Journal of Gerontological Nursing

AGING: BROADENING OUR VIEW FOR IMPROVED NURSING CARE

Terri A Cutillo-Schmitter, MSN, RN, CS

Abstract

Viewing aging from a wider perspective potentiates the creation of more effective nursing interventions that enhance older adults' quality of life. A broad view affords seeing aging as a lifelong evolution as well as an ending stage, offering opportunities and developmental challenges for growth, change, productivity and finishing well.

In my older adult groups, patients often tell me that they continue a desire to feel "self-satisfaction" or the "thrill" that comes from accomplishing a task well done. In return, I agree that we are really never "finished products," always challenging my patients to set goals in order to experience mastery and pleasure. At times I find it useful to emphasize the unselfishness of requesting help when needing assistance to accomplish a desired task. As "unfinished products," older adults continue to develop new talents, learn new tasks and fine tune qualities such as patience or assertiveness including learning to ask for help after a lifetime of independence.

Older adults at the ending stage of life face unique developmental tasks and challenges that may or may not include shifts in functioning such as increased physical fragility or changes in cognitive or financial status. When biopsychosocial changes occur, as happens with individuals of any age, older adults can experience overload or underload while adjusting. Unexpected events as well as late-life stage transitions contain inherent potential for strain and stress as older adults adapt to changes brought about by life cycle entrances and exits such as retirement, grandchildren, changed living arrangements, family migrations and deaths. In this process, late-life individuals relinquish and /or assume new statuses and roles, shifting relationships to maintain family bonds and ultimately prepare for their own deaths (Carter & McGoldrick, 1980). Opportunities continue into the ending stage, such as tying up loose ends in order to finish with integrity and /or experiencing a personal legacy, such as witnessing an offspring's capabilities. When normal aging limitations or disease strike, as nurses, we can be helpful by normalizing changed roles and statuses or even reframing the challenges as growth-enhancing opportunities affording family restructuring to assure continuity.

My elderly patients often relate that decrease in physical stamina or difficulties with cognitive functioning cause them to feel "panicky," "depressed," and "defeated." By normalizing unavoidable dependency needs in late life we can potentiate optimal functioning in older adults as well as instill pride instead of shame, security instead of fear and hope instead of defeat. Older adults can grow through a process of learning to accept degrees of unavoidable dependency. In the process of acceptance of their dependency needs they can offer appreciation and status to their adult children and /or loved ones for their competent care and concern. And loved ones can grow from the process of assuming a more central family role as they reciprocate some of the care provided them through the years. This process of long-term family reciprocity is an invaluable gift, enhancing family members' sense of belonging. Moreover, the process of short-term nurse-patient reciprocity is also a gift, enhancing healing, hopefulness and self-satisfaction. The caregiver's gift is the felt appreciation and status bestowed by the care receiver. In turn the care receiver's gift is the experience of the caregiver's warmly bestowed care and concern.

This more expanded perspective on aging provides a more balanced view from which to help older adults. In addition it is more conducive for including in our evaluations the assets aging brings, such as richness of long life and resiliency gained from accrued life experience along with our assessments of any décrémentai changes in biological, psychological or social reserves. Wim this framework, we not only empower…

Viewing aging from a wider perspective potentiates the creation of more effective nursing interventions that enhance older adults' quality of life. A broad view affords seeing aging as a lifelong evolution as well as an ending stage, offering opportunities and developmental challenges for growth, change, productivity and finishing well.

In my older adult groups, patients often tell me that they continue a desire to feel "self-satisfaction" or the "thrill" that comes from accomplishing a task well done. In return, I agree that we are really never "finished products," always challenging my patients to set goals in order to experience mastery and pleasure. At times I find it useful to emphasize the unselfishness of requesting help when needing assistance to accomplish a desired task. As "unfinished products," older adults continue to develop new talents, learn new tasks and fine tune qualities such as patience or assertiveness including learning to ask for help after a lifetime of independence.

