Memories of past, pleasant happenings recorded by familiar and/or significant others on a 30-minute tape may be therapeutic for the institutionalized person.
Selye1 has established the axiom of stress or "general adaptation syndrome," which postulates that the body responds to stress of any kind with a unified defense mechanism, characterized by specific structural and chemical change. This reaction can raise the resistance to stressful agents and can also be used to protect against disease.
One of the most threatening aspects of aging is stress. Stress occurs in everyone including the mentally impaired elderly. Barad et al2 found the aged person to be capable of sensitive, emotional response, even in the presence of organic brain damage. Goldfarb3 found that in the elderly patient organic brain syndrome and disorders of mood interact and reinforce each other terminating in a variety of symptoms. With the proper assessment and treatment, "irreversible" and "reversible" components can be distinguished and much can be done to help the person adapt by improving his mood and behavior. Nurses can help by encouraging the mentally impaired elderly, helping them to become as self-sufficient as possible.
Entering a nursing home, sometimes at great distances from families, can cause prolonged, intense stress in the elderly. Hill et al has postulated that when family member contact is high, the significant other acts as a reliever of stress.
There are several methods currently used to accomplish this end. Some of the more popular today are encouraging family correspondence, visitation, and, whenever possible, telephone contact. These practices are sometimes enhanced by the intervention of an energetic social service department. There are many economical and social circumstances, however, that hamper the consistency and frequency of accomplishing these affiliations in our society. For those institutionalized aged affected by these conditions, the result is stress.
Staff on the Nursing Home Care Unit-Hospital at VA Medical Center, Bath, New York became interested in studying residents' behavioral changes that they felt were stress induced. The setting for this study was a 40-bed nursing home unit on the fourth floor of the hospital complex. Resident population included 38 males and two females, with a mean age of 78. Many of these elderly people manifested noticeable mood changes that were not relieved by the usual supportive nursing service intervention. This was especially true around the holiday season when many of the residents appeared depressed. One such holiday, Christmas 1970, the daughter of one of the residents made a very pleasant recording with music and voice. On tape she recalled happy experiences shared with her father at their family home. Other residents' families hearing the tape became interested and made similar tapes for their relatives. Staff began to play the tapes when residents appeared depressed. It was observed that the tapes appeared to distract the resident and produce a calming influence. The staff began to ask themselves how effective these tapes would be if used in any stressful situation. They began to keep anecdotal records of behavioral changes noted after playing the tapes to patients manifesting stressful behavior. The following anecdotal records were compiled.
1. A 75-year-old male resident with a residual leftsided hemiplegia following a cerebral vascular accident, generalized arteriosclerosis, and arteriosclerotic heart disease, was manifesting pronounced behavioral fluctuations, including throwing food and alternating periods of weeping and restlessness. On one occasion, when he was moaning and restless, having exhausted all nursing comfort measures, a tape, made by his favorite niece was played for him. The recording began by the niece talking about the resident's sister. The resident's response was tearful. Shortly thereafter, the niece changed the subject and began to talk about another relative's small dog, then about a dog the resident had once owned. The resident appeared to quietly concentrate and relax. A quiet chuckle was distinctly heard.
2. An 81-year-old male resident with a history of chronic brain syndrome, arteriosclerotic heart disease, and an arterioseptal synocardial infarction with a recent pacemaker, became totally withdrawn and was unresponsive to staff. He sat for long periods with his arms folded across his chest apparently oblivious to everything. A tape was played in his room. As the sound began, he became instantly alert. His eyes began to gleam and a broad smile spread across his face. He responded verbally to what was being said on tape; his upper body bent forward toward the sound of the voice. He nodded his head at intervals and began to explain the events being referred to by his relative. When the tape finished, he appeared quite alert and remarked, "I got lost in here a little while ago, didn't know where I was." As we were leaving the room he said, "Is there any chance at all of my getting out sometime?" This was the first reference he was ever known to make regarding leaving the nursing home setting.
3. An 84-year-old male whose condition was guarded, was discharged to the hospital following a recent cerebral vascular accident. At 1:55 PM that afternoon, we visited this patient in the hospital area and played a tape recorded by a close friend, a very devoted lady from the community who had known him for a period of years. The tape was a recording of an actual conversation between the resident and this friend. When we saw the patient, he was restless and had a fixed, glassy stare. We started playing the tape at 2 PM. It was a review of boyhood memories. At 2:05 PM. this very ill patient appeared to be straining toward the sound of the taped voices. At 2: 10 PM he began to show (by eye movements) some alertness. His eyes, previously wide and staring, began to relax with periods of complete eyelid relaxation. At 2:20 PM there appeared to be total relaxation. At 2:25 PM the resident gave the staff member a slight hand squeeze. His color, previously pale, showed a slight, but noticeable flush. There were no overt manifestations of restlessness or anxiety, but rather a quiet, peaceful contentment.
4. In 1974, an 85-year-old male died on the Nursing Home Care Unit. During the terminal stage of illness, there were periods of extreme restlessness and apprehension. His sister, an infrequent visitor from New York City, had made a tape recording of some joyful holidays they had spent together. This tape was played several times during the dying process when his restlessness became extreme. Each time it was played, his restlessness reverted to an unexplained calmness.
