Introduction

Chapter I: The Nursing Process: Geriatric Assessment

Chapter II: Psychological Assessment

Chapter III: Physical Assessment and Recording the Findings

Chapter VI: Drug Therapies for the Elderly Client

References

Chapter V THE CHARACTERISTICS AND CRISES OF
LATER MATURITY

COGNITIVE CHARACTERISTICS IN LATER MATURITY

1. STEROTYPES

Contrary to the stereotype, intellectual functioning does not automatically degenerate in later maturity.  Assessment and nursing care must be directed toward the healthy characteristics as well as toward any limitations that might be present.

Chronological age is rarely a reliable index of the elderly person’s mental development.  The initial level of ability is crucial.  Those persons with high IQ scores as children show progressive gains in general information, comprehension, vocabulary and arithmetic when retested in later life.  A bright 20-year-old, all things being equal, will usually be a bright 70-year-old.  This bright 70-year-old will function better in cognitive skills than the average 20-year-old.

Cognitive functions refer to mental and intellectual processes of drive, perception, interest, motivation, memory, reasoning, thought, learning, problem-solving and judgment.  These functions include the ability to examine a situation; take in, process and recall information; orient self in time and place; organize complex data; and respond appropriately to stimuli in content, emotion and over time.

2. PROBLEM-SOLVING ABILITY

The brain possesses a tremendous reserve capacity.  Perhaps this is why the senior may cope very well despite the decrease of functioning nerve cells in the central nervous system.  This decrease is influenced by cellular, circulatory and metabolic changes occurring in the body with aging (Botwinick 1967).

The older person may be able to tolerate extensive degeneration in the central nervous system without serious alteration of behavior or cognitive function in a supportive social environment.  The person often remains relatively unimpaired because he or she has developed ways to counteract slight memory loss or difficulty in learning.  Certain social skills or pleasant responses help him/her through a situation.  Therefore, others might not notice a slight cognitive deficit.  If others’ responses, in turn, remain positive, his/her self-confidence enables the senior to use skills he/she does possess.  Thus, daily functioning is likely to be unimpaired.  Even in unusual situations, he/she is likely to come up with the best solution for him or herself.

The initial level of ability is crucial for continued learning.  Those with high IQ scores at a younger age are usually better to cope with current stresses, manage new situations or work more effectively in familiar situations.  In familiar situations they can use a variety of skills that are enhanced by thoughtful experience and maturity.

The elderly person is likely to be superior to the younger person in overall factual knowledge; coordination of facts or ideas, life experience and wisdom; use of authority and power to get things done and maturity of judgment.  All of these could enhance or maintain problem-solving ability and work performance.  Yet, how the senior uses his or her skills to do problem-solving may differ from that of a younger person.  The older person performs more accurately when stimuli are logically grouped and sequential; and more accurately when given a larger amount of data, instead of isolated bits of information.  He/she also does better when given a longer time to process the data.  He/she is likely to work out mentally how to do something before he/she acts it out.

The senior is less likely to take advantage of information that is not directly relevant to the situation.  He/she is unlikely to acquire new ideas or concepts unless they are better than currently held ideas or concepts.  Tasks that require making analogies, forming new concepts, or new classifications and finding novel or creative answers are more difficult to perform.  However, with enough time, the senior would come up with a workable solution to the problem.

3. CREATIVITY

Rigidity and concreteness in thought are typical of old age.  The older person seems more rigid in his or her thinking because he/she is cautions and emphasizes accuracy instead of speed.  Caution results from a tendency to avoid risky decisions.  This is likely due to a fear of failure or he/she has learned from past experiences.  Yet, when a decision can’t be avoided, the elderly will choose high-risk or innovative solutions as are younger people.  The elderly are more concrete in thinking and strive to be functional or practical instead of abstract.

