It has become increasingly important to promote health and prevent illness in individuals 65 and older. The proportion of the population in this age group is growing rapidly and will continue to do so. The aging of the population is recognized as one of the most significant demographic trends in U.S. history.
Numerous researchers have found an association between individuals with high levels of stress and onset of illness (Elliott & Eisdorf er, 1982; Johnson, 1998; Norris & Murrell, 1987; Preston & Mansfield, 1984; Rahe & Arthur, 1978). With the advancement of age, elderly individuals are susceptible to numerous stressors, such as loss of significant others, retirement, financial difficulties, health changes, and disturbances in social support networks. Therefore, it is desirable to ameliorate or eliminate the factors (stressors) that increase stress levels because they increase the likelihood of illness onset.
In general, early studies measuring stress in adults 65 and older used instruments specifically designed for this group that were not valid and reliable, or the researchers used tools developed for middle aged and younger individuals. It was not considered that the stressors, as well as experiences and outcomes of stressful events, differ greatly in older adults. As a result, the ability to identify common stressors specific to elderly individuals has been limited. Without adequate information related to the stressors most likely to affect older adults, it is difficult for health care providers to accurately assess client status and implement appropriate interventions. In 1988, Stokes and Gordon described a valid and reliable scale for measuring stress in older adults based on data collected between 1984 and 1986.
The purposes of this article are to report a study completed to determine the most commonly experienced stressors in adults 65 years of age and older, using the Stokes/Gordon Stress Scale and to suggest nursing interventions directed at alleviating the most common stressors. The theoretical framework for this study was based on Lazarus and Folkman's (1984) definition of stress as a particular relationship between the person and the environment appraised by the person as taxing or exceeding resources and endangering well-being. Additionally, they stated that perceived stress is the cognition and appraisal, by the individual, that the relationship threatens or interferes with the person's needs. Lazarus and Folkman (1984) further described stress as a situation that exceeds a person's adaptive capacities or resources.
Lazarus and Delongis (1983) maintained the aging process is highly individual, with some elderly individuals aging well and others aging poorly. The variability arises not only from the environmental conditions of living, but also from personal characteristics and agendas that shape one's appraisal of and encounters with stress. This affects the manner in which one copes with stress and, therefore, can have a profound affect on morale, social functions, and somatic health.
Several major stressors have appeared to dominate previous research on the older adult. Among those are:
* Loss in all of its ramifications, particularly loss of a significant other (Aldwin, 1990; Fitzpatrick, 1998; Krause, 1991).
* Diminished social support (Counte & Glandon, 1991).
* Impairment of activities of daily living (Friedman, 1993).
* Chronic financial strain, specifically as applied to older women (Krause, 1991).
* Health (Aldwin, 1990).
Some researchers have attempted to gather information on the most common stressors experienced by older adults. Johnson, Waldo, and Johnson (1993) ranked stressors by the number of individuals reporting them. Their sample of 82 individuals older than 65 was drawn from the rural areas of the western states. The five most common stressors were sleep changes, decreasing number of friends, loneliness, time to short with family, and loss of a driver's license.
NURSING INTERVENTIONS FOR THE 10 MOST COMMON STRESSORS
Backer (1995) interviewed 100 older women residing in the community. The major stressors identified were concern about the welfare of others, personal health, strained interpersonal relationships, and household hassles. Krause (1988), in a study of 351 older adults in Galveston, Texas, stated that health problems of the participant, deaths among family and friends, and network crisis were most frequently reported events. In a more recent study of 1,017 older adults, Krause (1991) reported fear of crime, financial strain, and recent deaths among family members as common stressors. Aldwin (1990), in three surveys in California and Boston, found deterioration of memory to be the most common stressor. Death of a friend, major deterioration in health or behavior of a family member, major decrease in enjoyed activities, and major personal injury or illness were among the five most common stressors in all three surveys.
The present study sought to determine the 10 most common stressors in a sample of healthy adults age 65 and older who were living on the East Coast of the United States in urban and suburban settings. The 10 most commonly reported stressors were selected to direct attention to where interventions would benefit the greatest number of people (Sidebar, left).
Data were collected from a convenience sample of 200 healthy adults age 65 and older from the East Coast of the United States. The sample ranged in age from 65 to 89 with a mean age of 72.4. Women comprised approximately two thirds of the sample. They were classified according to currendy used groupings as young-old (65 to 74), middle-old (75 to 84), and old-old (85 and older). The young-old comprised the vast majority of the group, and only 5% were old-old.