Older adults at the ending stage of life face unique developmental tasks and challenges that may or may not include shifts in functioning such as increased physical fragility or changes in cognitive or financial status. When biopsychosocial changes occur, as happens with individuals of any age, older adults can experience overload or underload while adjusting. Unexpected events as well as late-life stage transitions contain inherent potential for strain and stress as older adults adapt to changes brought about by life cycle entrances and exits such as retirement, grandchildren, changed living arrangements, family migrations and deaths. In this process, late-life individuals relinquish and /or assume new statuses and roles, shifting relationships to maintain family bonds and ultimately prepare for their own deaths (Carter & McGoldrick, 1980). Opportunities continue into the ending stage, such as tying up loose ends in order to finish with integrity and /or experiencing a personal legacy, such as witnessing an offspring's capabilities. When normal aging limitations or disease strike, as nurses, we can be helpful by normalizing changed roles and statuses or even reframing the challenges as growth-enhancing opportunities affording family restructuring to assure continuity.

My elderly patients often relate that decrease in physical stamina or difficulties with cognitive functioning cause them to feel "panicky," "depressed," and "defeated." By normalizing unavoidable dependency needs in late life we can potentiate optimal functioning in older adults as well as instill pride instead of shame, security instead of fear and hope instead of defeat. Older adults can grow through a process of learning to accept degrees of unavoidable dependency. In the process of acceptance of their dependency needs they can offer appreciation and status to their adult children and /or loved ones for their competent care and concern. And loved ones can grow from the process of assuming a more central family role as they reciprocate some of the care provided them through the years. This process of long-term family reciprocity is an invaluable gift, enhancing family members' sense of belonging. Moreover, the process of short-term nurse-patient reciprocity is also a gift, enhancing healing, hopefulness and self-satisfaction. The caregiver's gift is the felt appreciation and status bestowed by the care receiver. In turn the care receiver's gift is the experience of the caregiver's warmly bestowed care and concern.

This more expanded perspective on aging provides a more balanced view from which to help older adults. In addition it is more conducive for including in our evaluations the assets aging brings, such as richness of long life and resiliency gained from accrued life experience along with our assessments of any décrémentai changes in biological, psychological or social reserves. Wim this framework, we not only empower our older adult patients, but we avoid disempowerment by unconsciously limiting potential based on untrue cultural aging stereotypes. Ageism is especially pernicious when it inadvertently undermines the older adulf s self-confidence or access to a full range of efficacious care. Assessing and treating older adults from a narrow focus potentiates distortions about the individual.

Consequently, assessment and treatment requires an eco-systemic approach (Neidhardt & Allen, 1993) in order to get to know the individual and negotiate that "goodness-offit" solution that supports older adult needs. An eco-systemic approach examines the individual as well as the social context in which the person co-exists. Context both reflects and creates who a person is. An individual's lived experience shapes self-image, attitudes, behaviors and resulting ability to adjust to changing demands. Assessing context as well as quality of the individual's relational system helps us capture a coherent picture of the older adult, since aging successfully or unsuccessfully emerges from an individual's lived experience or "biography" of the person. Biography includes universal data such as child development, education, occupation, medical, marital and family histories, sexual and drug histories, financial and legal involvements, functional capacities, lifestyle habits, living situations, cultural, family and personal preferences and relational systems. Just as it is important to assess for an infectious process, endocrine disorder or drug toxicity so is it important to evaluate how the individual's relational system in the family and wider community impacts positively or negatively on present adaptive ability. Further, our assessments must evaluate how the patient's biopsychosocial functioning in turn affects his personal environment. By understanding beliefs, norms, patterns, roles and caretaking expectations of aging patients, their families, institutions and the larger society in which they live, we can better determine sources of trouble and influential variables impacting the older adulf s stress, health and ability to adapt to changing circumstances. Obtaining a sketch of the individual's most salient biographical features helps us not to overlook important elements which can distort our formulation of needs, resources or solutions. A more fragmented approach may cause us to label a reversible condition as irreversible or something quite manageable as unmanageable. Clearly, by employing a comprehensive eco-systemic focus in the process of getting to know an older adult's needs and resources, we can frame solutions best matched to the individual's life circumstance.

Once we examine the individual by employing a wide angle lens in getting to know and understand, we may also improve our ability to utilize assets and avoid overwhelming capacities. For example, in one instance, we may need to adapt our nursing procedures to accommodate a patient's preferred patterns and routines in order to protect the individual's personal sense of coherence and avoid overwhelming capacity. In another instance, we may challenge the person by introducing a novel situation, role or activity to stimulate memory or a creative exploration of new interests in order to facilitate adjustment to changing circumstances and promote growth and self-confidence. According to Minuchin and Fishman (1981), individuals adapt to life challenges and changes by moving between two poles, representing security of the known on one hand, and exploration of new possibilities on the other. Knowing when and how to accommodate or challenge, moving between the known and the novel, requires listening to what the person is communicating, observing responses to stimuli and analyzing whether our care interventions are beneficial or nonconstructive. In a helping process, we must constantly nurture and challenge in order to foster a personal sense of coherence and security as well as a sense of possibility and self-satisfaction until latelife individuals are ready to " let go" of life. As nurses, we must be willing to move beyond the status quo, exploring and selecting new paradigms and care strategies which afford older adults optimal functioning and hope that things will work out as best as can be expected.

