Given the critical role that nurses play in public education regarding assessment of medical problems, practitioners working with geriatric patients who have alcoholism must assess their own personal attitudes toward the disease if they are to provide effective intervention services. This article reviews the magnitude of problems associated with alcoholism among the geriatric population, notes potentially dysfunctional attitudes in nurses and other health-care professionals that are likely to impair the provision of high quality care, and provides information on effective ways to monitor and modify negative attitudes toward patients with this problem.
SCOPE OF THE GERIATRIC ALCOHOLISM PROBLEM
Alcoholism and alcohol abuse are increasingly recognized by health-care professionals as major problems confronting society. This is seen, in part, by the growing demands placed on the nursing profession for the development of screening, diagnostic, treatment, and rehabilitation competencies that can be used with patients who have a primary or secondary diagnosis of alcoholism. Given the important role that nurses have historically played in public education, it can be anticipated that the nursing profession's role in alcoholism education and related intervention strategies will become even more pronounced in response to the societal need for such services.
As serious as the alcoholism problem may be among the general population, it may take on an even greater magnitude in the geriatric population, a segment of our society that will constitute a significant percentage of the general poulation by the year 2000. Even when the most conservative estimates are used, alcohol-related problems are disproportionately large among the elderly.1 Although reported prevalence rates for alcoholism and alcohol-related problems in the overall population range from 2% to 10%, 2^ these rates rise dramatically when hospitals and other institutional settings are sampled.57 These settings typically have an over-representation of geriatric patients. In fact, several investigaron have suggested that more than half of all hospital admissions of aging individuals are directly traceable to alcoholrelated problems.38
MEDICAL SEQUELAE AND PUBLIC EDUCATION
Among the elderly, the medica] sequelae of alcoholism and alcohol abuse may be especially serious, although the public is relatively unaware of these sequelae. This poses an immense challenge to the nursing profession from an educational perspective; a significant body of information currently exists regarding alcoholism among the elderly that must, of necessity, be disseminated to the public.
With advancing age, tolerance of alcohol typically diminshes,9 as does the efficiency of the metabolic breakdown of alcohol. When alcohol is administered to persons of various ages in constant and controlled amounts, the most elevated blood alcohol levels are generally produced in the elderly. 1C With aging, then, the potential impaci of the diminished tolerance levels is further exaggerated by the enhanced blood alcohol levels attributable to increasing metabolic inefficiency. The aging process itself results in cell loss in target organs, especially in the brain and central nervous system. Although the levels of alcohol absorption of these target areas may .decrease, this is offset by the probability of increased sensitivity of these organs to alcohol ir older individuals. Thus, the aging process itself magnifies the potentially deleterious effects of any alcohol intake in aging patients.10
A number of specific adverse consequences of alcohol ingestion have beer identified in the geriatric population. Alcohol has been recognized as a significant factor in the onset of liver and pancreatic disease,11,12 and as a contributing factor to the development of gastrointestinal disorders.13,14 Among elderl) persons, even small amounts of alcohol can decrease cardiac output and coronar) circulation in patients with heart disease,15,16 decrease respiration effectiveness in patients with lung disease,1' and exacerbate the effects of existing diabetic conditions in such patients. 10 Elderly persons with alcohol problems have decreased reserves and are at higher risk for intercurrent medical illnesses.17 Additionally, alcohol has significantly disadvantageous effects on the neurological status of patents with alcohol abuse histories.18·19 With older individuals, even small amounts of alcohol may increase neurological deficits.20
Perhaps most significantly for the elderly, as a result of its cumulative negative physiological impact, chronic alcoholism may shorten overall life expectancy by as many as 10 to 12 years.21 In a recent report based on mortality data from the National Center for Health Statistics, it was estimated that the number of alcohol-related deaths in the US may represent up to 16% of all mortalities.22
Compounding the medical sequelae problems is the possibility that many geriatric patients who have alcoholrelated complications may go unidentified and their problems undiagnosed.2326 The lack of early identification of alcoholism among the elderly in our society may be attributable to several factors. First, geriatric patients with alcohol problems may legitimately be unaware that a problem exists, which, in turn, would negate their entry into the medical service delivery system in many instances until secondary problems necessitate intervention services. Second, although symptoms may develop of which the person is unaware, the person might fail to associate them with alcohol usage and fail to report such usage to nurses and other healthcare professionals. In this light, the symptoms may be so subtle that they escape detection by family members or health-care professionals. Finally, the patient and family may simply deny the existence of any alcohol-related problems. Thus, nurses and others may delay an accurate diagnosis until the condition has reached an advanced stage of development.27
Present estimates suggest that the number of geriatric patients who have alcoholism will increase significantly in the future.28 The public must be made aware of this growing health problem. This emphasizes the need to effectively plan for such an eventuality, including the development of efficacious screening, diagnostics, treatment, and rehabilitative strategies for the general public.28"30 A particular health concern is that, despite the complex patterns of symptomatology seen among geriatric patients with alcoholism, as many as 85% receive no treatment for the primary disorder.31 It therefore becomes incumbent upon nursing personnel to assume greater responsibility for providing services to the aging sector of our society with regard to alcoholism and alcoholrelated problems. To most effectively take on this responsibility, nurses must assess, and modify when necessary, their own attitudes towards such individuals.
