain non- to liver disease, dementia, peripheral neuropathy, judgmental and should allow older adults to express insomnia, poor nutrition, incontinence, depression, a full range of feelings, including fear, anger, hostil- inadequate self-care, and medication reactions. Use of ity, and grief. alcohol increases the risk for falls, hip fractures, and 3. Ensure that older adults receive adequate nutri- other accidents. tion, rest, and pain relief. Persons who are hungry, fatigued, or in pain are likely to have difficulty • Older men are more likely to use alcohol to cope with coping with other stressors. Plan care to minimize financial problems, whereas older women are more these basic physical stressors. likely to use alcohol to cope with death or loss of 4. Assist older adults in identifying personal relationships. strengths and previously successful coping strate- gies. Older people typically use a variety of coping Box 13-5  Risk Factors Related to Problems with strategies throughout their lives. Unless older adults Coping or Stress Tolerance in Older Adults suffer from chronic mental illness, they have prob- ably managed to cope rather successfully to have • Recent social, physical, emotional, or financial losses reached old age. The coping behaviors that were • Physical illness used throughout life can act as a basis for coping • Major life changes with current situations. 5. Explain a variety of stress-reduction techniques. See Box 13-5 for a list of risk factors for problems A variety of stress-reduction techniques can be used related to coping or stress in older adults. to help older adults reduce stress. Progressive relaxation is a simple technique that can be used NURSING DIAGNOSIS by older adults. To learn to relax, the person is first taught to identify the difference between muscle   tension and relaxation. Once he or she can identify the different sensations, the person is taught to Ineffective coping alternately tighten and relax muscles, starting at the feet and working upward through the body. NURSING GOALS/OUTCOMES IDENTIFICATION This is done until the entire body is relaxed. With practice, this technique can be done quickly, effec-   tively, and at will. Self-hypnosis takes relaxation a step further and The nursing goals for older individuals with ineffec- tive coping are to (1) communicate feelings of stress; allows individuals to actually place themselves (2) identify personal strengths and effective methods in a trancelike state. This technique is more of coping; and (3) participate in decision making. complex and more difficult to learn than other relaxation techniques. Commercial audiotapes are available to teach self-hypnosis. Imaging is a relaxation technique in which individu- als are taught to think of a calm, peaceful setting. This can be whatever setting the individual finds most relaxing. The person should visualize this setting and try to picture it in detail, taking

Coping and Stress  CHAPTER 13 231 FIGURE 13-2  Regularly scheduled socializing activities serve to older adults and their families have difficulty coping combat isolation among older adults. (From Christensen BL, on their own. Most communities have mental health Kockrow EO: Foundations of nursing, ed 5, 2006, St. Louis, Mosby.) clinics or senior citizen help lines to assist in times of stress. pleasure from each aspect of the environment. 3. Use any appropriate interventions that are used in Then the person imagines being in this environ- the institutional setting. ment, relaxing and enjoying the experience. Meditation is a somewhat more difficult, but highly NURSING PROCESS FOR RELOCATION beneficial, relaxation technique. Time and effort are required to learn to meditate effectively.   Individuals must learn to shut out external stimuli and focus on calming their thoughts. To STRESS SYNDROME gain this internal focus, most meditators use a mantra, which is a word or sound that is repeated Relocation stress syndrome describes the physiologic over and over again. To facilitate meditation, the or psychosocial stress that occurs when a person is individual should be provided with a quiet place transferred from one environment to another. Reloca­ where distractions can be minimized and should tion stress is a common problem with aging and can be assisted into a position that promotes comfort occur with many types of relocation, including the and relaxation. following: 6. Encourage older adults to participate in activities • From a private home to the home of a family (Figure 13-2). Physical and diversional activities can reduce stress by focusing excess nervous energy in member productive ways, but people experiencing stress • From home to an apartment or other shared living may be reluctant to participate. Encourage these individuals but never force them to attend activi- arrangement ties, because forcing only increases stress. • From one area of the city to another 7. Consult with mental health specialists, ministers, • From home to a hospital or counselors. Many techniques are available to • From home to a long-term care facility help older adults cope with stress. If the problem is • From home to a hospital and then to a long-term severe or if nurses are unable to help older adults cope with stress, consult with a specialist. care facility The following interventions should take place in • From one unit in the hospital or long-term care facil- the home: 1. Encourage the family to provide emotional support ity to another unit in the same facility to older adults. It is often difficult for older adults • From one room to another in a hospital or long-term (or anyone else) to cope with stress alone. Encourage families to spend time with older adults, listening care facility and providing emotional support. If the family Older adults who are required to change residence dynamics are disturbed and the family is a source are likely to experience losses, fears, and concerns that of stress, it may be necessary to reduce family increase stress. Loss of independence, loss of personal contact and help the older person identify other possessions, loss of friends and neighbors, fear of the sources of emotional support such as friends, min- unknown, and concern about the future