Human beings are constantly required to make adaptations in order to maintain homeostasis and achieve growth. With advancing age, however, one's ability to adjust and adapt becomes limited.1 Normal age-related changes, combined frequently with one or more acute or chronic illnesses, may necessitate a decision to relocate an elderly person either temporarily or permanently.
Alternatives to institutionalization and unnecessary transfers are being explored. Options are being offered in the form of various home care and day care programs. However, a significant number of elderly persons have been and will continue to be relocated. In Canada, for example, about ten percent of those over 65 and 25 percent of those over 85 are presently in an institution on any given day. Furthermore, while the average person in Canada spends two days in an acute hospital each year, those over 65 spend an average of eight days per year in such settings.2 Consequently, at a time when one's ability to cope with major life changes may be limited, the likelihood is increased that one will have to adapt to a new environment.
Nurses are often involved prior to, during and following the transfer of elderly persons from one environment to another. The purpose of this paper-will be to explore factors relevant to assessent, intervention, and evaluation involved in the relocation process. What high risk factors seem to relate to poorer adjustment to relocation? Can we, along with other health team members, reduce the potentially hazardous effects of relocation? What principles can be implemented in program planning to reduce "transplantation shock"?
A number of studies have been conducted on the responses of elderly persons to relocation. Many of these studies conclude that persons with poor physical status are prone to adjusting poorly following relocation.5 Kay and Roth's findings supported the hypothesis that severe physical illness is prognostic of early death of the elderly upon admission to a psychiatric hospital and this risk is greater for men than women.4 Blenkner concluded that the one factor which emerges from studies in this field as being an indicator of "high risk" is severe brain dysfunction.5
Consequently, in identifying high risk patients, nurses need to be aware of known physical health problems, and alert to indications of undiagnosed illness. Adequate medical treatment before, during, and after a move may mitigate stressful effects of the move.
Normal age-related changes need to be assessed. Neuropsychological changes include impaired vision, hearing loss, and brain functions dealing with perception, thinking, intelligence learning, and coordination of motor behavior.1 Should any of these impairments exist, the individual may be prone to developing confusion and difficulty adjusting to a new environment. Since these changes vary significantly from organ to organ and person to person, it is imperative that individual systematic assessments be conducted.
An evaluation of the elderly person's functional health status will be necessary to make decisions regarding the level of care needed and the type of facility best suited to provide that care. A variety of systematically devised tools are available and could prove useful for this purpose.
A variety of psychosocial factors require assessment in regard to relocation. Lieberman demonstrated that persons who were depressed prior to a move were more likely to have adverse reactions to the move.6 In a later study he showed that survival following a move correlated with having the ability to extend one's self into the past and future, having high self-esteerrt and having a dominant-aggressive personality trait. Lieberman noted, however, that the most sensitive predictors of survival were not simply the converse of the most sensitive predictors of nonsurvival.7
Researchers have also shown that one's life satisfaction influences one's adaptation to a move. Pastorello showed those who are happy with their life, friends, and activities tend to adapt better to relocation.8 Consequently, a person who is dissatisfied with his life may be grappling with the final developmental task which Erickson has termed "integrity vs despair."9 Such persons may once again pose a higher risk for problems following relocation.
Another psychological factor to be assessed is a person's general perception of stressful life events and the total number of recent stressful events which the client has encountered. Holmes and Rahe have shown that people who have experienced many recent life changes are more likely to develop serious illness.10 Thus an older person who has experienced recent changes such as loss of spouse, loss of house or loss of income, may be considered a poorer risk following a move. The way he perceives the move, however, is significant in terms of the degree of additional stress this imposes. Two case illustrations demonstrate the importance of assessing a client's perception of his move.
