In the past, the emphasis in health care for the aged has been primarily on meeting physical needs. This is changing. Research has demonstrated that the elderly have such complex interacting health and illness problems, that they require a comprehensive approach to their health care needs. Our health care system has many health providers who are able to care for the elderly. However, their health care approach is limited to their unique perspective. The elderly do not benefit from this type of fragmented care. They do benefit from a holistic approach to their health and illness problems.
The Primary Health Care Nursing Approach
Nursing is by nature and by tradition holistic and health focused in its approach to people presenting with health and illness problems. The gerontological nurse practitioner is in a unique position to render holistic care to clients, being able to perceive them within a wellness model rather than an illness model. Master's level education provides the additional knowl- edge to accomplish this. Practitioner skills are developed through indepth laboratory and clinical practice. Client care is based upon a comprehensive data base that views health holistically; it includes strengths and assets as well as weaknesses and liabilities.
The data base is composed of a thorough history and physical examination and is followed by the development of a comprehensive plan of care. The history places particular stress on the nature and severity of the clients' problems, their effects on clients' current life style, and strengths clients display in coping with their problems. An assessment of the clients' psychological make-up, the clients' sociologie and economic status, and the clients' adaptation to occurring problems are important components of the assessment.
More than half of the elderly clients who come to a primary care practitioner with a new problem are also suffering from some form of unpleasant emotional arousal, such as tension, worry, sadness, or fear. These emotional states are often characterized under the general headings of anxiety or depression.1
Such emotional states may: (1) exist with no organic disease, (2) be symptoms of organic disease, or (3) be psychological reactions to the presence of an organic symptom. The practitioner is aware of these possibilities and is able to assess the differences between them.
The following case presentation describes a holistic approach in the care of one elderly client, Mrs. V, who was experiencing emotional problems. The source of physical and emotional problems and their status throughout the therapeutic period are identified. The end result of the therapeutic process was that Mrs. V was able to assess her strengths and weaknesses and then maximize her strengths to enhance her life situation.
Mrs. V is an 80-year-old woman of German descent. She describes her life as becoming "increasingly lonely" over the years. Her husband died in 1957, and her only child, a stepson from her husband's first marriage, died one year ago. Socialization is difficult for Mrs. Vbecause she either walks or depends upon public transportation to visit others or participate inactivities. Financial difficulties are also responsible for Mrs. V's socialization problems. She states, "I just about get by on my Social Security check."
On her first visit to our ambulatory clinic, Mrs. V sat across from the practi tioner wi th her head down, her facial expression was taut, and her hands were clenched in her lap. Sh'e tersely answered questions explaining that she was "embarrassed to socialize because of this voice problem." Further questioning revealed that three years ago she began to have problems speaking. The problem was not in articulation but in sound. Her words came out in a warbled frog-like manner. Health care providers at the previous clinic were unable to find any organic base for this problem, and Mrs. V believes it was due to "nerves and tension."
Past history also revealed diabetes, which was diagnosed four years ago. Mrs. V demonstrated adequate knowledge in all aspects of this condition. She had been taking Diabenese 125 mgm od, Benadryl 50 mgm prn for sleep, and Elavil, 10 mgm ("I usually take one a day") for tension.
A complete physical assessment was unremarkable except for the fact that her weight was 128 lbs, a loss of 50 lbs over the past five years. The loss was deliberate and accomplished through dietary regulation and physician consultation. All laboratory tests, including a chest x-ray and EKG, were found to be within normal limits. Of particular interest were the T3 and T4 normal results and the fasting blood sugar of 79.
A mental status assessment performed with Mrs. V proved to be within normal limits. However, we both agreed that she had an emotional problem. Therefore, we discussed the possibility of a referral to our mental health clinic or of her visiting with this practitioner on a regular two-week basis. She chose seeing this practitioner.
Before Mrs. V's next visit, I reviewed her emotional and psychosocial history with a geropsychiatrist. She brought out the fact that the voice, one of the first behaviors of the infant, often serves as an emotional outlet for many anxieties. Voice changes could be the result of an emotionally traumatic experience of long standing or an experience being suffered at the present time.
