Mrs. S, an almost deaf 65-year-old woman, usually sat in a corner of the dayroom by herself. She mumbled incoherently whenever anyone stopped to talkwith her. She would get extremely angry if anyone asked her to repeat what she had said. She took great pride in showing the staff or volunteers her neatly kept room that contained her collection of old photographs, jewelry, several old geography books, and other assundry items.
Mrs. Κ, a widowed 73-year-old woman, kept her graying hair dyed a bright red. She often sat in the dayroom with two other ladies chatting amicably with them. Mrs. Κ was usually able to carry on a coherent conversation. However, whenever she seemed anxious she would launch into a delusion, declaring that she was an "Italian countess with several million dollars," or into her hallucination that her "husband talked with her often through the wires in the ceiling."
Mr. C had been an engineer before he retired about five years ago at age 62. About that time his wife also died of a stroke. He had been living with his daughter and her family until about two months ago when they brought him to a nursing home. Mr. C's daughter said that he had become increasingly absent-minded, often forgetting recent events and certain activities of daily living such as eating meals regularly and dressing appropriately. He also seemed somewhat depressed and withdrawn. However, Mr. C would recall some vivid, past memories with some of the staff members who stopped to talk with him.
The commonalities in these examples are that each person described is in the geriatric segment of the population and each has a tremendous need for meaningful communication. "Meaningful" as referred to here is "purposeful, goal-directed activity and... the pursuit of goals in certain predetermined ways."1
The primary purpose of this paper is to describe various communication techniques based on a holistic view of the geriatric patient and his environment. Hopefully, such techniques within the framework of a systems approach will ultimately be of therapeutic value to the aging patient.
In assessing the patient, the nurse should focus on the "linkages" between systems and between subsystems as illustrated in Figures 1 and 2. This systems approach is one way to organize a variety of interrelated variables. Often the nurse restricts her view to the patient and his needs (Fig.l), but she should also analyze the transactions between the patient and the other systems (Fig. 2). Only by examining the communication processes at the "linkages" in relation to an assessment of the patient's needs can the nurse plan effective, scientifically-based interventions. The nurse can also use this framework to evaluate her nursing interventions.
PATIENT'S NEEDS: INTERACTING SUBSYSTEMS WITHIN THE PATIENT
The following is a discussion of the various communication techniques which are aimed at the "linkages" between systems and between subsystems:
All of the subsystems whether physiological or psychosocial within the aged person have slowed down considerably or there is a decrease in or lack of interest in some areas where once there had been great interest, e.g., sociocultural or spiritual activities. This reduced speed in all processes is enhanced if the aged person is ill, psychologically or physically or both.2 Thus, in conversing with the elderly person, the · nurse must do much concentrated listening and respond according to the former's pace. The aged person takes time to absorb the sensory input, to integrate, and to deliver the appropriate output in response to the nurse's message.3
In Mrs. S's case, the nurse met with her consistently each day for about an hour. In the beginning the nurse just listened to Mrs. S carefully and then taped Mrs. S's voice and played the tape back to her. Mrs. S was surprised at her own garbled speech and revealed that she had been very anxious about her ability to carry on a flowing, spontaneous conversation with anyone. As time passed Mrs. S began to speak more clearly; consequently, she was better able to express her needs and desires to the nurse and other staff members. Making her needs known helped her to have them met more effectively, e.g., Mrs. S was fitted with a hearing aid and the staff learned that Mrs. S enjoyed listening to classical music and talking about great composers.
If any person including the aged is exposed to prolonged periods of a monotonous environment, he may suffer from sensory deprivation that includes severe psychological changes from depression and irritability to hallucinations.3 The geriatric population is especially prone to this condition because of the "theory of disengagement." A reduction in the number and quality of social interactions occurs as the person ages. This withdrawal is initiated by the individual himself or by others in his environment.4
Communicating both verbally and nonverbally with elderly patients can be an important mode of stimulation for them. The adequate and appropriate use of touch or "stroking" provides for stimulation, trustbuilding, and an increased sense of reality and decreased sense of isolation.5
PATIENT AND OTHER SYSTEMS: INTERACTING SYSTEMS OUTSIDE OF THE PATIENT
Mrs. S, in the first example, had suffered severely from sensory deprivation. As the nurse interacted with her she would touch Mrs. S's hands occasionally. Slowly, with much encouragement from the staff, Mrs. S became more socially and physically active. Having a hearing aid greatly helped to increase environmental stimuli and to maintain orientation. The staff included her in making decisions about her care which helped to enhance Mrs. S's self-esteem. Thus, making changes in one or two subsystems may change the whole person and possibly the environment.