The group was predominantly married or widowed with a small number who were divorced, separated, or single. The majority had educational levels of eighth grade or high school completion. Approximately one quarter had completed college or received advanced degrees. Most participants were White (Table 1).
Participants were recruited by the researchers and graduate assistants from retirement communities, senior citizen centers, and personal contacts. The criteria for inclusion in the study were that the participants had to be healthy older adults and able to read English. For the purposes of this study, healthy was operationally defined as living in one's own home, possessing the ability to care for oneself, and being able to leave home on one's own when desired. Older adult was defined as 65 and older.
Data were collected using the Stokes/Gordon Stress Scale (SGSS) (Stokes & Gordon, 1988) and the Individual Data Form. When participants consented to enter the study, they were given the study materials. Postage-paid envelopes were included so the study materials could be returned directly to the principal investigator.
The SGSS is an instrument specifically designed to measure stress in adults 65 and older (Stokes & Gordon, 1988). It lists 104 stressors, weighted according to the amount of stress each one generated based on appraisals by individuals 65 and older. Respondents are asked to indicate the stressors they are currently experiencing, resulting in a "stress score."
While the scale was developed using cognitive appraisal to weight the items related to the amount of stress engendered by each item, the study examines only the most commonly experienced stressors and not the degree of stress each produces. The test-retest reliability of the SGSS with three convenience samples (n = 11, 23, and 18) had a Pearson's r of .98 (p < .001). The Cronbach's alpha for 63 participants was .86.
DEMOGRAPHIC DISTRIBUTION OF SAMPLE
Concurrent validity between the SGSS and the Geriatric Social Readjustment Rating Scale (Amster & Krauss, 1974) was .65, and between the SGSS and the Schedule of Recent Events (Holmes & Rahe, 1967), .81. Predictive validity in a 1-year study correlating level of stress and onset of illness was .36 (p = .01). The Cronbach's alpha for the current sample was .87. The Individual Data Form is a questionnaire developed by the authors used to request demographic information, such as age, gender, and marital status. Both forms can be completed in approximately 15 minutes.
TEN MOST COMMON STRESSORS FOR NON-INSTITUTIONALIZED HEALTHY OLDER ADULTS
The 10 most common stressors are shown in Table 2. The 10 stressors found to be most common in this study is an expansion of those reported as most common in earlier studies. Krause (1988; 1991) singled out the following four as the most common:
* Deaths among family and friends.
* Network crises.
* Financial strain.
* Fear of crime.
While the present study supports the first two and, partly, the third, fear of crime was not among the top 10.
Johnson et al. (1993) and Johnson (1998), found among the 20 most common stressors in rural and isolated populations two among the top 10 in the present study: change in sleep habits and decreasing number of friends or losing friends. However, they found certain stressors common in the rural and isolated groups that are not among the common ones in the present study, and that may reflect the contrasting environments of the sample. For example, loss of a driver's license is among the most common stressors in both of the aforementioned studies, while it does not appear at all in the urban or suburban sample of this study. The greater reliance on driving for transportation may be evident in a more isolated setting. Additionally, they found loneliness among the most common stressors, but this was not mentioned in the present study. Again, an existence in more isolated settings could contribute to this.
Aldwin (1990), in three surveys, found deterioration of memory, death of a friend, major deterioration in health or behavior of a family member, major decrease in activities enjoyed, and major personal injury or illness among the top five stressors. While these stressors are not precisely supported by the current study, aspects may be partially reflected. Death of a friend could be a part of "decreasing number of friends or losing friends." Major decrease in activities enjoyed and deterioration of memory may partially reflect two of the most common stressors of the current study, namely "slowing down" and "decreasing mental abilities."
Of great importance, however, is the lack of emphasis in other studies conducted to determine common stressors on the following:
* Slowing down.
* Concern for world conditions.
* Constant or recurring pain.
* Decreasing mental abilities.
* Thinking about one's own death.
* Feeling of remaining time being short.
* Wishing parts of life had been different.
While these conditions, individually or in combination, are present in the literature, viewing them as stressors underscores the need to address them to decrease stress levels and, thereby, decrease stress-induced illness in older adults.
The identification of "slowing down" as the most frequently identified stressor may signify the frustrations older adults experience when they no longer are able to perform activities once taken for granted. Age related changes, such as decreased physical ability and stamina, make it difficult for elderly individuals to perform daily tasks, leisure activities, and work-related duties. Older individuals are susceptible to loss in many areas of life, and "slowing down" may reflect this. They grieve over their former, younger selves and the resultant changes in lifestyle, selfimage, and relationships. Decreasing mental abilities, another frequently identified stressor, echoes the frustration elderly individuals experience when they can no longer rely on their memories, and when simple decision-making becomes a difficult task to accomplish.