Case No. I
As a graduate student affiliating in a counseling and referral centre for the elderly, I received a request for help from the two nieces of Mrs. H, an 86-year-old widow who lived alone. The nieces felt their aunt could no longer manage to live alone and neither could take her into her home. My goals in working with the family were to arrange for medical and psychiatric assessment, interpret the findings thereof, counsel the family regarding placement possibilities and provide support before, during, and following the proposed move. Mrs. H proved to be a fiercely independent lady, however, who refused all options offered ranging from home care to a nursing home. Since involuntary committment to an institution was not warranted at that time, my role shifted to helping the nieces deal with their feelings of responsibility and guilt and work out a plan of support which was consistent with their energy and time.
Case No. 2
Mrs. C, an 82-year-old retired nurse, was a member of a group with whom I met weekly in a family care home. She was dissatisfied with the home, as indicated by covert expressions of hostility towards the home operator and several of the residents. My nursing role was to help her clarify her thoughts and feelings, assist her to communicate her needs more clearly, and ultimately to feel positive about making a decision to move. Her social worker assisted her in finding new accommodation, her physician helped stabilize her medication regime and her family was encouraged to accompany and support her during the move.
Each of these elderly people had unique perceptions of what moving would mean for them. Mrs. H was convinced that unless she lived alone, she might as well be dead. Mrs C wished to change homes but lacked the resources to follow-up on her decision. In each case it was essential that the client's perception of the move be assessed and taken into account when planning for meaningful intervention.
These two cases also illustrate the importance of involving the client's whole family system when planning for relocation. The importance of involving professionals of a variety of disciplines is demonstrated as well. The nurse may well play a central role in coordinating these activities.
External Environmental Faciors
A number of external environmental factors need to be assessed in planning for relocation. Lawton and Cohen state that "the environment, with its variations in constraint, has the potential for influencing life satisfaction of the elderly, who more so than general populations, may be influenced by environmental factors."3
Nurses have traditionally been aware of problems in the design and equipping of facilities in which geriatric care takes place. Wells notes, however, that we have been neither knowledgeable nor willing to take responsibility for altering unsatisfactory settings to meet our clients' needs and our needs in caring for clients.11 Assessing a patient's environment prior to and following a move could provide useful baseline information upon which to make decisions about altering a new setting. One ought to consider factors such as providing for territoriality, personal belongings, resident choices of color and design, communal spaces and meaningful opportunities for use of time. Verwoerdt notes that these concepts contribute to a "home-like" atmosphere.1 They may be assessed and planned for regardless of the setting.
Another factor which may influence adjustment following a move is timing. Verwoerdt compares a sudden environmental move to the intrusion of a foreign element into the body. He deduces that a gradual move to an unfamiliar environment will permit gradual defence mechanisms to compensate whereas a sudden move may be overwhelming.1
Case No. 3
A 60-year-old couple realized they could no longer adequately care for their mother at home. Neither they nor their mother could accept easily the possibility of a permanent nursing home placement. A home-care worker was assigned, enabling the couple to transfer some of their care-giving feelings and duties in a gradual way. When a move was finally deemed necessary for medical reasons, acceptance of the move had been somewhat resolved by the couple. The elderly mother maintained her denial of reality following her move and commented frequently that she'd be "going home soon." N'oatiempt was made to break down this defense and the nursing home staff was helped to appreciate that this was her way of coping with a potentially devastating experience.
A program designed to facilitate environmental relocation may be incorporated into existing health care facilities or established as a separate branch of health care delivery. Hall has conceptualized that a family utilizes six processes "to facilitate the growth-promoting potential in crises-laden situations."12 These concepts would provide a useful framework for planning a relocation program.
Cognitive Mastery is the intellectual understanding of the event and may be hampered by lack of accurate information or intellectual ability. A relocation program should incorporate assessment of a client's mental status and provision of information which can be clearly understood. Pre-move tours of various facilities or the use of audio-visual aids could be useful ways of providing some of the needed information. The family can be assisted to formulate a step-by-step plan for the move, eliminating last minute confusion.
Hall states that families also secure Compliance from the environment to "meet their system-maintenance requirements."12 Some families seem to be able to master this quite independently while others find it difficult to obtain the resources needed. A relocation program would make provisions to assess the family's ability to obtain goods, services, and information, and if necessary, provide assistance.