POSITIVE ATTITUDE TOWARD ALCOHOLISM AS A CONCEPTUAL FOUNDATION FOR ALL NURSING SERVICE PROVISION
TOWARD A CONCEPTUAL FOUNDATION
Although it is possible to identify a number of specific, desirable professional competencies for nurses who work with geriatric patients with alcoholism or alcohol -related problems, perhaps none are as crucial or fundamental as that of a positive attitude towards the problem. In a most general sense, then, a positive attitude becomes the conceptual foundation upon which all service provision is based (Figure 1).
As suggested in this diagram, a positive attitude lies at the very core of all services provided by nurses working with geriatric patients. This attitude affects the quality of assessment, diagnosis, and treatment strategies employed by the nurse. Inherent in the nursing process is that education is ongoing and is integrally linked with each of the aforementioned activities. Education, by nature, is the reciprocal process such that information acquired by the nurse is, in turn, disseminated to others via inservice and public education activities.
REASONS CITED BY NURSES FOR REJECTING GERIATRIC PATIENTS WITH ALCOHOLISM14
Unfortunately, research suggests that nurses tend to have more negative attitudes toward alcoholic patients than nonalcoholic patients,32·33 although this data is less than conclusive.7 These negative attitudes may be due, in part, to the professional perception that alcoholism and alcohol-related problems are difficult to manage in a medical setting.34 If, indeed, these negative attitudes do exist, they effect the assessment and diagnostic processes as well as subsequent treatment provided to the geriatric patient. The following case studies are suggestive of the impact of negative attitudes toward geriatric patients who have alcoholism.
Mr. B is 60 years old and had been a resident of a skilled-care nursing facility for approximately 2 years. His primary diagnosis was chronic obstructive lung disease. Mr. B was an alert, coherent, ambulatory individual with varied interests in life. He was often reported to leave the facility to visit friends or relatives for the day and, at times, overnight. One particular afternoon, Mr. B appeared irate to the nursing staff of the facility, complaining of problems with his medication. The staff nurse stood quietly by, nodding her head in agreement. After Mr. B walked away, the social director asked the nurse what the problem was. The nurse commented, "Oh, don't worry about him. He's just an alcoholic. He probably doesn't even know what he's getting." Approximately 9:00 p.m. that same evening, Mr. B was admitted to the hospital with an elevated theophylline level.
Mr. H, 66 years old, was admitted to a skilled-care nursing facility. His principle diagnosis was organic brain syndrome with cerebrovascular accident secondary to arteriosclerotic heart disease. His history revealed episodes of forgetfulness coupled with periodic blackouts. A respected man in the community, politically active, a retired farmer, and primary caregiver for his invalid wife, Mr. H was well-known by all the staff at the skilled-care nursing facility. When admitted, the nurses were most sympathetic and attentive to Mr. H's every need, attributing the deterioration of his health to the fact that he had been the sole caregiver for his invalid wife for years.
Several days after admission, Mr. H's condition became progressively worse; hallucinations and unruly behavior were exhibited that were uncharacteristic of the patient. The staff physician was called, and ordered Mr. H to the hospital. The diagnosis made was delirium tremens. After Mr. H's departure, one of the staff nurses remarked, "He wasn't really sick; he was just an alcoholic."
Discussing Mr. H with the physician, it was revealed that Mr. H totally denied any use of alcohol, stating that he was not a "boozer" and he "went to church every Sunday." Later, Mr. H admitted that he did use alcohol, but only to "ease the pain in his back." Mr. H's health was deteriorating rapidly, and months later he was readmitted to the same skilled-care nursing facility. The attitude of the staff had changed significantly and was succinctly reflected in the statement of one nurse, who commented, "Don't bother with him. He's just an alcoholic here to dry out."
