Sitting in a physician's waiting room for a scheduled appointment is a good excuse for sampling a few editions of popular office reading fare. A perusal of the magazine rack yielded a July, 1982, issue of the JOURNAL OF GERONTOLOGICAL NURSING. As a graduate student in primary health nursing, my attentions are on community-based programs tailored to the needs of older adults. Discovering and implementing creative and rewarding interventions sensitive to this expanding segment of the population is the focus of my current nursing practice.
Skimming the journal's content page brought me to an article entitled "Aging and Memory Loss." According to these authors, memory retention and memory loss are areas of concern with special significance for older people and health-related disciplines alike.1 One gauge of a person's ability to adapt to the environment depends upon memory as a process and product, allowing an individual to be responsive, interactional, and able to care for self and others.2 Memory is a complex phenomena with many facets, however, short-term memory loss has profound effects on older people who desire to maintain a level of independent community living. In this article, short-term memory loss was defined as "a decrease in the ability to acquire and retain information.1 Another definition of shortterm memory loss is "the loss of recall for recent events as compared to a loss of recall for events that occurred in the past" or remote memory.3
Each of us can relate incidents in which older adults had some difficulty recalling whether or not medicine had been taken or what had been eaten that day. Yet a casual remark made to this same person can trigger vivid memories of events that occurred years ago. A gradual loss of memory hinders a person's ability to maintain contact with the environment leading to diminished self-awareness and self-esteem.1
Much has been written regarding the nature and causes of memory loss in the aged including physical, psychological, social, and environmental conditions or a combination of these factors. Elders who realize their memory losses exhibit feelings of frustration and sometimes of self-loathing. The anxiety-produced feelings may actually perpetuate a pattern of impaired memory function. However, other than a valid diagnosis confirming memory loss as a sign of illness or as the result of injury or degenerative mental changes, there is some support for that well-worn but time-honored saying, "What you don't use, you'll lose."
We attempted nursing intervention employing a memory retention course especially designed for groups of older adults. The intervention was implemented by four graduate nursing students at a geriatric day care center. We were guided by Garfunkel and Landau's booklet about memory retention.4 The main goals of this program are "to provide strategies and devices that can lessen the number and effect of memory lapses and to reduce stress and fear related to memory loss.4 The strategies of this intervention combine simple teaching and learning principles with memory facilitating aids and devices applied to activities of daily living and self or assisted care for non-institutionalized older adults. The students agreed with the course developers' philosophy that aging, often negatively stereotyped, need not be a time of life marked by deterioration and decline. Regardless of the outcome of this program we believe that the knowledge, gained from the exploration of nursing interventions to enhance the quality of life for all people, is a primary function of current nursing theory, practice, and research.
The site for this shared nursing experience was an adult day care center located in a rural community. In general, adult day care services provide programs of activities within protective non-residential settings to people who are not capable of full-time independent living. This particular day care center has facilities for a maximum of 30 clients per day, five days a week. Clients are provided transportation if needed to and from the center via a specially equipped van. Individuals attend this program for a portion of the day which includes snacks, a hot luncheon, balanced rest and exercise periods, and structured activities in a pleasant, safe, therapeutic environment under the supervision of caring personnel.
Day Care Population - The day care population is comprised of clients drawn from five settings and includes people who live alone independently, live with their families, live in a community co-op or domiciliary care unit, live in adult foster care or live in an institution with the potential to return to the community. These clients, predominantly women with an average age of 68 years, have been referred to the center by a community case worker, family, friend or self-referral. Generally, clients have a recognized health dysfunction in terms of the physical, psychological, sociological and emotional domains. The goal of the day care is to enable mentally and physically disabled or infirm clients to live in the community either independently or with a care provider.
While the primary focus of the day care is socialization, an active health component is provided by a nurse clinician and graduate nursing students under her supervision. Through nursing interventions emphasizing health promotion for daily living and the prevention of further limitations, we attempt to enhance the well-being of these clients by maximizing their existing health potentials through the exercise of holistic self-care practices.
As defined by Orem, self-care is "the practice of activities that clients personally initiate and perform on their own behalf in maintaining life, health, and well-being."5 The self-care concept integrates holistic caring and interprets health care as involving and attending to all aspects of human endeavor as a whole - the mind, body, and spirit. Self-care is practiced to maintain the rights and privileges of people requiring some form of health assistance and helps the clients help themselves when at all possible. Self-care has allowed nursing to expand its boundaries beyond the perimeters of hospital-based nursing practice.
Initially, the memory retention program had been suggested to the day care clients during one of our group sessions. A portion of the nursing practiced with these clients is on a one-toone basis, but we have found that needs surface and can be met by interacting with the client group as a whole. Each person in the group was asked to express feelings and concerns about memory abilities at that time in their lives.
If clients showed an interest in participating in a memory retention program, they were asked to complete a simple pre-test checklist compiled from situations suggested in the memory program appendix.4 We added questions taken from our own assessments of the knowledge, skills, and health patterns exhibited by the clients. A sample question was, "Do you remember where you put your eyeglasses?" Each question had a choice of four answers; always, most times, occasionally or never. We tried to compose the pre-test to include items that would be reasonable accomplishments for all the client regardless of sex, level of function, and living arrangements. We realized that many needs, such as taking medicine or remembering appointments, that would require the use of memory had been assumed by family members and other care providers. With fewer needs to fulfill, it is logical to demonstrate reduced motivation toward memory activity and follow-through practices. Despite this acknowledgement, the ensuing discussion, favorable reactions to the suggestion of a memory course and the results from the pretests indicated a desire in these older people for learning new memory retention skills and recycling old ones.
