Concern for the psychosocial needs of the aged is coming to the surface of society's interest and attention. It is understood that the physical and psychosocial needs of an individual are closely interrelated and that it is often difficult to separate the two.
Self-esteem is the foundation of psychosocial health. The influence of these changes are magnified when an elderly individual enters an institution. Factors influencing the self esteem of elderly clients, particularly those in institutions, are to be considered by identifying problems that interact with self esteem in a causal-effect relationship.
Every individual strives for self esteem. Maslow states that self esteem, in the form of a high evaluation of one's self, comes first from acceptance by others; only then can an individual accept and respect himself.1 Without self esteem one lacks the courage to attempt new challenges and is hesitant to interact with others.
For the elderly individual, high self esteem implies that the past has been effectively integrated into the present and that the individual operates QB the basis of what is rather than what might have been.2 Conversely, an individual who has a low self esteem often wishes to live his life again.
There is a wide variation in the way that elderly individuals perceive themselves. It is well documented that some elderly persons experience low self esteem, this especially being true of the dependent or institutionalized elderly.2 It is, therefore, important to differentiate those individuals whose self esteem needs have declined because of their increasing dependence due to age related changes from those who have demonstrated low self esteem throughout their lives. It is questionable as to what extent the health care worker can influence the latter.
Although self esteem is a global concept, it can be broken down into its component parts. The components of self esteem are: roles, touch, meaningful relationships, sexuality, independence and space. All of these components have the potential of influencing each other and of being influenced by the aging process. Consequently, all can influence an individual's level of self esteem.
Roles - These help create self identity and foster self esteem. As people reach later life, there is an increasing tendency to become removed from social roles.3 When the role a parent has fulfilled successfully during the younger years of a child's life becomes unnecessary as the child matures, the parent may experience a sense of loss of self esteem. A similar blow can be dealt by the loss of the husband role, work role, or friendship role. Society has not yet created replacement roles of equal value and worth to roles lost through the aging process.
Touch- A fundamental element of self esteem. Studies indicate that the elderly are often "touch hungry."4 Many elderly individuals have lost their spouse, probably their main source of touch. In addition, they might not be in close geographical proximity to their children or grandchildren, so gone are all the usual sources of touch. It is documented that nurses do not demonstrate touching behaviors with the elderly as often as they do with other age groups.5 Touch can serve as an overt expression of closeness that says to the elderly individual "I care for you." Such nonverbal behavior assumes primary importance in demonstrating acceptance and caring especially when verbal communication is impaired.
Meaningful relationships - We need to be involved with other people since it is through interactions with individuals important to us that we gain acceptance of ourselves. Such contacts also serve as opportunities to practice social skills. Age often sees a decrease in the number of such relationships due to the death of a spouse, sibling, or peers, the geographical distancing of children, or the relocation of the elderly individual into an institution.
Sexuality - This relates to how one perceives one's self and goes beyond the physical act of intercourse. Self esteem is fostered by the knowledge that one is perceived by another as attractive and sexually desirable. Society often equates old age with sexlessness. Such an attitude contributes little to the maintenance of self esteem.
Independence - Society equates control over one's own life with independence. Most individuals choose to live their later years as they have lived their lives but often this is not possible. The elderly individual entering a health care institution is vulnerable to loss of self esteem because of the loss of control and independence that admission implies.
Space - Space includes three related concepts: territory, personal space and privacy. Territory is used to describe the state in which an individual lays claim over an area of physical space. Such a claim is symbolized by the individual's control over who enters this area, his possessive attitude towards it, and his decoration of it with personal artifacts.
This is in contrast to personal space which does not have a fixed geographic area. It is the invisible bubble around the body that moves as we do, and changes in size as needs and mood change.
The third related spatial concept is privacy, described as the right of the individual to withhold information about himself from others. Research indicates that an individual with a low level of self esteem requires an increase in the size of his personal space. For the institutionalized elderly these needs are especially hard to meet. Even the bathroom, the most sacred room in the North American home, is communal ground. It has also been demonstrated that space needs, in particular personal space, increase with age.6
What happens when these components of self esteem are not acknowledged or not met? Problems may emerge when self esteem of the elderly individual is weakened.
The first area of concern is loss and grief. The elderly are asked to cope with numerous losses. Because of the losses that they face and the fact that these losses are often cumulative, the elderly are particularly vulnerable to grief. Murray defines grief as "a feeling of sadness."7 Losses and resulting grief occur as one's physical health declines, as mobility becomes impaired, as family ties are weakened and as spouse and peers pass away.