Loss is also associated with social support as shown by the items, decreasing number of friends or losing friends and time too short with children or grandchildren. The high frequency of these responses suggests close, family and friends may not be readily available to this group. Lack of social support has been shown by the research to leave older adults vulnerable to both physical and psychological dysfunction (Callaghan & Morrissey, 1993; Krause, 1997).
Concern for world conditions was another of the most frequently reported stressors in this study. Those older than 65 have lived through the Depression and World War II, both devastating times in world history. With increasing crime and terrorism throughout the world, elderly individuals may fear that history will repeat itself.
Additionally, elderly individuals have seen and experienced dramatic changes in science, technology, politics, economics, social customs, and philosophies. Bewilderment with the many rapid changes during their lives may be reflected in this stressor. They may also be gready concerned about the health care crisis in this country and the affect it may have on them. Concern for world conditions could also reflect the increased exposure to news through television. With decreasing physical abilities, watching television becomes a prime leisure activity for older adults. Elderly individuals may fear for the future of their children who must live in such an unsettled world.
Somewhat startling is the fact that "slowing down" and "concern for world conditions" are both absent from the list of most common stressors in the rural and pioneer samples studied by Johnson et aL (1993) and Johnson (1998) while they are the two most common in the urban or suburban population. While it is interesting to speculate on the reasons for these discrepancies, only further research will produce the evidence needed to answer these questions.
Neugarten (1968) and Erikson (1963) both hypothesized with the advancement of age, older adults experience introspection and reflection as they become aware of approaching death. This is supported by the frequent identification of the stressors, "thinking about one's own death," "wishing parts of one's life had been different," and "feeling of remaining time being short." While older adults experience stress related to the approaching end of life, that feeling may be necessary to reach a sense of integration.
The identification of "constant and recurring pain or discomfort" by 36% of the sample supports the findings of other studies on pain that between 25% and 50% of older adults living in the community suffer from some type of pain (Magni, Marchetti, Moreschi, Mersky & Luchini, 1993; Mobily, Herr, Clark, & Wallace, 1994). It further suggests that they may suffer chronic illness or disabilities, which may contribute to further consequences to the client's well being. It is noteworthy that "pain" is one of the most stressful items on the SGSS in addition to being one of the most commonly occurring. Older adults may not complain about pain to health professionals because they have been told it is expected as part of growing older (AGS Panel on Chronic Pain in Older Persons, 1998). It should be noted that the literature on common stressors does not generally mention pain as a stressor, although it is noted to occur commonly in the older age group.
While changes in sleep patterns have been noted in elderly individuals, it is not commonly cited as a stressor in the literature. Morgan and Clarke (1997) reported that 21% of elderly individuals of their study had some form of insomnia. The current study finding of 37% would suggest changes in sleep habits present a greater concern than previously thought. This is further supported by findings of Johnson et al. (1993) and Johnson (1998), who reported that 64% and 88% of the participants, respectively, experienced sleep changes.
Although the literature identified retirement as a cause of stress among older individuals, the participants in this study reported it with a low frequency (17.5%). While the mean age of the sample is 72.4, many of whom may have been retired for some years, it is important to note that retirement was not listed as a common stressor, even by the young-old. The fact that the sample was two thirds women may also have some bearing on this. This is in agreement with the findings of Aldwin (1990) that retirement is one of the least common stressors.
Death of a spouse was one of the most frequently named stressors in the literature (Fitzpatrick, 1998; Krause, 1991). In this study, however, death of a spouse was not commonly identified as a current stressor, possibly because 54% had no spouse. Thirty-nine percent of the respondents were already widowed and were not currendy experiencing stress associated with the loss.
CLINICAL IMPLICATIONS AND INTERVENTIONS
The instrument used in this study, the Stokes/Gordon Stress Scale, identifies stressors in older adults, and can be used by health care professionals as a diagnostic aid because of the many relevant stressors it specifies. Interventions can then be directed toward reducing the impact of experienced stressors, and in so doing, decrease the risk of developing new stressors and illnesses.
Although this term is non-specific and broad, it basically refers to the inability to perform physical and mental activities in the same manner as in the middle-adult years. Agerelated changes, such as decreased physical ability and stamina, make it difficult for elderly individuals to perform daily tasks, leisure activities, and work-related duties. Planning for aging is an important intervention to be performed by the professional nurse and this can begin during middle age or with the young-old.