Reduce use of abstraction skills has other results.  Research indicates that appreciation of jokes increases but comprehension of subtle content decreases in old age.  Past studies on creativity and productivity, measured by publications and discoveries, indicated that people are most creative between the ages of 30 to 50.  Actually, there is no age limit for creativity, since creativity is not limited to publications and discoveries.  The human is creative in various ways.  Current research indicates that the senior is often creative, even if he/she has not had very much formal education.  He/she uses past experience and insights in new ways in order to meet current situations.  He/she usually integrates experience on a higher level – absorbing, sifting and reconstructing reality on his own terms.  He treats as hypothesis what most people treat as fact.  He recognizes that anything encountered is incomplete, that it is in need of further study and reflection.

Regardless of how creativity is defined – as superior quality or as total productivity – the peaks and declines are the result of more than intellectual changes.  Will power, working strength, endurance and enthusiasm are all part of creativity.  With the trends toward longer educational preparation in many fields of work, future studies may reveal that creativity increases with age, since many people will be older before they can become productive.

4. REACTION TIME

Reaction time usually becomes slower as the person ages.  However, some older persons, especially physically active seniors, react as quickly as some younger people.  The senior needs extra time to perform physical tasks.  Performance scores tend to be lower and are used to explain intellectual decline.  Yet, by practicing a task, the older person can learn to improve his or her reaction time.

Seniors perform certain cognitive tasks slowly do to:

1. Decreased visual and auditory acuity.
2. Slower motor response to sensory stimulation.
3. Loss of recent memory.
4. Changed motivation.

He or she may be less interested in competing in timed intellectual tests.  Further, an apparently shorter duration of alpha rhythm in the brain wave affects the timing of response.  Reaction time is also slower when the person suffers significant environmental or social losses.  It also is slower when he/she is unable to engage in social contact and when he/she is unable to plan his/her daily routines.  The person, who is ill, often endures environmental and social losses by virtue of being in the patient role.  Thus, he/she may be slower responding to your questions or requests (Murray 1980).

Yet, some tests have shown that mental reaction time begins to decline after 26 years of age.  In one study, adults who were 71 were compared with 43 year-olds.  Both sets of subjects were given the same test for vigilance or clockwatching.  Seniors were just as attentive and vigilant as young adults for 45 minutes.  After that period, loss of interest and fatigue reduced their degree of vigilance.  However, an attention span of 45 minutes is acceptable in young adults, as evidenced by the length of a class hour (50 minutes), in most colleges.

Reaction time is affected by pre-existing expectations for stimuli as well as expectations during the experiment.  The senior is more likely to expect change rather than repetition in sequences.  He had developed a bit of a “gambling” attitude toward life over the years.  Thus, he/she responds faster to stimuli that are not repetitious.  Most tests for reaction time involved repetitious stimuli, which may influence test scores.

The person over 50 performs less efficiently in tasks requiring speed or when given little advance time to respond to the task.  The older person has a longer response initiation time, especially when hand movements are involved.  He/she usually takes longer to convert verbal stimuli to a mental image.  Response is slower if action must be carried out without seeing what is being done, when a large quantity of data are presented in illogical order, when a quantity of evidence must be placed together without using memory aids such as notes and when abstractions are presented.  Yet many younger people also have difficulty under such conditions.

The average elderly man performs less accurately in fast-paced than in slow-paced situations.  He is less likely to try in fast-paced situations unless he is sure of the accuracy of his response.  Performance of the average elderly woman is comparable to that of younger highly verbal men and women in fast-paced situations.  Throughout life, women excel in verbal ability and fluency tests.  Older women respond more readily to cognitive, psychomotor tasks than to elderly men.

5. MEMORY

Memory is the ability to retain or recall past thoughts, images, ideas or experiences.  A progressive loss of memory does not necessarily occur in later maturity, although memory loss affects more people as they get older.  Loss of short-term memory, recall for recent events, is more likely to occur than loss of remote memory, recall for events that occurred in the past.