As persons grow older they experience the loss of physical abilities and the loss of friends and relatives. The aged patient may grieve over these losses and may express other concerns such as feeling lonely, frustrated, or anxious about growing older. In communicating with the elderly, the nurse should assist them with verbalizing pent-up feelings.6
Mrs. K, in the second example, had been married toa very wealthy man who died of a "coronary" when they were in their fifties. She had also been an actress on stage for most of her life. The nurse had several sessions with Mrs. Κ and encouraged her to express some of her feelings. Mrs. Κ soon began discussing some of the grief she felt over the loss of her husband and the loss of her physical beauty. She soon joined a drama group led by the recreational therapist. One big production was presented to the local community each year in which she became actively involved with the group. She derived much satisfaction from her accomplishments and received reinforcement from the patients and staff.
Elderly persons enjoy reminiscing about "days-gone-by." They may also have significant friends or relatives whom they may enjoy describing. The nurse should assist the patient in describing that which is meaningful to him. She should focus on the "there-and-then" as well as the "here-andnow" to maintain the patient's self-respect for what he has been.5
In her interactions with Mr. C in the third example, the nurse discovered that he loved to recount some of his boyhood experiences. He also enjoyed mentioning his satisfying relationships with his children and grandchildren who were able to visit only about once or twice a year. He admitted he was lonely since he could not see them very often. The nurse suggested they telephone each other at least once a month. Mr. C glowed with pride with the increased attention and communication with his family. There was a children's day care center near the nursing home which the nurse felt would be an excellent diversion for Mr. C. She arranged for Mr. C to spend a couple of hours once a week at the center. Mr. C enjoyed telling stories to the children. "I feel 10 years younger, " he declared to the nurse. The children in turn were exuberent about this grandfather-like figure. Mr. C and his wife had always gone to church together on Sundays. After her death Mr. C's interest in religion declined and he stopped attending church. With some of the other people in the home he began going to a church nearby and was able to develop even more friendships with the people he met there. All of these experiences helped him feel zestfui about his life situation.
In the cases described in this paper most or all of the subsystems of each person were affected prior to the staff's interventions. Likewise, some of the systems (external to the person) were influenced. Communication techniques were aimed at the appropriate linkages among subsystems and systems. Evaluation of the success of the interventions can be accomplished by examining the same linkages in relation to the total person within his environment.
The whole area of communicating effectively with the aged person needs to be examined more closely in light of scientific rationale and research. This stage of development is a critical one for the more than 20 million people (or one out of every 10) in our country.
Simone de Beauvoir7 writes: "It is rare for old age to be looked upon as the crown of life; but it does happen " And, perhaps, it is the nurse who can facilitate such an outlook in the elderly patient and in those around him through the use of meaningful communication techniques. Finally, we should keep in mind the quotation from Longfellow:
For age is opportunity no less
Than youth itself, though in another dress.
- 1. Szasz TS: The Myth of Mental Illness. New York, Dell Puhl Co, Inc, 1961, ρ 14.
- 2. Jennings M: Physiologic functioning in the elderly. Nurs Clin Ν Amer 7(2):240-247, 1972.
- 8. Carlson S: Communication and social interaction in the aged. Nurs Clin Ν Amer 7(2):270,277, 1972.
- 4. Reed DL: Social disengagement in chronically ill patients. Nurs Res 19(2)109, 1970.
- 5. Burnside IM: Group work among the aged. In Mereness D (ed): Psychiatric Nursing, Second Ed. Wm C Brown Co, 1970.
- 6. Ujhely, GB: The environment of the elderly. Nurs Clin Ν Amer.
- 7. De Beauvoir S: The Coming of Age. G. P. Putnam's Sons, 1972, ρ 505.