As we watched these events and others occur time after time, we became interested in studying further the use of therapeutic tapes. It was determined that the importance of this project would be: (1) reducing stress in the institutionalized elderly; (2) developing more positive interpersonal relationships with families and/or significant others; (3) enhancing the quality of the Nursing Home Care resident's life; and (4) assisting those persons with long-term care needs to develop communication as a portion of their rehabilitation program. The use of therapeutic tapes was also thought to be a valuable tool for the nurse who would need to budget her time and would sometimes be unable to intervene immediately to help stressful residents.
Maslow says that all of us have basic kinds of needs: physiological, safety, social, ego, and "self-actualization." These needs are in hierarchy from lower (physiological) needs to the highest and most complex, self-actualization. Staff in nursing homes usually have no problem meeting lower order resident needs, but it is frequently the higher needs that are not met. These needs include the sense of belonging, affection, and response. As nurses, we can be supportive and assist the resident to cope with his nursing home environment and he has a right to expect his help. Barrell6 has postulated that when an individual experiences a hazardous event (eg, entering a nursing home), he is for a time unable to utilize former coping measures. During the time he is depending upon a support network (staff) and coping with the event as well as understanding his own reaction without distortion, he is in crisis.
To allow the resident to perceive the impact of a nursing home admission, we are proposing that the process be a gradual one. If he had access to the familiar voice of a family member or friend that had been recorded on tape and played periodically while he was adapting to his new residence, his stress may be reduced. He would be reminded to recognize himself as a cared for individual, and one who had not been abandoned by his loved ones. As a consequence, he could begin to build up sufficient resources to cope with future stressful situations. Family and/or significant others could feel they are playing an important role in the treatment program of their friend or relative when making the tape, and as a consequence, their own stress and guilt level might be reduced.
Because of the complexity and the intensity of the problems of aging, we need to develop specific treatment modalities. Existing nursing practice, geared to the acute hospital care, will not be sufficient to meet the different kinds of needs in long-term settings. The nursing home resident does not usually need the same care as the acutely ill. The nurse's most important contribution in the long-term setting may be to help the resident use his own strength in solving his problems. In addition, nurses have an obligation to nourish his sense of belonging to a family and his sense of being valued by a significant other as a dear friend. If the family or significant other can help to bring the world outside to their loved ones in a nursing home through the media of reminiscing on tape, it will assist the resident in adapting to the institution and the life review process and in maintaining his self-respect by increasing both mental and social stimulation. Clearly nurses are serving the most intimate needs of their clients 24 hours a day, seven days a week. They will receive ideas from observation and interest and promote these ideas with research.
Thus, from an interest in stress experienced by institutionalized elderly and observations of stress reduction, a major study is underway at the Bath Veterans Nursing Home Care Unit. The Psychological Stress Evaluator (PSE)* is being used in this study and tested for validity and reliability. This machine is used for voice analysis and only very preliminary work has been done using it in a clinical setting. The project is essential to test the hypothesis that reminiscence about past, pleasant experiences with a significant other will reduce stress among geriatric patients. Most importantly, the project is exploring whether there is a significant difference between playing a tape of a significant other or playing a tape of music.
Reducing stress is important to many institutionalized elderly. Physical ailments, behavioral changes, and sometimes severe management problems resulting from stress commonly occur in the nursing home setting. Limited staffing can complicate prolonged nursing intervention. The staff of the Bath Nursing Home Care Unit observed that pleasant memories of the past recorded by family and/or significant others appeared to relieve stress in several chronically ill elderly nursing home residents. This hypothesis is currently being tested in a major nursing research project at the Bath Veterans Administration Nursing Home Care Unit. The conclusion thus far in a sample of 20 resident suggests that playing a tape of a significant other may indeed reduce stress in the geriatric patieni. Analysis to date indicates that the PSE rating has adequate interreliability but clinical judgments that show statistical significance in the sample do not correlate well with PSE ratings on a one to five scale. The method of scoring the PSE charts in this study may have tended to skew the distribution pushing a high number of scores to middle range. From previous PSE reliability and validity testing, there is some indication that if the entire response had been given only one score, the range of scores may have been greater. It is important now that a larger sampling of geriatric residents be studied using both the PSE and clinical judgment, in order to assess the total degree of effectiveness of significant other tapes as a treatment modality.
We wish to acknowledge that this study has been funded by the Veterans Administration Health Services Research and Developmenl Service.
- 1. Selye H: Am J Nurs 65 (3):97-99. March 1965.
- 2. Barad M, Altshuler KZ, Goldfarb AJ: A survey of dreams in aged persons. Arch Gen Psychiatr 4:118/424, April 1961.
- 3. Goldfarb AI: Aging and Organic Brain Syndrome, Health Learning Systems, McNeil Laboratories, Inc. 1974, ? 14.
- 4. Hill R, Foote N, Aldous T, et al: Family Development in Three Geriatrics. Cambridge, Massachusetts, Schenkman Publishing Co, Inc. 1970, pp 75-76.
- 5. Maslow A: A theory of human motivation. Psychol Rev 50:370-396, 1943.
- 6. Barrell LM: Partnership in problem solving nursing. Clin N Am 9:5-15. March 1974.