The person’s permanent memory is an organized network of concepts interrelated in specific ways.  If the relationship between these concepts cannot be used because of loss, decreased retrieval or lower access, the person loses conceptual richness or spontaneous use of memory links.  Such loss is more likely to occur in older people than in younger people and in persons institutionalized than in persons living in the community, apparently because of the number of life crises and less intellectual stimulation for the former group.

Memory loss may occur for various reasons:

1. Interference from other memories that are valued by the person and accumulated with age.
2. Sense of worthlessness or depression, so that less energy is directed toward recall.
3. Loss of interest in current events; past memories are more pleasant.
4. Neurochemical and circulatory changes may affect cerebral function.
5. Loss of cells in the central nervous system.
6. Difficulty in information acquisition because of deficiency in neural synapses in the storage system.

Short-term memory is central to learning processes that would not otherwise decline with age.  Synthesis, analysis, comparison and ability to organize content are less dependent on short-term memory, and these functions do not decline with age.  The problem in learning occurs because the person loses the pieces of immediate information needed to process, code or synthesis.  Short-term visual memory appears to be more susceptible to aging than is auditory memory.

The senior has difficulty in ordering the time sequence of more recent events, in rote memory and in immediate recall of new learning.   He or she uses fewer mental images to enhance verbal phrases he/she hears and to act as memory mediators, which may account for the poorer performance on memory tests.

Long-term or remote memory, including vocabulary, personal history, past experience and basic knowledge, is highly resistant to the effects of normal aging.

6. FACTORS THAT INFLUENCE COGNITIVE RESPONSE

Many factors must be considered when you assess the intellectual level, problem-solving ability, creativity, reaction time or memory of the older person, including the following:

1. Interest in living and in events about him or her.
2. Sensory impairments that interfere with integration of sensory input into proper perception.
3. Amount of time since in school or in an intellectually demanding position.
4. Educational level, past involvement in learning activities or earlier cognitive incapacities.
5. Amount of deliberate caution; using more time to answer or do a task, which can be interpreted as not knowing.
6. Presence of adaptive mechanisms to conserve energy rather than showing assertion or time-consciousness.
7. Degree of motivation to please those around him or her or to participate in a testing situation.
8. Presence of ill-health.

Previous life-style, present behavior patterns and general coping mechanisms all affect cognitive       function and must be considered in assessment.  Observe behavior in a variety of situations and   listen to the person’s conversation and reminiscences.  Talk with family members or friends.  Consider the total, unique individual physically, emotionally and socially so that you can increase the accuracy of your cognitive assessment.  Too often cognitive impairment of the person in    later maturity is considered as irreversible brain damage or chronic brain syndrome.  Recent research indicates that mental impairment may be caused by a number of interacting    relationships of biological, psychological, social and environmental factors.  Even when brain damage is present, impairment may range from slight to severe.

7. EMOTIONAL FACTORS

Some of what is called mental impairment results from our approach to older people.  Society expects the older person to become deteriorated or “senile”.  If his or her self-image is affected by a role expectation of mental dysfunction, his/her behavior becomes “senile”, an example of the self-fulfilling prophecy.  Institutional life also limits motivation to behave appropriately because opportunities are not used to draw out functions assumed to be lost in old age.  The institution is often devoid of time and environmental cues, and confinement causes disorientation and confusion.  Reactions of others markedly affect the person’s motivation to stay alert, to learn, to be creative.  The person who feels worthless is less likely to try.

The person who suffers marked losses, especially the loss of a significant person, tends to perform less adequately on psychometric and personality tests.  Often general behavior and problem-solving abilities are noticeably less effective as well.

The relationship among three cognitive ability factors (ability to process information, manual dexterity in response to stimuli and ability to analyze patterns), and three personality dimensions (anxiety, extroversion and openness to experience) were examined in over 900 males aged 25 to 82 years.  Persons, who were highly anxious, scored lower on all three cognitive ability factors.  Persons open to experience, scored higher on ability to process information and analyze patterns.  Introverted persons scored higher on ability to analyze patterns than did extroverts.  Older people performed less well than younger ones on manual dexterity and ability to analyze patterns, but they did equally well on ability to process information.