The groups' verbal responses and pre-test scores served to predict motivation, attitudes, and biases for the successful implementation of the memory intervention. Indicators of outcome for the program would be based on client post-testing using a duplicate of the pretest, the evaluation questionnaire designed by the program developers, group participation, and verbal feedback.
The self-care approach to nursing encourages people to be active participants in their own health care, so we enlisted the aid of the clients in planning the memory program. For example, the clients liked to hold group sessions first thing in the morning over coffee and a snack. In assessing their own capabilities they were aware that they had higher energy levels and concentration powers during the morning hours. Other than this stipulation, they agreed to the suggested six memory sessions of about an hour each, one day a week for six weeks.
Our group of 15 people fell within the size constraints recommended for good discussions of this type.4 We also enlisted the aid and support of the regular day care staff and encouraged them to join our sessions.
The first session of the memory program is considered to be extremely important for setting the tone for success.4 It attempts to establish an atmosphere of welcome, trust, and a sharing of strengths and weaknesses benefiting both individuals and the group. As suggested, we asked everyone to think of something they had trouble remembering but was important to everyday functioning. All of these items were written on a large poster board with room for additions. This vital-todaily-functioning list was used for review and to stimulate further discussions of memory coping techniques as the program progressed over the six weeks.4
Formal introductions weren't necessary for these clients as this is a fairly stable group that attends day care regularly. We did play a little name game, just for the fun of it and to get the ball rolling. We were aware that the group disintegrates during the day. Some choose to be alone, while others join smaller circles. No one was coerced to participate in the memory program, but we did coax those who kept to themselves to come to our meeting spot and sit together around one large table. Even one hyperactive client who seldom joined any activities was able to sit with us during these weekly sessions. This individual never participated verbally, but did sit quietly and appeared to be listening.
Each of the six sessions had a leader as well as program objectives. The graduate students took turns as group leader while the rest of us sat with various clients whom we assessed as requiring additional help in the form of repeating and explaining comments that hadn't been heard or understood. The theme that runs through all the sessions is reassurance.4 To be able to remember people, places, and things is fine, but if you forget some things, that's OK, too.
The second session and all those that followed reviewed key points from each of the previous weeks' discussions. Two new concepts were introduced, association and concentration. We appreciated the course's pacing strategy; it didn't overload the clients with too many new ideas at one time. We placed emphasis on ways to remember items taken from the vital-to-daily-functioning checklist constructed by the group in the first session, memory jogging aids and devices such as the use of calendars, notes, etc, and the principle that there is a need to have a place for everything and everything should be in its place.
Session three introduced the principles of motivation and repetition, the value of list-making, and encouraged the group to add more items to the vitalto-daily-functioning checklist. Failing to remember the names of books, flowers, and places can be annoying but not incapacitating.4 The important thing is to be able to recall the sight, sound, smell, touch, and sense of pleasure derived from active involvement in life's experiences. A coping strategy that could be used for people who are unable to read and write is the picture list. A grocery list might consist of a drawing of a cow for milk or a chicken with eggs. One of the clients suggested drawing a light bulb or bolt of electricity as a reminder to pay the electric bill.
Session four discusses memory lapses and attitudes toward them, lifestyles, and illnesses that affect memory.4 Association, concentration, and repetition were reviewed. Large posters with these three words remained on display at the day care center for the duration of the memory sessions. Following the program outline, we called for ways of coping with memory changes including the use of humor. Personal successes were related at this point in the program.
Session five simply reviewed memory tools and devices, added new ones, and recounted problem-solving techniques.
During the sixth and final session, we assisted the group in completing the post- test and evaluation forms. We asked for individual and group comments regarding the entire program. We brought out the "hidden agenda" one more time, and reminded the group to exercise their memory abilities regularly. Our formal memory program concluded with a ceremony and distribution of individual certificates of achievement, followed by a party.
Although we did not submit our findings to statistical analysis, the results of the post-test and evaluation gave some indication of a positive change in attitude for memory retention in the majority of the group. Clients still carry their memory certificates in wallets or purses. When they rediscover the certificates, it stimulates renewed discussions of memory skills and of ways to cope with memory loss. We have continued to use the principles of Garfunkel and Landau's program in subsequent nursing interventions initiated with the day care group and during individual interactions as well in an effort to maximize their health potentials through self-care practices.
- 1. Maloney JP, Bartz C: Aging and memory loss. J Gerontol Nurs 1982; 8(7):402-404.
- 2. Kart CS. Manard BB: Readings in Social Gerontology. Port Washington. New York, Alfred Publishing Co. 1976.
- 3. Murray RB, Huelskoetter. MMW. O'Driscoll DL: The Nursing Process in Later Maturity. Englewood Cliffs. New Jersey, Prentice-Hall, Ine, 1980.
- 4. Garfunke I F, Landau G: A Memory Retention Course for the Aged. Washington. D. C, The National Council On The Aging, Inc. 1981.
- 5. Kearney BY. Fleischer BJ: Development of an instrument to measure exercise of self-care agency, Nursing and Health 1979; 2(I):25-34.