In keeping with a broad perspective and an eco-systemic approach, the following broad overview of a salutogenic care model incorporating biopsychosocial factors influencing older adults' health, stress and coping provides a basis for designing effective older adult care strategies. Although complexly interwoven, following Birren and Cunningham's (1985) model, aging issues will also be considered from three domains: the social, psychological and biological. Emerging insights from gerontological, family systems, and neuropsychological research are shedding new light on the interplay of social, psychological and biological factors which determine how successfully individuals grow, thrive and adapt to change. Therefore, I have incorporated findings from selected studies as guides for triggering additional creative and effective nursing care strategies, fostering a helping role. Ultimately I believe, as nurses, we must strive to:

1. employ a wide angle lens in order to get to know the individual and the context in which each coexist;

2. engage individuals in a healing process that affords solutions contributing to a personal sense of coherence and sense of possibility;

3. mobilize resources for meeting dependency needs, affording a proper balance of family and /or community caregiving aid;

4. initiate solutions that foster pride, security and hope in order to promote opportunities for finishing well, i.e., with integrity and dignity.

ANTONOVSKY'S SALUTOGENIC MODEL

Antonovsky's (1979) research examines biopsychosocial factors mat impact on an individual's ability to effectively adapt to life challenges and crisis events. Employing a salutogenic model emphasizing health rather than disease, he views individual health as situated at a fairly stable point on a health-ease to dis-ease continuum. Movement can occur in either direction in response to:

1) life events;

2) existing resources;

3) interpretation of life stressors; and,

4) an individual's ability to mobilize resources.

Antonovsky's conclusions have important implications for geriatric nursing. For example, nurses can offer a different perspective about a life stressor, reframing it as an opportunity for growth or as manageable, helping to mobilize appropriate resources not at a patient's immediate disposal. For neurologically impaired individuals experiencing catastrophic reaction when faced with a new situation, a nurse's smile and warm voice tones may help to orient and impart a feeling of safety and security rather than stress, fear or defeat.

Additionally, both Antonovsky and Neuman (1980) postulate that multiple variables buffer and influence effective adaptive ability in response to stressors such as an illness event or life transition. For instance, Antonovsky found that the following "generalized resistance resources" help individuals successfully adjust to change:

1) a rational, flexible, and farsighted coping strategy;

2) knowledge and intelligence or at least the ability to access resources;

3) social supports and reciprocal relationships;

4) genetic inheritance;

5) religion or a philosophical outlook providing a stable set of answers;

6) preventive health orientation;

7) cultural stability;

8) ego identity;

9) wealth or material resources.

In our counselling and health education promotion roles, nurses can assess for these resources as well as help individuals develop potential assets and/or obtain resources to compensate for limitations.

According to Antonovsky, the other type of variable buttressing individual adaptive ability relates to "specific resistance resources" which are at the individual's immediate disposal, such as a family member or health care provider who fosters hope and helps mobilize resources during crisis situations. Indeed, through caring and presencing ourselves with patients, nurses can be a "specific resistance resource," fostering security and a sense of possibility.

Finally, in Antonovsky's view the more life experiences are characterized by: 1) consistency, 2) participation in shaping outcome, and 3) an underload-overload balance of stimuli, the more the individual is likely to see the world as coherent and thus more adaptively mobilize resources independently. As nurses, we can contribute to our patient's personal sense of coherence by asking about and following, where possible, patient preferences, habits and patterns to increase a sense of predictability and security. To the extent possible, we can allow patients to determine and direct a course of action avoiding overload thereby fostering hope and ability to mobilize inner resources. Carlsen's (1991) research corroborates Antonovsky's emphasis on the crucial relationship between a personal sense of coherence and adaptive capacity in older adults. In Carlsen's view, a personal sense of coherence is promoted when an older adult is received and seen by others without undue distortion to have some influence in comprehending and managing a meaningful life. Following tìus model, nurses must, to the extent possible, allow individuals to maintain control of life circumstances, affording familiarity and security of the known even when introducing something unfamiliar or potentially stressful.