The senior is more apprehensive about new learning situations, especially in a competitive atmosphere.  He anticipates difficulty in learning new tasks and asks for more detail and specific directions.  Certainly questions should not be interpreted as mental incompetency.  The older person is usually more cautious than the younger adult because of his/her experience, which accounts in part, for the difference in experimental test performance.  Whenever possible, tasks are selected that have less risk or at which the person has a higher probability of success, probably to avoid a negative self-evaluation.

8. SOCIAL FACTORS

Our culture values a rapid verbal and motor response.  The older person has internalized that value.  Because he/she cannot respond rapidly to a question, statement or task, he/she may devalue him or herself.  Further, he/she may have internalized the cultural expectation that school is only for youngsters.  Hence, he/she lacks confidence in pursuing formal or informal learning activities.  He/she may consider him or herself and other older people too stupid or too slow to learn.

The older person should be seen as a productive person who has been learning all of his/her life.  Any decline of mental power is more likely to result from the brain getting too little rather than too much work.  Lack of environmental stimulation, forced isolation and disengagement hasten mental and physical decline.  The person feels less like making the effort to respond intellectually.  Those who continue to work have more normal brain function and have higher intelligence test scores in later maturity, than do those who are idle.  Society needs the cognitive potential of our senior citizens and should provide opportunities for them to use their skills.

9. PHYSICAL FACTORS

Sensory impairments that accompany aging can cause the person to miss certain stimuli and as a result, appear intellectually impaired.

In one study of relationship between visual and mental function, subjects were divided into three groups on the basis of visual acuity:

1. Adequate vision…………………........better than 20/70
2. Low vision…………………………...20/70 to 20/100
3. Legally blind…………………………20/200 or worse

The group with adequate vision scored highest on the mental status questionnaire.  Lowest scores were in the legally blind group.  That most older people could cooperate with vision and mental testing, was also shown.

At this point, whether vision loss causes impaired mental functioning or organic brain disease causes impaired vision is unknown.  They are probably interrelated.  Also, medications, general physical health and emotional state, can affect both visual and mental function.  A direct relationship also exists between hearing loss and reduced cognitive effectiveness.  Hearing loss results in changed speech perception, reduced ability to define concepts, to describe abstract relationships and even to recall stored information.  Thus, hearing loss affects cognitive test scores, reaction time and personality.

If the person cannot see adequately or hear what you are saying, his/her response may appear confused, disoriented or stupid when none of these characteristics is present.  The problem is increased if you are speaking English and the elderly person’s first language is not English.  Inability to differentiate among environmental stimuli and decreased speed of processing information also limit the person’s ability to assess the possible constraints and opportunities within the environment.  This limits his/her coping strategies.

A serious illness or injury in early life often causes damage to certain brain cells.  The person must relearn the functions regulated by these cells.  Later cognitive impairment can result from incomplete relearning and the illness rather than from the aging process alone.

Numerous illnesses can reduce cognitive function and cause disorientation or confusion.  Poor health and lower energy levels cause the person to resist becoming involved in planned learning activities and to score poorly on intellectual tests.  Even mild disease negatively affects intellectual performance, especially memory, adherence to given tasks, answering appropriately and ordered sequence of thought.  Thus, any ill person will show less mental acuity, which must be considered when planning and giving care.

Rapid declining cognitive function may be a predictor of death if the person has previously been alert and mentally capable.  Studies indicate that intellectual functions decline in the aged person primarily one year before natural death (Murray 1980).

THE CRISIS OF DEATH

In the Middle Ages, the person was very aware of natural signs or premonitions that he/she was dying and was active in doing the rituals that prepared for death.  Loved ones quietly kept the vigil with him/her.  Death was familiar and near.  It evoked no great sorrow, awe or fear.  About the eighteenth century, death became romanticized and became intertwined with love.  Concerns about the death of others became of greater concern than personal death.  Gradually, death was viewed as a disruption.  Sorrow was openly and intensely expressed.

