Holism is a health perspective that advocates harmony in the person's whole self including the mind and body and their interaction within the environment. Nursing texts and literature abound with the idea that holistic care of the elderly is the hallmark of gerontological nursing. Often missing from these writings are a consensus of what exactly constitutes a holistic intervention and reports of how the elderly respond to existing interventions. This article will describe one holistic health intervention designed to promote a sense of well-being and control of health in the elderly, and will discuss how one group of senior citizens responded.
Selected Literature Review
The literature does contain a few research studies and some descriptions of holistic health promotion interventions with the elderly. Perhaps the best known holistic intervention for the elderly is the SAGE (Senior Actualization and Growth Exploration) Project. Formed in 1974, it organized the elderly into small groups and utilized a variety of stress management techniques, such as biofeedback, meditation, art and music therapy, yoga, and breathing exercises. The SAGE literature contained participants' self reports of improvement. For example, one 73year-old woman stated, "At SAGE I have been learning how to be alive and vital again."1
Salveson described a health education club for elders which certainly could be termed holistic. This clubcalled the Senior Health Source - utilized meditation, biofeedback, visualization, therapeutic touch, and health practices such as taking blood pressure. Salveson2 stated that ". . . the role of holistic health for senior citizens goes beyond communication, contact, and power, to promoting a sense of excitement about fully experiencing this sunset time of life."
Another holistic approach to health promotion in the elderly is the WaIIingford Wellness Project.3 This project identified four pillars of health to be included in any health promotion program for the elderly. Tlie Wallingford Wellness Project, in a holistic manner, recommended what it called synergy, a putting together into a comprehensive program the four pillars of health: stress management, nutrition, physical fitness, and personal and community selfhelp.
In a quasi-experimental study, Slivinski and Kosberg4 compared the effects of a holistic intervention, the Personal Health Management System, on a group of 53 elderly subjects and a nonequivalent control group. Content covered during the ten weeks of onehour classes included stress management, nutritional awareness, selfresponsibility, physical fitness, spirituality, and the environment. Results indicated a significant increase in the experimental group in physical health, life satisfaction, activity, level of spirituality, and social and economic resources, while the control group had no changes.
Other clinicians also advocated holistic interventions for the elderly. Schrock5 thought that holistic interventions should provide life style education to promote health. She saw the necessary components to be the triad of rest, nutrition, and activity including exercises. Dangoth and Kalish6 expanded the components of a holistic intervention to include stress management, personal growth, and reminiscing.
In the literature, even though several holistic groups for the elderly were discussed, their content varied greatly. Each group, however, did focus on promoting well-being including physical and mental dimensions. Although the elderly appeared to benefit from the interventions, only one study demonstrated how the elderly changed. Nurses need to agree on just what constitutes a holistic intervention and to report exactly how the senior citizens respond to these interventions. Nursing research is needed in this area to help clinicians improve the senior citizen's quality of life.
The Holistic Health Intervention Group
Based on the recommendations of clinicians, reports of existing programs, and limited research findings, the group to be discussed in this article, the Holistic Health Intervention (HHI) Group, included the following components: stress management; visualization; self-responsibility training; physical fitness; nutrition; reminiscing; and environmental sensitivity, which covered the topics of sensory and memory enhancement and dealing with loss.
The HHI Group was one of several groups compared in a larger research project.7 Members from this HHI Group were recruited from a high-rise for the elderly and asked to participate in six weekly, one-hour, small group discussions. This particular HHI group had 13 members. All of the participants were women, had at least a high school education, and all but one were over 70. The content and some responses to the weekly discussions follow.
Content presented by the group leader the first week introduced the participants to the topics of wellness, selfresponsibility for wellness, stress, physical and emotional responses to stress, and life styles that counteract stress.
Discussion was opened by the group leader who asked the participants what wellness meant to them. To the leader's surprise, one woman almost immediately stated that wellness included mental aspects as well as physical. The group seemed in general agreement about the role of self-responsibility in wellness.
When the concept of stress was introduced, one woman gave an almost textbook response. She noted that everyone needs some stress, and without it everyone would probably be "in the morgue."
The participants readily volunteered a variety of stress-provoking situations in their lives. For example, one woman said that she felt stressed when family problems occurred with her children and she was unable to help. Another member said that stress occurred with life's traumas and related two traumatic episodes in her life. Both involved situations in which her young children were very ill with life-threatening diseases. Others stated that stress can occur over little things and at times when a person feels trapped. Growing old and moving into a high-rise were also listed as sources of stress.
The members were able to discuss ways of handling stress in the same free manner in which they suggested sources of stress. Many said they used prayer to alleviate stress, and one woman said that a person must do what she can first before putting it in God's hands. Other suggestions were exercising, walking, proper nutrition, keeping busy and interested, playing cards, and helping others.
Near the end of the meeting, a participant asked if stress can cause cancer and then continued to answer her own question. She recounted how several widows became ill after their husbands' deaths. Responding to this, another woman said that she thought people are born with the ability to produce cancer cells and stress initiates their production. She then discussed how she had breast cancer after her mother died and her blind father moved into her household.