THE SOCIAL DOMAIN

Strongly influencing individual identity and well-being, status, a social position, and role, the enactment of a particular status, vary in accordance with cultural values related to such attributes as individual accomplishment, ethnicity, race, sex and age (Cavanaugh, 1993). Social age is defined by the qualities a society imputes to a particular life stage. In our society social status recedes, with a lifetime of accumulated wisdom and experience tending to be dismissed, as social age increases and individuals disengage from work and family roles.

The Committee on an Aging Society emphasizes the need for developing older adult roles to enhance quality of life and benefit the community. The Gray Panthers, advocates of creating productive older adult lifestyles to reverse the existing paucity of formal social roles, are actively challenging commonly held myths of elder non-productivity. Wherever possible, nurses may wish to encourage older adults to utilize their accumulated knowledge, skill and expertise.

The influence of role on women's self-concept and sense of well-being is demonstrated in a recent Cornell University study by Moen, Dempster-McClain & Williams (1995) correlating multiple role maintenance with "inoculation" against depression. Tracing 213 women over three decades, the study correlates a higher number of elected roles with increased selfesteem and more optimal health as aging progresses.

Since diverse social involvement affords purpose and guidance for life, in our work with frail older adults, we can increase awareness of available roles such as friend, good listener and appreciative care receiver. In my nursing practice I find for the frailest of frail, meaning and purpose for living is often derived from observing how life unfolds for others. With healthier older adults we can encourage volunteerism, parttime jobs or other creative pastimes such as yoga, gardening and art classes. For example, recently I observed a depressed older gentleman, missing the self-satisfaction obtained from restoring destroyed buildings, become excited at the possibility of utilizing his talents with Habitat for Humanity.

When helping an older adult expand or assume a new role, it is useful to encourage visualization of key steps involved in the new activity. Cognitive rehearsal (Beck, Rush, Shaw, & Emery, 1979) helps individuals anticipate and prepare in advance for any obstacles that might compromise success. Likewise, patients can be encouraged to rate pleasure and mastery of existing daily activities as a basis for exploring satisfying new role involvements. By encouraging older adults to become socially engaged to the extent possible, we will be "inoculating" against depression while promoting the highest quality of longevity.

Additionally, it is important to keep in mind that with age, as a result of becoming more reflective, philosophical and perhaps more spiritual, individuals can make significant contributions in their 80's and 90's. For instance, our two President Roosevelts saved many natural resources affording present generations access to the splendors of our national parks. As late-life individuals, Picasso and O'Keefe continued to produce beautiful works of art and Laura Ingalls Wilder wrote her first book at age 64, completing her final seventh novel in the renowned "Little House" series at age 75. As nurses we can inspire patients to engage in more activities by increasing their awareness of role models such as these. Additionally, we can enhance status by showing an interest in their role as historians.

Sternberg, Conway, Ketron and Berstein (1981) found that older adults can develop new interests, thought patterns and deeper wisdom. Moreover, later life phases afford greater enjoyment and reported deepened appreciation for nature and the arts, actively expressed in a broad range of activities such as gardening, bird watching, painting, pottery making, or playing a musical instrument. An important distinction here is that such involvements are generated by heightened sensory appreciation versus an aimless desire to fill up empty time. Apparently, at any age the human drive to lead a meaningful life is a prime motivator (Carlsen, 1991). In fact, Buhler (1977), correlating creative activity with increased selfesteem, finds all self-expressive activities contain life story essentials reinforcing life meaning and purpose. Moreover, White and Epston (1990) purport that narratives shape lives and experience, actually fostering "performances;" that is, mastery and continued interest and involvement in the life process. In this manner, the past can often serve as a springboard to the future. Exploring and reviewing personal history can be an empowering experience because it validates older adults as the authority on their own lives, needs and solutions. Nurses comfortable in realms of imagination and emotions can stimulate creative self-expression in older adults through peer groups and individual activities such as photography, poetry, painting, horticulture, and oral and written life stories, contributing to self-confidence and expanded future possibilities.