In the twentieth century, death has become frightening, taboo and unfamiliar.  Although death is frequently presented in the mass media and movies and many disasters are publicized, few people have direct contact with death.  Mourning has been suppressed.  The language of our culture avoids death with phrase like; “He passed on.” “He grew weak.” “He is sinking.” “She is gone.”.  Humor may be used to refer to dying, to express fears of death, to predict death or to convey doubts about staff competence.  Medical care technology further depersonalizes and denies death.  The person is no longer in charge of his/her dying, even if he/she are aware of his/her status (Murray 1989).  The senior has lived through some of this evolution.  He/she may have helped care for sick and dying parents at home and is perplexed, perhaps angry, when he/she is sent to a nursing home or hospital.

Although considerable literature and media coverage are devoted to death and dying, people in the U.S. still seem uncomfortable with the topic.  In spite of increased efforts at professional education about death and dying, care of the dying elderly population still is neglected in many institutions.

Some cultures believe that life and death can be controlled by the person.  Voodoo death or spontaneous deaths are well documented.  The person was either a victim of the enemy or he/she “willed” him or herself to death when he/she has broken a taboo and then he/she dies shortly thereafter.  The medicine man is important in many cultures to organize the community’s attitude toward the dying person.  It has been seen that if support is withdrawn, the person gives up and soon dies.  If the medicine man conveys that the person is curable, the community becomes supportive and the person survives.

The situation for our elderly may not be too much different.  Being hospitalized and cut off from the rest of the community, may hasten death.  This is something Native Americans, Orientals, Chicanos as well as the elderly have “known” as they were subjected to impersonal treatment.  However, since hospitals are at times necessary, efforts have been made to create a warm, supportive environment.

Premonitions of death are apparently present in many seniors, although they may be reluctant to say so.  Sometimes the senior will predict when he/she will die.  The elderly may exert more control over their longevity and time of death than is commonly realized.  Often it appears that the person will not give up life until he/she has said farewell to a certain loved one.

Longevity is increased when the older person posses the following characteristics:

Interestingly, one study found that the patient, who survived longer than predicted, was angry about his illness, fearful of death and determined to live instead of being resigned to death (Benoliel 1970).  Attitudes about death differ in various cultures.  Morality occurs at an earlier age in lower socioeconomic groups and among racial minorities in the United States.  Therefore, death may be perceived differently by different groups.  In a study comparing Black Americans, Mexican Americans and White Americans, fears of death were related more to age than to racial group.  Middle-agers expressed more fear than the elderly, and women were more expressive of their feelings than men.  However, they did not think about death as frequently.  Whites were less preoccupied with death than the other minorities.  Elderly Mexican Americans expressed the least fear of death.  Young Mexican Americans expressed the most.

In the United States, death is expected to come to the elderly, to people no longer in the work force.  Thus, society overall is not concerned with death unless it occurs to the young or occurs violently.  Even if death comes early, little disruption occurs because work is organized so that major institutions are relatively independent of the persons who carry out work roles within them.

Fear of death is apparently more common in the young than in the elderly.  However, the elderly express fear of death when a crisis in the social environment is disrupting prior life-style and acceptance.  For example, those who are moved to or live in a nursing home are more fearful than the elderly who live in the community and who are not experiencing relocation.  The elderly suffering psychiatric illness may also express fear of death.  The elderly in a stable situation feel more peace and equanimity about death.

1. MEANING F DEATH

To the elderly, death may have many meanings:

• a friend who brings an end to pain and suffering
• a teacher of transcendental truths uncomprehended during life
• an adventure into the unknown
• reunion with loved ones
• a reward for life well-lived

Death may mean the great destroyer; the cessation of life with eternal nothingness; punishment and separation; or a way to force others to give more affection than they were willing to give in the past.  Suicide may be seen as a way to gain control over dying, join loved ones or end an apparently hopeless situation.