all increase isters, or others. stress. Stress is greatest when many losses or changes 2. Identify community resources that can provide have occurred, when these changes occur in rapid suc- support to older adults and their families. Many cession, when the changes are unexpected, and when the individual has had little or no say in the decision- making process. Older adults experiencing relocation stress syn- drome exhibit emotional, behavioral, and physical signs of stress. Most newly relocated older adults experience feelings of powerlessness, helplessness, and insecurity. They often verbalize unwillingness to relocate or dissatisfaction with the new living arrangements. They are likely to express feelings of grief, anger, apprehension, anxiety, loneliness, sadness, and confusion. To cope with these feelings, older adults may demonstrate a variety of behaviors. Some attempt to maintain control of the situation by demanding attention and verbalizing many needs. They may be more dependent on caregivers than their physical condition justifies. Others attempt to cope with the stress by becoming hostile or angry. They often deny the necessity of the change and refuse necessary assistance or care. Still, others cope by with- drawing and isolating themselves from contact with staff, other residents, and even family. These behaviors

232 UNIT III  Psychosocial Care of Older Adults the number of people providing care to a minimum and provide care in a consistent manner. Respect are usually a result of lack of trust or feelings of the individual’s preferences and meet his or her powerlessness in the new setting. needs promptly. This helps build a sense of trust and decreases the stress that results from rapid or In addition to behavioral changes, recently relo- unpredictable changes. cated older adults are likely to experience physical 6. Encourage the use of familiar objects and belong- signs of stress. Changes in eating habits, weight loss, ings. Encourage older adults to bring as many gastrointestinal changes, changes in elimination pat- prized personal possessions as space allows. terns, and changes in sleep patterns are commonly Personal belongings enhance the sense of belong- seen in newly relocated older adults. ing. Seeing and using familiar items makes a new ASSESSMENT/DATA COLLECTION environment seem more familiar and reduces stress. Display personal possessions so that the person can   easily reach or see them. Because most people feel that their personal belongings are extensions of See the assessment for ineffective coping earlier in the themselves, always treat these belongings with care chapter. and respect. NURSING DIAGNOSIS Relocation to a new environment can be confusing and even disorienting to older adults. Selected items such   as calendars, clocks, night-lights, and personal belong- ings will help older adults make a smoother adjust- Relocation stress syndrome ment to a new environment. NURSING GOALS/OUTCOMES IDENTIFICATION The following interventions should take place in the home:   1. Allow older adults to participate in decision making and planning for the change. It is impor- The nursing goals for older individuals with reloca­ tant to include older adults in decisions that will tion stress syndrome are to (1) recognize the reasons have a significant impact on their lives. When a for the move or change; (2) identify ways to maintain major change (e.g., a change in residence) is neces- control and decision-making powers in the new envi- sary, the older adult, his or her family, and possibly ronment; (3) verbalize concerns about new living a social worker should make decisions together. arrangements; and (4) identify methods for coping The person should know the reasons for the change with change. and the available options. When choices are avail- NURSING INTERVENTIONS/IMPLEMENTATION able, respect the preferences of the individual. Enabling older adults to retain control of these   choices reduces the sense of powerlessness and thus stress. The following nursing interventions should take place 2. Anticipate fears and concerns, and allow adequate in hospitals or extended-care facilities: time to implement the change, when possible. 1. Encourage verbalization of feelings, fears, and Help older adults and their families anticipate and plan for the change. In cases where a change in concerns about the move or change. When a person environment occurs because of a medical emer- holds in all fears and concerns, his or her stress level gency, planning is not possible. In many cases, remains high. Allowing older adults to discuss their however, there is adequate time to prepare older concerns openly and freely initiates the problem- adults for a change. Use this time to allow the indi- solving process. Anger is common when older vidual to accept the fact that a change of environ- adults disagree with moving. Accept this anger as ment is necessary. In addition, the individual can a normal and even healthy response. sort through personal belongings and distribute or 2. Discuss the reasons for the move or change. Nurses discard them as desired. Scheduled visits to the new and families should be open and honest about the environment before the actual move allow the reasons for a move or change. Answer any ques- person to become more familiar with the physical tions the individual has as completely and honestly structure and people. as possible. Attempting to shield older adults from 3. Use any appropriate interventions that are the often harsh reality is likely to result in anger and used in the institutional setting (Nursing Care loss of trust. Plan 13-1). 3. Include older adults in care planning. Whenever possible, encourage active participation of older adults in planning care. This allows older adults to maintain some degree of control over decisions that affect their lives. Whenever possible, offer choices and respect the individual’s preferences. 4. Encourage a positive attitude about the move or change. Help older adults identify the benefits that will come with the change, and avoid making per- sonal or negative comments about the move. 5. Maintain continuity of care to enhance feelings of trust. When an older adult is newly relocated, keep