Typically, as we offer life story opportunities, we become more aware and sensitized to the fear many older adults have about being a burden and losing the love and caring of family and friends as they decrease their level of productivity due to a shift in functioning. As age increases, as spouses die and as health limitations intensify, it becomes more likely that an older adult will receive help simultaneously from family members and formal care providers (Nieto, Coward & Horsley, 1989). Although fewer than one in ten persons age 65 to 74 requires help, four in ten who are 85 or older need assistance with personal care, mobility, activities of daily living or nursing care (Feller, 1983). When frail older adults need help to manage life tasks we can help families and formal care providers by objectively assessing strengths and limitations and normalizing realistic dependency needs. This information facilitates decisionmaking about the proper balance of family and community aid needed to foster optimal functioning, pride and security.

Such an assessment should evaluate the quality of family caring and connectedness, crucial both to quality of life and family restructuring. Typically, issues of dependency and caregiving balance constitute key concerns for older adults and their families. For younger family members a significant life task at this stage involves respecting their older relative's wisdom and experience and providing support without over-functioning (Carter & McGoldrick, 1980). When attachment and affectionate bonding are such that family ties constrain rather than support older adult optimal functioning or family members are unable to come to terms with latelife dependency needs, nurses can often intervene to help individuals mobilize resources successfully.

A nursing family assessment interview (Cutillo-Schmitter, 1993) is useful for identifying patient and family concerns, problematic caregiving tasks and expectations while also evaluating for overly enmeshed or disengaged family patterns contributing to a patient's functional decline. Enmeshed family members, lacking ability to recognize an older adult's strengths and capacity to participate more fully in life, are overly intrusive and often constrain possibilities for more optimal self-functioning. Disengaged family members, on the other hand, minimize an older adult's needs and fragility, failing to provide adequate resources or allowing unsafe conditions to exist. Over-functioning or under-functioning for elders should be avoided. Education and anticipatory guidance is often enough to help individuals manage activities of daily living tasks as well as changing roles and statuses. We can often unleash a family's healing power by joining them in respectful interactions, fostering cooperation, affectionate connections, and tolerance for differences as we help them support their aging relative's needs. According to Minuchin and Nichols (1994), families tend to have untapped resources of support, love, and caring that often escapes our notice. Positing the existence of a "family self," they maintain family members experience a sense of loyalty, responsibility and kindness including commitment to avoid giving pain. In cases of extreme abuse or violence, however, community services is often the only viable solution.

Currently, family caregiving remains an American ethic despite a popular belief that families are abandoning their elders. Providing long-term care to communitydwelling frail, dependent elders is becoming an increasingly common experience (Brody, 1985) creating unprecedented farnily strain. Nurses can decrease family stress by referring appropriate individuals for home care services. In general, families considering long-term care to be less respectful of individual dignity and family bonds, attempt to prolong making the decision for nursing home placement. Additionally, the move to a nursing home is one of the most traumatic transitions for late-life individuals (Caron, 1992), made at a time when caregivers are experiencing major strain and burnout. When nursing home placement is the choice, Caron recommends encouraging family members to make a biography of their relative's life in order to process feelings as a means of coming to terms with their decision. The biography can be a picture book, collage, journal or any other medium the family chooses to capture shared experiences, validating relationships and their loved one's life journey. Moreover, shared with nursing staff as a source of information, it can serve as a means of introducing their relative, thereby increasing the likelihood of more concerned care in the new environment.

THE PSYCHOLOGICAL DOMAIN

Psychological age is determined by the ability to respond successfully to environmental demands. Thus, an individual is considered younger or older than chronological age according to adaptive behaviors including subjective dimensions such as motives, feelings and attitudes as well as intelligence, learning ability, memory, and motor skills. Clearly all of these characteristics impact on selfesteem and well-being.

Late-Life Developmental Issues

Retirement from former employment, often prompting for the first time recognition of the aging process, results in important lifestyle changes in social networks, economic base, time management and selfimage. These changes can impact on an individual's ability to adapt in a healthy manner. A key task at this life cycle transition is to differentiate ego from work role identification in order to begin the process of reordering a meaningful life. The extent this transition reaches crisis proportions will be determined by:

1) advanced planning;

2) quality of existing family relationships and other social support;

3) the meaning of retirement and work; and,

4) whether retirement is viewed as an end or a transition to a new lifestyle (Neidhardt & Allen, 1993).

A nurse's understanding of a retiree's perception about this major life transition is important. With insight, we can help reframe the situation, imbuing it with a new sense of options to facilitate more adaptive responses.