The mature person recognizes that dying and death are phases of living and life.  The decreased energy level, religious beliefs and loss of most significant people also facilitate a philosophical attitude toward closure.  Children and grandchildren also bestow on the older person the remainder of continuity of life and tangible evidence of his or her ongoing contribution to mankind.  The person who has left issues unsettled, dreams unfulfilled, hopes shattered or let meaningful things pass him/her by, is sometimes reluctance to die.  Knowing of one’s morality allows the person to start preparing early for the last developmental stage—to live life instead of passing through it.

2. PREPARATION FOR DEATH

Most people admit to thinking about death at some time.  Usually these thoughts are triggered by external events such as an accident or near-accident, a serious illness or death of someone close.  Yet, some older people do not make plans for death, as if planning will hasten death.  The elderly are more concerned about the dying process and:

1. The pain
2. Being a burden
3. Loss of bodily and mental functions
4. Dependence upon others
5. Rejection
6. Isolation and separation from loved ones
7. Inability to take care of personal business
8. Loss of social roles

The more relationships that are important to the senior, the more ties he/she has to undo.  This causes grief to be greater.  Most do not wish to have life prolonged by machines.  However,  there are times that such treatment is warranted.  Life-support machines give seniors and family extra time to prepare for their death.  Some seniors feel the best way to avoid prolonged suffering, dying and preparation for death is to express their desires to family and physician through the Living Will. 

Death can be planned in different ways.  For example, a prominent Protestant theologian and his wife put their affairs in order, said their farewells.  They wrote a note to their children and grandchildren.  The note explained the reason for their behavior.  They wrote that their health was quickly failing.  They required almost constant care.  Soon they would be too dependent to live without dignity.  They did not want to take up space in a world where there were too many mouths to feed and too little food.  They felt it was a misuse of science to keep them technically alive, so they committed suicide.

They thought carefully and believed they had the right to decide when to die, and the decision was not turning against life as the highest value.  They clearly were not acting from depression, despair, pain or mental incompetence.  They risked condemnation because their religion does not sanction this.  However, they felt their action was logical and this will become more acceptable in the future.

Charles Lindbergh also planned his death, but in a different way.  When he knew he was terminally ill, he selected his grave site.  It was on a tropical island of Maui.  He then made all the necessary legal arrangements.  Eight days before his death, when the doctors told him he had little time left to live, he flew from New York City to Maui.  Then, with his family, physician and two nurses spent the last two days looking at the place he loved and reminiscing.  He received the necessary care, but no measures to prolong life.  His death was like his life; simple, well-planned, considerate and humble.

Most seniors do not have the means to fulfill their dreams as Lindbergh did.  Many are taken to institutions.  They endure a variety of tests, drugs and procedures.  They have minimal control over their living or dying.  Preoccupations with symptoms, pain and the rigors of treatment preclude quiet contemplation, meaningful life review or serene acceptance of death.  Medical staff may resist death more vigorously than the patient and often do not credit the senior with enough maturity to understand or accept the finality of his/her condition.

Although a few seniors maintain denial, most desire a plan for their demise.  You may be of assistance to them as they validate ideas or need specific tasks to be done.  Or you may assist them by letting the doctor know that the senior can accept his/her condition.  The doctor can state the diagnosis and prognosis honestly without conferring hopelessness.  If the person insists that he/she does not want to be told anything, his/her request should be honored.  Often, the person is aware of the truth, but avoids talking about it.  Preparation for death is more important for some elderly than for others.  Some need to make provisions for their heirs and finalize business and legal affairs.

For many elderly, a spiritual preparation for death is of great importance.  Premonition of impending death may give opportunity for long-deferred self-examination and for gaining new meaning in life and death.  A reconciliation of conflicts is one’s religious faith can be accomplished.  Personal hurts can be amended and tenuous relationships can be strengthened.  Each day becomes precious and meaningful.