Helping the individual to maintain activities and be realistic is necessary. Time management for older adults can provide an appropriate balance to life, conserve energy, and maintain safety. Elderly individuals should be encouraged to rearrange their activities rather than to eliminate them. Scheduling fewer activities in a day, with adequate rest periods, should allow them to continue many of the activities of past years, both of daily living and recreation.
Routine physical exercise has been reported to maintain mobility and independence (Buckwalter & DiNubile, 1997). A daily routine of brisk walking or exercise, such as tennis, golf, or swimming, is encouraged. Older persons need to be helped to examine activities appropriate to their abilities. For example, ballroom dancing and walking may be better than horseback riding and rock climbing.
Concern for World Conditions
Those older than 65 are an elite generation. They have lived through the Depression and World War II, both devastating times in world history. With increasing crime and terrorism throughout the world, elderly individuals may fear that history will repeat itself. Finding a forum to discuss these events can provide a stimulating and supportive oudet for concerns. Concern for world conditions could reflect the increased exposure to instant news with graphic pictures, on television. With decreasing physical abilities, watching television may become a prime leisure activity.
Planned non-television activities can provide a more balanced perspective for a medium that seems to glorify the dark side of humanity. For example, older adults can be encouraged to enter into fora that permit transmission of the wisdom of their age (e.g., foster grandparents or small business associations). Participation in political campaigns or community action groups can promote a sense of contribution to society.
Time too Short with Children or Grandchildren
An interesting present-day phenomenon is that older adults often move to retirement communities at a great distance from family (Adams & Blieszner, 1995). The ability to keep in touch with family becomes more difficult. While the companionship and age-appropriate physical adjustments in these communities makes them very desirable, the connection with family is decreased. Williams (1988) found that increased family contacts were related to decreased depression, increased self-esteem, and improved attitudes toward aging.
Children, particularly grandchildren, communicate increasingly via email. Although electronic communications may at first seem daunting for the older adult, elderly individuals need to be assured they can become facile on the computer to connect with the modern family. Computer courses at local libraries or schools can provide the training needed. Exchange of audiotapes and videotapes can further enhance communication, although the older adult may need some occasional refreshing on the use of the VCR. Tapes can be reviewed numerous times and provide an ongoing feeling of closeness.
Providing the older adult with a calendar with family pictures made at a local copy shop will be a constant reminder of connections. Taking the time to develop an oral or written family history can enhance the feelings of closeness and a shared life (Luborsky, 1993). The experience can be a joint one where older adults ask family members what they want to know about their life experiences over a period of 60 years. Books and computer programs for developing a family tree are also available.
Thinking About Own Death
Older adults need to assess the meaning of the thoughts they are experiencing. Is there concern for unfinished business, longing for increased time, or what Neugarten (1968) and Erikson (1963) hypothesized as age-appropriate behaviors of introspection and reflection? Older adults need to be able to discuss with someone the reality that death will occur. Their end-of-life and afterdeath wishes need to be acknowledged and written. The nurse can suggest writing a health care proxy, as well as planning wills and trusts to handle financial concerns. Discussing wishes with family for distribution of belongings or planning for a funeral can put both the family and older individual at ease.
The professional nurse, with education and experience in end-of-life matters, can facilitate this dialogue. This is also a good time to plan how elderly individuals wish to be remembered. Organizing photos, awards, documents, and memorabilia can help the family member live on, and cherished belongings can be hung on the wall or put into a shadow box.
Change in Sleeping Habits
A thorough assessment of the problem needs to be conducted (Beck-Little & Weinrich, 1998). Is it a problem of falling asleep or staying asleep? Older adults can make a plan for sleep and wake times. Decreasing day time naps, increasing daily physical activities, and limiting fluids 4 to 5 hours before bedtime may be part of the answer. Developing a bedtime routine is key to a consistent pattern of sleep and feeling rested. Planning some constructive or relaxing activity to fill wakeful nighttime hours may, however, help the individual be less troubled by the awake time and learn to accept it, if it cannot be avoided.
Decreasing Number of Friends or Losing Friends
The need for continuing social support and companionship of others cannot be overemphasized in helping the older adult cope with the changes brought on through aging. The presence of family and friends in the life of the older adult has been shown to have both direct and mediator effects on stress and health outcomes (Counte & Glandon, 1991; Krause, 1991). Planning for a cohort of friends in old age begins during middle-age or as a young-old adult. The individual should be encouraged to build a circle of friends. Joining with other people of like interests should be suggested. This may mean religious groups, ethnic groups, neighborhood groups, or special interest groups (Koenig, George, & Siegler, 1988).