How the retirement transition is negotiated will also affect relationships with spouse and children. In fact, for married couples, retirement represents a significant milestone (Walsh, 1980) necessitating adjustments to less structured time schedules, increased interactive levels, and re-negotiation of household roles and expectations. Each partner must maintain self-esteem and competence, balancing the partnership to potentiate optimal functioning for each of them.

In fact a late life task involves maintaining individual and/or couple functioning and interests in the face of social and health changes (Carter & McGoldrick, 1980). For instance, most couples will face an acute or chronic illness in self or partner requiring continued emotional support and changes in the division of household management. In helping spouses manage multifaceted and complex tasks, it is useful to track the interactive content between partners to evaluate communication and problem-solving abilities. Skill deficits can be improved by gently coaching and modeling to teach such cognitive strategies as self-disclosure of feelings; summarizing perceptions of what was heard prior to adding opinions; and clearly defining desired goals and options for framing workable solutions. Confining interventions to a couple's presenting problems, Wolinsky (1990) utilizes marital life review to strengthen the marital bond. She finds an exploration of earlier relationship achievements and past conflict solutions provides them insight for settling current challenges. Nurses can discuss issues surrounding illness events by utilizing cognitive strategies and marital life review processes to potentiate couples' effective planning for restructuring household management and maintaining emotional support for each other.

Another major late life task that often comes to a nurse's attention involves coming to terms with loss of spouse, siblings and peers as well as preparation for one's own death. With each loss the elder must find new meaning to continue. A convergence of losses can limit opportunities for refueling through a process of integrating real and anticipated losses. Grief counselling and the confirmation of emotional pain must be woven into older adult nursing care. Reminiscing strategies, such as encouraging patients to share memorabilia or pictures of loved ones, help older adults connect crucial thoughts and emotions that stimulate grief resolution and healthier coping responses. Likewise, when someone has missed an opportunity to say goodbye, a role play or ritual can afford the opportunity to do so. Emotional availability tends to emerge from such completions, enabling individuals to meet social needs by reconnecting to former relationships or forming new affiliations.

Providing peer support and validation in group sessions further helps ameliorate personal pain by contributing solutions for grief and loss as well as enhancing warmth and intimacy among group participants (Lewis & Butler, 1974). In a peer genogram group I conducted at our facility, a depressed 85-year-old woman was able to receive validation from her peers and attain closure with her deceased mother-inlaw. Although their relationship was characterized by a lifetime of ambivalence, the group helped this woman hear the heartfelt appreciation in her mother-in-law's last words, "Thank God my son has you." Focusing her on these final words of appreciation enabled her to move beyond a belief that her mother-in-law never considered her to be good enough for her son.

Further, we can facilitate older adults coming to terms with their own death by encouraging involvement in life review, a systematic evaluation of life events and relationships. Some researchers, like Butler (1963), believe life review enables the aging person to accept and integrate aging and impending death. Further, Butler believes elder wisdom and serenity can be achieved through this process. It is important to note that while beneficial in most cases, life review can reawaken painful and unresolved material. Therefore, we must observe responses to any life review process we initiate to make sure the patient is benefiting. Butler (1963) identifies three types of individuals who appear to be especially prone to negative outcomes and psychiatric symptoms:

1) people who always avoided the present and placed emphasis on the future and now see most of life behind and a reduced future ahead;

2) people who have consciously injured others and must now deal with guilt and recognition that they may never have a chance to ask forgiveness; and

3) people who are arrogant and prideful; living a life centered around self, disturbed by the realization that the world will go on without them.

Finally, as nurses considering the psychological domain of aging, we must also realize that death, like no other life event, stirs intense emotionally directed thinking in older individuals and those around them. Many older people are unprepared to die. A large number die alone, locked into incommunicable thoughts, unable to speak openly to close family members (Bowen, 1978). Sadly, final moments with loved ones often pass without remarks and actions providing meaningful conclusions. Frequently, younger family members express regret over lost opportunities to say good-bye. According to Bowen (1978), two processes prevent more satisfying closure:

1) an intrapsychic process involving some denial of death;

2) a relationship system closed to free expression due to fear of causing upset.