Such case histories are familiar to nursing personnel who have dealt with geriatric patients exhibiting alcoholism and alcohol-related problems. They J illustrate the point that negative attitudes of nursing personnel toward alcoholism and alcohol abuse may interfere with the assessment and diagnostic processes in that nurses with negative attitudes may tend to overlook symptoms of alcoholism when present. Additionally, such nurses may fail to refer those patients whom they do identify.35
Prognostic pessimism on the part of health-care professionals toward the patient with alcohol-related problems also presents a serious barrier to treatment effectiveness.36 Specifically, if nurses do not believe that such problems can be overcome or that such patients can be helped, chances are slim that favorable treatment outcomes will occur. In these cases, a self-fulfilling prophecy develops. That is, when professionals anticipate poor outcome and deliberately or inadvertently project that to the patient, the patient does, indeed, tend to respond less than favorably.37 Conversely, positive attitudes on the part of the nurse produce positive nurse-patient relationships.35 Thus, pessimistic expectations of the involved health-care professionals directly and negatively impact on patient outcomes.
In a similar vein, health-care professionals frequently react pessimistically to and even reject patients who have alcohol-related problems.38*41 These negative attitudes are very complex36 and may manifest themselves either consciously or unconsciously during a treatment regimen.42 Typical reasons for rejecting geriatric patients who have alcoholism cited by nursing personnel are presented in Figure 2.
EXPLORING NURSING ATTITUDES
Given the tremendous influence that both conscious and unconscious attitudes can have on the ultimate treatment outcomes of patients with alcoholism, it becomes crucial for nurses to identify and explore their own attitudes prior to contact with geriatric patients who have alcoholism. Figure 3 presents questions that can be used to identify patterns of attitudes that exist for nursing personnel. These should not be considered an exhaustive list, but should * instead serve as catalysts for more intense and personal probes of one's own belief system. In addition to selfanalyses, small open discussion groups with other interested nurses and healtiicare professionals can be an effective means of identifying maladaptive attitudes.14
Two problem attitudes are identified most frequently among nurses as they move through this process of self-analysis (Figure 4). The first potentially undermining attitude is the perception of alcoholism as being primarily a moral problem.7,31,43 Such a perception may be attributable to society's legal and moral sanctions against alcohoi abuse.7 When present, this attitude results in overt or covert communications of hostility or condemnation of the geriatric patient. As a result, it is difficult, if not impossible, to establish an accepting and trusting relationship between nurse and patient. Similarly, the potential effectiveness of alcoholism treatment provided to the patient is impaired.
A PERSONAL EVALUATION OF ATTITUDES TOWARD THE GERIATRIC PATIENT WITH ALCOHOLISM14
OUTCOMES OF NEGATIVE ATTITUDES
The second attitudinal barrier is the potential tendency of the nurse to evaluate the geriatric patient's alcoholism in the context of die professional's own pattern of alcohol usage. For example, if a nurse uses alcohol infrequently or completely abstains, there may be a tendency to artificially inflate the magnitude of the alcohol problem exhibited by the geriatric patient. Conversely, if thè nurse's personal level of alcohol consumption is high, then there may be a tendency to minimize the problem in geriatric patients whose intake of alcohol is less than that reflected in the nurse. Either inaccurate perception may result in less than optimal levels of caregiving by nursing personnel.
COPING WITH NEGATIVE ATTITUDES
To help nurses overcome limiting negative attitudes, a number of alternative interventions may be effective. Research has suggested that nurses with master's degrees tend to have more positive beliefs about alcoholism than do baccalaureate-prepared nurses.7 Thus, the provision of graduate coursework may serve to enhance nurses' attitudes. Additional educational experiences, especially those emphasizing information about alcoholism and alcohol-related problems, can provide nurses with effective treatment strategies. A large proportion of nurses report having limited classroom training in alcoholism and express a need for additional inservice education in this area.32 Nurses who see themselves as competent and able to provide effective treatment to patients with alcoholism are less likely to possess negative attitudes toward that condition.
Support groups of other health-care professionals who work with alcoholics might also facilitate the development of more positive attitudes among nursing personnel. Such groups have been proposed as being effective in assisting nurses in coping with the negative feelings that might arise when caring for patients with alcoholism.32
Although the preceding thoughts are far from the definitive solution to a significant problem that faces the nursing profession, perhaps they will provide stimulating challenges to the practitioner who is working with geriatric patients with alcoholism. The implications for public education are enormous, but it is anticipated that nurses will rise to meet the increasing societal demands for optimal service provision to the aging sector.
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REASONS CITED BY NURSES FOR REJECTING GERIATRIC PATIENTS WITH ALCOHOLISM14
A PERSONAL EVALUATION OF ATTITUDES TOWARD THE GERIATRIC PATIENT WITH ALCOHOLISM14