Linked to this is the concept of being needed. All the above cited losses have the potential of causing the elderly individual to feel neither needed nor useful. An older resident often laments "my family doesn't need me anymore," or "I feel so useless." It must be recognized also that some individuals do not grieve until long after the loss has occurred. It appears that a delayed grief reaction takes place. This is particularly evident in the elderly as an anniversary date comes around.
A second area of concern in which psychosocial problems may emerge is in the sphere of sensory alterations. As an individual ages, changes in sensory modalities are experienced. Visual acuity also declines. There is often a difference in the ability to hear. There is a decrease in the pitch of sounds that can be heard. These physiological changes can produce a reduction in self esteem, related to some degree of sensory deprivation. Wolanin talks about sensory deprivation as being a decrease in the amount of intensity of stimulus which can produce a reduction in self esteem.4 Often, too, individuals with hearing difficulties retreat inward and withdraw from their external environment.
Often, institutionalized elderly are susceptible to deprivation of sensory input. Only recently have health care institutions changed from the pastel colors of beiges, which are almost impossible for an elderly person to recognize, to the brighter colors. The confinement of the resident to a limited area, perhaps from a reduction in their mobility or through chemical or physical restraints, can produce a very unstimulating environment. The monotonous routines in an institution can contribute to sensory deprivation. These factors must be considered in the individual who appears to think little of himself and who fails to initiate interactions with others.
The problem of invasion can also produce low self esteem in an elderly individual. The term 'invasion' has been coined to refer to entrance of an individual into the space of another without the permission of the latter. This is extremely common in health care institutions. Intrusion might be in the form of walking up to a client's bed and moving the chair that stands beside the bed or opening the client's locker without permission or at least acknowledging that territory as belonging to the client. Both examples demonstrate invasion of a client's physical area, or territory. The most important territory we own is our physical body and this area is perhaps invaded by health care workers more than any other area. Feeding, bathing, dressing, insertion of enema tubing and foley catheters all represent a direct threat to the integrity of the body.
The individual may react to any of these invasion threats in several ways. They may resist it by facial expressions, hand or body gestures, or reducing eye contact. They might pretend to be asleep, a very common form of withdrawal. Direct physical aggression is also seen by health care workers; the client who hits another with her cane because the latter is sitting in her chah·. Often though, the worker fails to make the connection between the need for territorial space and invasion of that area by another. They simply label the client violent.
It is interesting to note that Allekian's study demonstrates that hospitalized patients were more upset at having their territory invaded than by having their personal space invaded.8 Perhaps they see invasion of personal space as a natural consequence of admission but do not view invasion of territory in the same light.
As people grow older and face possible institutionalization there is a loss of control over their lives. This can contribute to feelings of powerlessness which Carnevali describes as an expectancy that the outcome of a situation is beyond the control of the individual.9 It can be manifested by loss of motivation, disinterest in the external environment, anxiety and withdrawal inwards. This powerlessness is the result of several factors, one being the loss of the determinants of power as Carnevali terms them.
Perhaps the most traumatic loss of power is through giving up one's home and entering an institution. Within the home, the individual held the reins of power, determined who entered and who did not, and decided when to eat and sleep. Entering an institution denies the individual these determinants. Instead of being in control, they are now often controlled by the rules and policies of the health care institution.
The other losses that often accompany aging such as reduction in physical mobility, in financial income and in peer involvement can all contribute to feelings of powerlessness.
Psychosocial problems may also be manifested in the depression so common in the elderly individual. Reactive depression is so common in fact that it has been referred to as the common cold of the elderly. The numerous losses that an elderly individual faces have already been identified. Most old people cope with these losses remarkably well considering the magnitude and scope of the losses. Yet, some elderly do not cope successfully with these changes and depression results. Epstein, in citing various studies, suggests that the prevalence of depression in the over-65 group ranges from ten to 65 percent.10 He goes on to state that depression is often overlooked because these feelings of sadness and low spirits are accepted as being inevitable as one ages. One is therefore not motivated to seek medical attention because such feelings are to be expected.
Often the symptoms of depression - the feelings of guilt, of hopelessness, lack of interest, of motivation, the poor memory are suggestive brain failure disturbances. The correct diagnosis is often missed. Common complaints are such physical symptoms as sleep disturbances, chest pains and bowel problems. These too are often described as the normal consequences of aging and no attempt is made to identify any underlying cause.