Physical attention required furMargo ther investigation of Mrs. V's diabetic status. An obese elderly person may be secreting insulin in quantities insufficient to meet body needs. This could have been the problem four years ago when Mrs. V was 50 lbs overweight. Another reason for pursuing this further is that Diabenese, 125 mgm od is insufficient to maintain a blood sugar at 79; in addition, over a long period of time Diabenese can cause depression. A subsequent fasting blood sugar plus a two-hour postprandial test were within normal limits. With my preceptor's validation, Mrs. V was instructed to discontinue Diabenese. Diet, exercise, urine testing, and signs of diabetic coma were all discussed with the client. During this visit and subsequent visits, much emphasis was also placed on the reasons for what Mrs. V described as "nerves and tension."
I suggested that Mrs. V "travel back through the years" and together we would discuss the life situations that she felt caused her nervousness and tension. Realization and verbalization of her fears and anxieties would lead her to a better understanding of herself and her emotions. My goal was for her to utilize coping mechanisms that would enhance the quality of her life, and which had been successful before rather than detract from it. Hopefully as we proceeded, the overt problem with her voice would also subside.
She described the bombings-the "awful shocks," the running from one building to another-when she was a young girl in Germany. When describing these experiences her eyes filled with tears and her hands were clasped so tautly her knuckles were white. Her voice was almost a whisper.
She commented on her relationship with her sister as "someone who always overshadowed me as a young girl, I was so shy." We spoke of the loneliness and depression she was currently experiencing "because I hate to socialize with this voice." I told her that I understood her feelings, but pointed out to her that I had always been able to understand her when she spoke.
Orientation to the Future
The future is not a happy thought for many elderly people. Future orientation in our society is associated with the young. It is synonymous with hope and possibility, with the exploration of new ideas and the reaching of new goals. The elderly tend to dismiss future planning and dwell on "past," because this is where they see their happiest times. This does not have to be. We all have "future," and it is one of our responsibilities to guide the elderly toward this realization.
I asked Mrs. V to think about her future-"What would you most like to do?" She regarded me rather quizically, but I pursued with, "Let's plan on discussing this during your next visit."
During following visits a determination was made that there were no untoward effects from discontinuing Diabenese. Mrs. V's fasting blood sugar remained normal, and her urines were always negative. This brought a great deal of delight to Mrs. V. She commented: "Whenever I went to the clinic, they always found something wrong with me- this is the first time someone found something right with me." No longer did she sit tensely with her hands clenched and head down. Now she looked directly at me when she spoke, her face was relaxed, and she even smiled once in a while.
We returned again to the subject of her future. She told me, "I've thought a lot about what you said; the one thing I would like to do is go back to Germany to visit my sister. I've been thinking about it for a long time, but I've been afraid to do it. Now I think I'm going to try. The diabetes does not seem to be a problem anymore, and even though my voice is still the same, you understand me and I noticed that most other people understand me, too."
Mrs. V and I worked together from the beginning of May until she left for Germany at the end of July. There was not any change in her voice during this time. However, Mrs. V's approach to life changed from that of a lonely and depressed lady to a life of hope and possibility. I was scheduled to leave the clinic the first week in September. Needless to say, I was delighted when two days before I was leaving, I noted that her name appeared in my appointment book. During our visit, she informed me that her trip was everything she had hoped for. She seemed relaxed and happy, and told me she rarely felt the need for Benadryl and Elavil anymore.
We spoke of my leaving, which she had been aware of before her trip. I introduced her to the physician who would continue her care. Change is part of all of our lives, but how I wished I could have stayed and continued her care myself.
The elderly possess unique personal, social, and physical characteristics, and these frequently complicate or facilitate therapy. Older people are characteristically individualistic because they have proceeded through a long life of developing individual coping mechanisms and life styles. A nurse cannot help any elderly person meet his needs unless she invests of herself; understands the physical, psycho- logical, and sociological, factors involved in aging, and views the patient as a unique and interesting person.3 In the distant past, Chen Jen philosophically stated, "When you treat a disease, first treat the mind; there are no diseases-only people." Personalities of individuals are in no way uniform or simple enough to pigeonhole in categories. Only through caring for the elderly holistically can their needs be met, and can they receive the health care they need and deserve.
- 1. Shulman B: Patient management problem no 1, in Psychiatric Consultations, Chicago, Illinois, Continuing Professional Education, 1978.
- 2. Williams FT: Diabetes mellitus in older people, in Clinical Aspects of Aging, Maryland, Williams 8c Wilkins Co, 1978.
- 3. Niland M: Understanding the elderly. Nursing Forum 11:273-289, 1972.