Week two focused on some specific methods for increasing health and reducing stress, namely, physical fitness, relaxation exercises, and the use of imagery. The members discussed their attitudes toward physical exercise and the benefits as well as the body's responses to it.
The group then practiced a series of mild stretching exercises which were completed at the beginning of each subsequent week. Members also participated in diaphragmatic breathing and progressive relaxation. The use of imagery was discussed, and the leader directed the group to visualize a scene which was personally peaceful. Each subsequent week ended with an imagery exercise.
As the day's topics were presented and opened for discussion, participants appeared particularly attentive to the physical fitness components. One woman was leading exercise classes and contributed much from her knowledge and experience, in addition to affirming the content that the leader presented. Also, the members were able to relate the information to what they had done in the exercise classes, such as comparing their dance steps to aerobic exercises. They were very eager to practice the stretching exercises that the leader presented.
Diaphragmatic breathing was new to most, and they needed to repeat the exercise several times before performing it correctly. Likewise, the imagery content at first appeared new to the participants. Members commented on enjoying the imagery exercise for visualizing a peaceful scene and discussed their imagery. One woman graphically described a resort in the mountains where she used to vacation and related the vivid green colors and the smells of fresh air.
The discussion turned to how imagery can be used to promote health when one woman contributed that she had heard of imagery being used with children who have cancer. A participant capped the discussion with the question, "Isn't this viewpoint called holistic health?"
Week three centered on the idea that responsibility for health included assuming responsibility for one's steeping habits, use of medication, and nutrition.
One woman asked the group leader if the members could start the class with the stretching exercises performed last week. The leader thought this was a perfect suggestion since the stretching exercises were already scheduled as the opening item. Again, the leader was somewhat amazed at how receptive this group seemed to be to the holistic protocol.
During the presentation on sleep, many of the members offered personal examples that correlated with the content presented. A woman, for example, stated that she wakes up several times during the night. However, she optimistically stated that waking up was a good experience because walking to the bathroom stimulated her circulation and made her less stiff in the morning. Another woman even suggested the progressive relaxation exercise performed last week as a remedy for not being able to fall asleep.
When the content centered on the safe use of medications, members seemed most inclined to share some of their own systems for taking medications. To depict what should not be done, a participant volunteered a story of a woman who brought a whole shoebox full of old medicine to her pharmacist to check on how much she could still take. The surprised pharmacist unearthed from the shoebox bottles from a pharmacy that had been out of business for years.
Another participant complained of being awakened in the hospital to take a sleeping pill, and this led to a litany of complaints about how people were not cared for or cared about in hospitals. A member stated that hospitals could benefit from discussion groups like this one where someone sat down and listened to them.
Concerning the nutritional content of their diets, this group seemed most interested in knowing which foods were high in fiber. The session ended with an imagery exercise in which the participants visualized themselves following healthy life styles of their choice.
This week's content was on relating to the world and dealing with loss. Relating to the world dealt with normal changes in sight and hearing with aging and how to adapt to these changes.
After the initial stretching exercises, the discussion about eyesight and hearing was short since the participants did not have many problems in these areas. All of the women had annual eye examinations, and two said that their eyeglass prescriptions had remained unchanged in recent years. The topic of driving at night was of interest since some related difficulty with night vision and depth perception; so these areas were discussed in more detail. Since the participants all had relatives or close Mends with varying degrees of hearing loss, their interest centered on how to better communicate with them.
During the discussion on loss, two people dominated. A single woman explained how she had lost her mother and sister with whom she had lived. Because she found it difficult to live in the empty house, she sold it and moved to the high-rise. The woman talked of the security she felt in a building full of people.
This led to another member's discussion of how she and her husband decided to sell their home and move to the high-rise while both were alive and healthy instead of being forced later to make the change alone. She stated that her house did not control her and that she has seen elderly people who let their homes, with their constant need for upkeep and repair control their lives. To her, moving into the high-rise was another phase of life, a new adventure. This week ended with the members visualizing how their strengths had helped them through periods of loss.
Improving memory was the topic for this week. After the stretching exercises, members discussed their own memories, some facts about memory and aging, and some devices for improving memory, such as making lists and mnemonics.
Members appeared eager to hear information on memory and aging. The leader tried to stress the idea (hat memory is a skill in which some individuals are good simply because they practice. A member affirmed this by relating a story of her friend who owned a pharmacy and knew the names of all her customers as well as the names of their family members. Even though retired, this woman still knows the names of her former customers when she meets them.
The majority of women complained of difficulty remembering names. After asking some questions, the leader discovered that the difficulty stemmed from the residents moving into the highrise with 175 new names. Initially, a new tenant is overwhelmed and men later feels embarrassed to ask others to repeat their names. Various remedies for this were discussed, including wearing name tags at socials and reading over the list of residents before attending functions. Also, the members thought the suggestions on the mnemonics handouts given to them would be helpful.