Participating in activities in the local community can provide ready access to people with similar interests. The elderly individual should also be encouraged and assisted to maintain or reestablish ties with members of their extended families, such as siblings and cousins, some of whom may have the same need. Family reunions or cousins "clubs" can be a valuable support to older adults. The focus should be on groups that have continual new members to provide a support group throughout the life cycle.
Constant or Recurring Pain or Discomfort
The nurse needs to reassure the older adult that pain is not a normal concomitant of growing old. Too often older individuals will not report pain because they think it is just a part of growing old and something to be endured. A variety of assessment tools are available for measuring pain. The nurse can employ techniques for alleviation of pain beyond the use of pharmacologic agents, as recommended in the guidelines developed by the American Geriatric Society (AGS Panel on Chronic Pain in Older Persons, 1998). Exercise, relaxation, imagery, therapeutic touch, and other cognitive-behavioral therapy and education programs are recommended.
Wishing Parts of Life Had Been Different
The nurse needs to assess what parts of the individual's Ufe are in question at this time. The nurse can help the older adult validate the reasons for making certain life decisions. Often when the individual discusses the decisions made at an earlier time with a significant other or in a support group, the individual can reach inner peace about why a particular life path was taken. Individuals who wish they had graduated from college can understand that the need to work to help support the family was more important at the time. If older adults can take pleasure in the fact that the family was nurtured by this gift, they may feel more at ease.
The nurse can also help the individual decide what is important to accomplish in the remaining time of life. If the individual wishes that more time had been spent with the family and that there were closer ties with the family, the nurse can suggest ways to accomplish that goal now. The nurse can organize groups for individuals to tell their stories and participate in reminiscence therapy. Life review is an effective way to avoid despair and achieve the integration central to old age (Burnside & Haight, 1994; Erikson, 1963; Phoenix, Irvine, & Kohr, 1997).
Feeling of Remaining Time Being Short
The nurse needs to assess this stressor to determine whether there are actual concerns related to the remaining time or whether this is one symptom of depression. It is estimated that between 10% and 18% of the adults older than 65 exhibit some degree of depression (Murrell, Himmelfarb, & Wright, 1983). Use of depression scales and interviews can assist the nurse in this determination. The nurse should interview the individual to determine the parameters of the problem. What would the individual like to accomplish in the remaining time? The nurse can then develop a realistic plan to reach this goal with the individual and family, or help the person accept the lack of the experience.
Decreasing Mental Abilities
There has been much public notice of the concern for decreasing mental abilities of the old. Stumbling over a name or date in youth is usually forgotten, but when this occurs with an older adult, the individual may experience great concern and anxiety. Older adults may wonder if they are developing Alzheimer's disease. While Alzheimer's is of concern, many less severe conditions may be the cause, and the degree of mental impairment needs to be carefully assessed.
Nurses should help older individuals who complains of forgetfulness to plan routines for each day. Nurse can suggest always placing items, such as keys, in the same spot, and developing a list of activities to be accomplished, people to see, and calls to make each day. Older individuals experience less forgetfulness when they keep their minds and bodies active (Ten, McCurry & Logsdon, 1997). Participating in some mental exercises by taking a class; participating in discussion or memory training groups; or by playing games, such as bridge or chess, keeps the older individual mentally alert. Individual activities such as completing crossword puzzles or watching quiz shows on television can also keep the mind working.
A limitation of the study is that the sample is a non-probability sample and, therefore, the findings must be applied with caution. Additionally, because the sample was one of convenience, it was not fully representative of the general population in the locations in which data were collected Further limitations include the lack of data related to the number of urban versus suburban participants and the return rate for study materials. Further work should be conducted with different populations to expand the usefulness of the findings.
It is only by thoroughly assessing stress and the associated stressors, that nurses can develop interventions to alleviate stress. The professional nurse's use of interventions such as those mentioned in this article may help in promoting health and preventing illness in a large segment of the population.
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NURSING INTERVENTIONS FOR THE 10 MOST COMMON STRESSORS
DEMOGRAPHIC DISTRIBUTION OF SAMPLE
TEN MOST COMMON STRESSORS FOR NON-INSTITUTIONALIZED HEALTHY OLDER ADULTS