Another area of psychosocial concern is for lonely individuals. To be alone is not necessarily to be lonely. In much the same way, being with others does not always imply that one isn't lonely. Loneliness may either initiate feelings of low self esteem or be the result of it. The elderly are perhaps more prone to loneliness than other age groups; they face institutionalization, separation from family and friends, and removal from familiar surroundings. Such loneliness may prevent interactions with others which would contribute to one's feelings of being accepted. The death of a loved one can leave an elderly individual with the feeling that no one cares. One often hears comments from elderly residents that they have outlived all their friends and that they are the last of their family.
The problem list is speculative. What components of self esteem that are not met and what problems that may emerge because of this are dependent upon the elderly individual himself. Some elderly clients have better internal and external resources with which to meet their needs. In such individuals, psychosocial problems are usually dealt with effectively by that individual.
Yet it is important that the nurse make no assumptions about the ability of the individual to cope. Every client requires a complete psychosocial assessment as well as a physical one. There are numerous assessment tools available but none completely address the potential problems identified. This is an area where research is required Based on the assessment, it is necessary to establish a realistic list of problem priorities and goals. It is then appropriate to identify health care interventions related to these priorities.
Interventions to foster self esteem may be identified as formal and informal. The former relates to specific recognized treatment modalities, such as reality orientation, attitude therapy. reminiscing, sensory retraining and pet therapy to name a few of the more common ones. Although diverse in focus, all these modalities have as their primary objective the re-orientation of the client to person, place, time and situation.
The majority of these treatment techniques also encourage social interaction. The final benefit of such modalities is that reinforcement of appropriate behavior is stressed. The elderly client's esteem rises as feedback indicates an appropriate response.
In implementing any formal treatment modality, there are three points to be considered:
1 . The client must be matched to the treatment modality. What is the focus of the modality and does it match the objectives of intervention identified for this client?
2. Should the focus of the intervention be achieved through individual or group means, or is a combination desired? Does the modality fit the framework selected?
3. It must be a united team effort, which includes the family of the elderly individual. Without a consistent approach by all members of the health care team, the intervention is almost doomed from the start.
Although it is the formal treatment modalities that are often emphasized in planning care, they cannot achieve the goals alone. There must be inclusion of the informal modalities: communication, fostering independence and meeting space needs.
Problems in communicating are common and these may be magnified in the elderly individual who has sensory impairment. Such factors as these must be considered when communicating with the elderly. Listening is a key component of communicating. Take the time to listen. People rarely do. Stop and listen to what the elderly client is saying and perhaps through this we can instill a feeling of self esteem, by saying "yes, I do value your comments."
Allow sufficient time to complete the interaction. Elderly clients are often slow to respond. They may be tired or hungry and these needs must be met. Any attempts to hurry up the responses may result in anxiety, embarrassment and missed key details. Identify clients by name, in a room full of elderly individuals it is often difficult to know to whom the remark is directed.
Remember too that facial expressions always accompany verbal comments. They can, in fact, communicate more than words do - a scowl will inform clients of the nurse's true feelings.
Fostering independence is another informal treatment modality that can result in an increase in self esteem in the elderly individual. This can be accomplished by providing the individual with some means to control his life. Of primary concern is involvement of the elderly person in the decision making process. Encourage the elderly to participate in planning their care; offer a choice of what to wear or in what activities to participate. Promote involvement in decisions involving their bodily needs thus reducing the feeling of invasion, as well. This might be as simple as consulting them regarding their food preferences.
Often an elderly resident will offer a health care worker a piece of fruit or a candy. Accept it. Acting as a host allows the resident to practice the social skills that contribute to self esteem. It also says to them that they have something to contribute.
Linked to fostering independence is the meeting of the space needs of the individual. It is a territorial characteristic of the elderly client to collect numerous small objects around him. Instead of the usual habit of removing these objects to tidy them up, leave them. They are there to help orientate the elderly to their environment and to stake that physical space as theirs.
There is a tendency to hang up dressing gowns, to put nightclothes away in the lockers. Yet we rarely seek the resident's permission to enter their locker or their drawers. Such common entry by the resident denotes the practice of sharing such space and denies the resident the territory that can be his alone. Ask permission, such a simple thing to do, but so easily forgotten or ignored. It is then reinforced that the client has some territory of his own.
Regardless of the specific modality chosen, it is important to remember that consistency must be incorporated into any intervention. The team approach, and inclusion of family members is essential to the success of any intervention. The goal of professional health care must be to assist the elderly in maintaining and increasing their feelings of self worth.
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