Most of the members appeared to be hearing about mnemonics for the first time. Their initial reaction was one of amusement. After presenting this, the group leader thought that mnemonics might be one area that required more time with homework and drills. The imagery exercise that ended this session was that of having the members pair each other's name with some interesting mnemonic associations.
Reminiscence seemed to be an appropriate topic for the final week. Again the stretching exercises were performed, and then the discussion began.
One of the members defined reminiscence as remembering the good old days - 40 or 50 years ago. Rom this statement, the group recalled and shared many memories. The theme seemed to be that change has left behind some good things, but has also brought forth some beneficial outcomes.
One member initiated the discussion quite well by stating:
We've seen a lot of changes. I wonder if just as much could change in the next 50 years; probably it will in ways we can't imagine. We've seen changes in everything ... in transportation, from horse and buggies to cars, planes and outer space ... in communication, the telephone, radio, and television ... in refrigeration, electricity, running water, and indoor plumbing. We've seen it all!
Various members commented on how life was without these things, and then the discussion focused on life in the country with various stories of farm animals, farm work, and country life. One topic people enjoyed discussing was how they entertained themselves without television.
The women talked of not having money to buy toys, but making games with things that they did have. Games they recalled were kick the can, run sheepy run, hide and seek, jump rope, and jacks.
Participants remembered the industries that used to be in the area, and one woman said that things were a little dirty, but people worked. This comment evoked from one woman's memory a story of how she used to hang sheets on the clothesline to dry. When a train would pass, it huffed black soot all over the sheets. This story brought forth many other members' stories of train rides they had taken. To the leader, the stories were so vivid that one could imagine what it would have been like to sit in the summer, on the plush red compartment chair, and brush the soot off your face as the wind would blow in through the open windows.
These stories led quite smoothly into the final imagery exercise which had the participants traveling down a country road. At various stops die women were to remember specific activities learned throughout the six weeks.
At the close of the last session, the members were given questionnaires and an evaluation form to complete. The members of this group were overwhelmingly positive about what they learned in the weekly discussions. When asked, "In what ways has this course helped you?", one member responded, "Made me think of exercising and health more." Other participants wrote that they were helped by "Discussion of health subjects"; "Selfimprovement"; "Relaxation"; and "Using the mind." A woman responded that she had learned to be ". . . Responsible for your health, your doctor, your medicine, overcome stress by meditation, exercise, and that you alone are in control." Another woman said that she had learned to "Be a survivor and that I am greatly responsible for my good health and outlook on life."
When asked what they liked most about the course, the respondents said frequently that the free conversation and open discussion were helpful, especially since they brought out the interests of the older person. Others commented about enjoying the exercising, overcoming stress, bringing back memories, and practicing imagery. There were no negative comments to the question, "What did you like the least?"
The Holistic Health Intervention Group was well received by a small group of senior citizens living in a highrise for the elderly. They were eager participants in the nurse-led, weekly discussions and evaluated the sessions quite favorably. Participants seemed to have benefited, and the leader definitely learned much about life through the generous and holistic sharings of the group members.
The content of the HHI Group represents one possible combination of topics for a holistic health intervention. Future groups could try other topics, such as enjoying sexual activity, living with arthritis, or developing new interests. The group leader might wish to solicit ideas from the members for future topics. The author would also recommend opening with the stretching exercises and closing with the imagery exercises because this increased the involvement of the participants and established continuity from week to week. Alternative activities, however, could be tried. Future groups could also experiment with having co-leaders or using guest speakers if the leader is careful to keep the meeting as a discussion and not a lecture.
The HHI Group can thus be adapted in a variety of ways. Nurses need to continue to report how the senior citizens respond to these adaptations. Nursing research should be undertaken to better define holism and evaluate the effectiveness of holistic interventions.
- 1. Dychtwald K: The SAGE project ... a new image of age. Journal of Humanistic Psychology 1978; 18(2):69-74.
- 2. Salveson C: Holistic health for the elderly, in Kreiger D (ed): Foundations for Holistic Health Nursing Practices: The Renaissance Nurse. Philadelphia, JB Lippincott Company, 1981, pp 231-248.
- 3. Eallcreek S, Mettler M: A Healthy Old Age: Sourcebook for Health Promotion with Older Adults. Seattle, Washington, Center for Social Welfare Research, School of Social Work, University of Washington, 1984.
- 4. Slivinski LR. Kosberg Jl: Assessing the effect of a persona] health management system within retirement communities: A preliminary investigation. Gerontologist 1984; 24(3): 280-285.
- 5. Schrock MM: Holistic Assessment of the Healthy Aged. New York, John Wiley and Sons, 1980.
- 6. Dangoth LR, Kalish RA: A Time to Enjoy: The Pleasures of Aging. Englewood Cliffs, NJ, Prentice-Hall, 1979.
- 7. Kutlenios RM: A Comparison of Holistic, Mental and Physical Health Nursing Interventions with the Elderly, doctoral dissertation. University of Pittsburgh, 1985.