A middle-class daughter I worked with was embarrassed to enter the welfare office on behalf of her eligible mother and yet responded well to my offer to accompany her.
Families exercised their Control in stressful situations. Individual goals must be congruent with group goals and family members can be very supportive of one another. This type of joint decision-making and support should be encouraged. Hall notes that the least adaptive mode of transaction is that of coercion through force or threat. Pathological transactions may be diagnosed and skilled intervention and role modeling instituted.
Functional family Coalitions assist in meeting crises. Health coalitions should be identified and relationships encouraged through personal contact- telephone or letter. Family counseling may be needed on a short-term basis, particularly when the family has undergone multiple crises or has had previous difficulty coping. Both of the latter need to be assessed.
Communications is an essential element in coping with stress. Stone has addressed the importance of assessing age-related communication difficulties associated with hearing and vision.13 These may interfere with an older person's ability to correctly obtain input. Clear, open discussion between family members should be promoted. In addition the family and in particular the older person being moved ought to be encouraged to develop clear communications in the new setting with the staff.
Families have Choice in selecting from alternatives and may need assistance and encouragement to do so in a healthy fashion. As nurses, it is necessary for us to remain unbiased when assisting families to problem-solve and encourage clients to recognize their responsibility for their choices.
Summary and Conclusions
This paper has attempted to uncover fundamental issues involved in the sometimes necessary transfer of older persons. Relocation is viewed as a potentially stressful event which occurs more frequently at a time when people may be least able to adapt. High risk persons are those identified as having severe physical, mental, or social impairments. As space in our long-term care facilities becomes increasingly scarce, these indeed will be the persons most frequently requiring placement. Some approaches have been suggested whereby we can begin to think now about whether our present patterns of relocating elderly people are part of the treatment or part of the disease. The importance of the total family response is outlined and a framework suggested for meaningful intervention.
The author wishes to acknowledge the supervision provided in this study of relocation by Mrs. Janet Galein. and Dr. Adrien Verwoerdt of Duke University.
- 1. Verwoerdt A: Clinical Geropsychiatty. Baltimore, The Williams and Wilkin* Co. 1976. ρ 223.
- 2. Health servîtes for the elderly. Final Report of the Federal Provincial Advisory Committee on Community Health. Ottawa Ontario Health and Welfare Canada. 1976. ρ 6.
- 3. Fisdorfer C, Lawton MP: The Psychology of Adult Development and Aging. Washington. American Psychological Association, 1973.
- ·!. Kay D. Roth M: Physical accompaniments of mental disorder in old age. Lancet 2:740. 1955.
- 5. Blenkner M: Environmental change and the aging individual. Gerontologist 7(2): 101-10?. 1967.
- 6. I.ieberman M: Relationship of mortality rates to entrance to a home for the aged. Geriatrics Ocl:515-519. 1961.
- 7. Lieberman M: Some issues in studying psychological predictors of survival. In Jeffers JC, Pal more F. (eds): Prediction of Life Span. Lexington, Health, 197i. pp 167-179.
- 8. Pastorello T: Relocation stress: a causal model of effect and mitigation. Paper presented at 28th Scientific Meeting of the Gerontological Society. Louisville. Kentucky. Oct 1975.
- 9. Erikson E: Identity. Youth and Crises. New York, WW Norton and Company, 1968.
- 10. Holmes T. Rahe: The social readjustment rating scale. J Psychosom Res 11:213-218, 1967.
- 11. Wells T: Toward understanding problems in care of the hospitalized elderly. Unpublished paper based on presentation to Canadian Association of University Schools of Nursing Annual Meeting. Laval University, Quebec. June 1976.
- 12. Hall J, Weaver B: Nursing of Families in Crises. Philadelphia. JB Lippincott, 1971.
- 13. Stone V; Keeping up with geriatric nursing. Nursing '72 11:32-33, 1972.