Yet older adults often tell us how helpful it is to speak about death to someone not correcting their way of flunking. Nurses, unresolved with their own death anxiety, or concerned about another's welfare, may fail to take advantage of opportunities to discuss death and dying with patients and/or their families. Once broached, however, a patient's reflection on death can lessen fear and anxiety about the unknown. Likewise, family members, aware of the impending death, often need courage to address the reality. Typically, they are relieved when we raise the issue of death and dying openly, thereby affording them opportunities to say good-bye to their loved one and finish well.

Herz (1980) suggests effectively coaching families through a death experience by:

1) using open and factual terminology such as "death", "dying" and "bury" while providing information such as medical prognosis, and helping the family decide when and how to use it;

2) establishing at least one open relationship in the family to assure communication within the family unit;

3) respecting a family hope for life and allowing family members to pace themselves in coming to terms with the death of a loved one;

4) remaining calm and objective while at the same time being able to express our own sadness honestly experienced;

5) checking on the progress of relationships and intervening if a family member is becoming symptomatic in response to anticipated loss; and

6) utilizing family rituals, customs, and styles as a basis for clarifying where the person prefers to die and burial preference.

Nurses can make dying as dignified as possible by not allowing physical tasks to pre-empt emotional issues, thereby affording private opportunities for intimate conversations. Awareness of the following four tasks (Williams, 1989) involved in grieving further helps nurses direct discussions with patients and their families:

1) experiencing the pain of grief;

2) finding and utilizing a grieving support system to assist readjustment;

3) handling practical matters resulting from the death; and

4) accepting the reality of the loss, and saying good-bye.

When grief counselling appears necessary, a genogram interview (McGoldrick & Gerson, 1985; CutilloSchmitter, 1993) offers the nurse a structure for focusing on these tasks and providing individuals with a potential source for opening family communication and grief resolution. Helping them reflect on important relationships, events and on the good times and struggles overcome offers them a final opportunity to punctuate their life journey together and to finish well (Hargrave & Anderson, 1992). As nurses, we can facilitate this process by providing counselling as well as referrals enabling families to engage in a life review process conducive to settling any outstanding family issues. In this manner, resources can be built into the intergenerational family.

Mental and Cognitive Function

Information processing involves making sense of information. Sensation, the reception of physical stimuli, and perception, the interpretation of sensory stimulation, are closely intertwined cognitive functions strongly affecting self-concept and adaptive ability. Recognizing the difference between sensation and perception and their effect on aging is vital since coping and interacting successfully with the environment rests in large part on detecting, interpreting, and responding appropriately to sensory information. For cognitively impaired patients, aroma therapy is beginning to be introduced as a means of evoking memories of relaxation and of security. Additionally, the clarity with which sounds are heard or sights seen greatly influences how the world is interpreted. An older adult's information receptors, especially eyes and ears, are less adept at picking up sensory stimuli. Due to the fact that senses play a key role in orienting individuals to the environment, sensory impairments can have devastating psychological consequences. Health professionals often misinterpret sensory deficits as senility, paranoia, or hallucinations. Treating patients for conditions they do not have obviously impacts negatively on functioning and health costs. Routine hearing and vision evaluations, for example, help protect older adults from misdiagnoses and sensory deprivation, as most visual and auditory losses can be corrected. Once corrected, they can respond more appropriately to environmental feedback, functioning at more optimal levels. As nurses, we should routinely check for and clean wax-clogged ears and be sensitive to any need for facilitating hearing aid adaptation. When corrective lenses no longer compensate for visual losses, other techniques, such as large print books and newspapers, magnifying devices, talking books, large numbers on rooms and clocks, proper lighting and safe furniture arrangement, can be tried.

Adaptation, and more specifically, information processing, also involve sensory memory, storage, retrieval and attention. Sensory memory requires rapid absorption of large amounts of information rapidly. Without attending, this information is lost quickly. Cavanaugh (1993) suggests the brain's speed in registering new information declines in later years. Consequently, a substantial portion of rapidly presented new information will not be retained by older adults. If we slow down, allowing older adults to find their own task completion pace, we increase overall feelings of competence as well as performance. In addition, due to the fact that older adults have more difficulty filtering out irrelevant information than younger adults (Cavanaugh, 1993), we can facilitate retention and feelings of self-esteem by eliminating insignificant detail when giving care directions and instructions. Moreover, cutting down on unnecessary stimuli in an older adulf s environment further fosters attention to task completion and feelings of competence. And, although elders are less adept in searching for information, cueing often provides the needed reminder to retrieve data, complete a task or follow a direction. Care environments utilizing visual cues can also enhance an older adult's sense of competence and security. Finally, since there seems to be no age-related differences in how efficiently information can be retrieved from sensory store (Poon & Fozard, 1980), we can expect healthy older adults to understand and utilize properly communicated information.

Normal memory declines can be managed in the same manner as for early dementia by teaching organizing techniques such as repetition and getting explicit instruction. Additionally, we can introduce patients to external aids such as calendars and memory logs (SchmitterEdgecombe, Fahy, Whellan, & Long, 1995). Helping to preserve remaining function by stimulating existing neuronal pathways in this manner is vital for management of a mild memory disorder.

Further, any memory problem requires assessment to determine its reversibility. Delirium and depression, for example, often presenting as a pseudodementia, are frequently undiagnosed and untreated, increasing unnecessary dependency and the likelihood of premature decline in older adults. Suicide, often the result of unrecognized depression, is one of the leading causes of death in the United States, with the highest rate in men over 80 suffering from a debilitating illness. Lebowitz (1994) reports mental health treatment efficacy rates surpass those for some physical disorders. These findings constitute still another motivation for nurses to be alert for treatable disease symptoms, assessing health and illness through a broad lens, thus offering hope and new possibilities for finishing well.

Depression, despair, and anxiety are frequently signs mat individuals lack creative possibilities and solutions necessitated by changing circumstances. Nursing psycho-educational interventions benefit older adults experiencing change such as mental health problems during late life. Carlsen (1991) suggests beneficial therapeutic tools mat foster creativity such as transcendental meditation, memory exercises, relaxation and imagery, bibliographic work and biographical life stories. She finds efficacious older adult care requires not only attending to practical matters but also to less quantifiable needs involving the inner core of human experience; mat is, dreams, imagination, fantasy, creativity, loving, grieving and dying. Utilizing genograms in individual, couple and group work facilitate attention to mese more qualitative matters, stimulating pride in achievements and struggles overcome as well as a new sense of possibility for working on "unfinished products."

THE BIOLOGICAL DOMAIN

Biological age is defined by the condition of organ and body systems relative to maximum life span. The brain, as a primary basis for intelligence, information processing and personality is a key determinant of adaptive aging. Neurons, the brain's building blocks, grow in size and complexity across the life span but do not regenerate. Recent research (Cavanaugh, 1993) on the aging brain suggests that while discrete brain cells die, the connections among the remaining cells increase, a compensation enabling older adults to think as in former years, albeit more slowly. Additionally, parts of the brain age differently, with neuron loss more prevalent in the primary visual field than in memory and reasoning areas. According to the Society for Neuroscience, the aging brain remains relatively healthy and fully functioning with most severe decline in memory, intelligence, verbal fluency and other tasks caused by disease.

Exercise can substantially postpone age-related decline in cardiac output, breathing capacity, muscle mass and strength, cerebral blood flow, and the brain's oxygen and glucose consumption. In addition, exercise improves blood cholesterol levels and blood pressure, protects against ligament injuries and promotes better sleeping patterns while enhancing perceived efficacy and psychological well-being. Moreover, Baylor and Spirduso (1988) find faster reaction times among regular exercisers compared to sedentary elders. Tai Chi is considered to be one of the most beneficial exercises that nurses can suggest for elders. Clearly, as nurses, we can enhance optimal physical and mental functioning by teaching preventive health orientations to our patients.

CONCLUSION

Normal health-related changes associated with aging do place basic constraints on later life activities. However, loss of reserve and decrease of homeostatic control occurring with aging do not necessarily undermine physical or psychosocial functioning. By incorporating a broader perspective and an eco-systemic approach in getting to know older adults, we can maximize our ability to potentiate healthy adaptation.

Additionally, when we foster a sense of new possibility and normalize late-life dependency needs, we instill self-satisfaction rather than defeat, pride rather than shame and security rather than panic in our older adult patients. By considering the interplay of social, psychological and biological factors influencing the older adult's adaptive ability when evaluating needs and resources, nurses more effectively construct strategies and solutions for helping their patients function optimally and finish well. A "goodnessof-fit" solution demands that we get to know our patients comprehensively and mobilize resources that support their needs. Remaining alert to opportunities for promoting a personal sense of coherence as well as a sense of new possibility affords hope and confidence, thereby, integrity and dignity as well as hope, even when cure is not a possibility, enhancing quality of life in older adulthood.

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