People die as they live.  Those who found meaning in life are unafraid of its end.  If success in life has been measured by material standards, death may be approached with bitterness and anguish.  Religious faith is not necessarily a factor.  Agnostics and atheist may accept death with as much tranquility as a religious believer.

Certain developmental changes occur in the last year prior to death that are unrelated to age and illness and appear to be predictors of death.  These characteristics of approaching death which are often monitored by the ill elderly include:

1. Poorer performance of various tasks
2. Lower energy level
3. Slower reaction time
4. Decline in cognitive functioning
5. Shortened memory
6. Decreased planning ability
7. Reduced emotional complexity
8. Decreased planning ability
9. Reduced emotional complexity
10. Decreased ability to cope with stress
11. A more negative self-image
12. Less capacity for learning
13. Less assertiveness and flexibility
14. Increased introspection

The senior expresses more anxiety, more hopelessness, but fewer expectations about the future.  He feels that his/her body is no longer functioning as well as it did, even before overt signs and specific symptoms appear.  The person may say, “I feel like I’m slipping and I don’t think I’ll be here next year at this time”.  The senior may show increased interest in his social and material environment; it is a disservice to isolate the senior at this time.

3. AWARENESS OF DYING

People today are better educated generally by the mass media about the manifestations of the main killers, cardiovascular disease and cancer, than they were in the past.  Further, the legal aspects of informed consent are rigorous.  Many procedures cannot be performed without giving the senior an honest explanation.  Thus, most people are likely to know intellectually even if they do not emotionally accept their terminal illness.  Yet, some doctors and families persist in wanting to keep the diagnosis and prognosis from the patient.  They feel that the elderly person will be unable to accept the news.

Different stages that the terminally ill patient may experience include:

CLOSED AWARENESS

Closed awareness exists when the person has not been informed.  Also he or she has not discovered the severity of his/her condition.  He/she may not be aware because he/she is also not knowledgeable about the signs of terminal illness.  Additional, he/she may be in denial and not aware of the severity of the disease.  Maintaining a closed awareness is easier in the hospital than at home.  The nurse, of course, may be placed in the middle, in such a situation, for it is difficult to communicate openly when a secret must be kept.  Family members are robbed of an opportunity to be honest, share their grief with the loved one or plan together for the future.  The patient has no opportunity to work through his/her doubts or fears or make plans for his/her loved ones.  No one ever learns of the resilience or maturity of the senior, who may be more able to cope than anyone realizes.  Keeping the patient uninformed is a travesty of care, in most cases.  However silent the patient might be about his/her condition, he/she may have a premonition about his/her status. The senior watches his/her caretakers and family closely for clues about him or herself.  He/she may come to the conclusion that he/her is very sick and dying as he/she overhears snatches of conversation or sees teary eyes (Benoliel 1970).

Isolation is experienced when family and friends relate differently to the patient after they learn that he/she is dying from a known terminal illness.  They no longer share with the patient.  Conversation becomes superficial, stilted and lacks spontaneity as they try to keep the patient from learning his/her diagnosis.  Suspicious awareness exists when the person believes he/she is dying but says nothing to confirm his/her idea.  Usually his/her deteriorating physical status, others’ silence or their brusque answers to his/her queries, a move close to the nurses’ station, extra attention from relatives rarely seen or shorter and fewer contacts with the health care team, confirm his/her suspicions.  The senior knows that he/she is dying but realizes that others around him do not know that he knows.

Mutual pretense occurs when family, patient and staff enter into a game.  All realize that the patient knows he/she is dying and continue to pretend otherwise.  The patient can plan his/her remaining life, but he/she cannot share this with anyone close.  No one can be honest; no one benefits from the patient’s awareness.  Even the patient cannot do anticipatory grieving or legal and business planning very well.

OPEN AWARENESS

Open awareness exists when the patient and family are fully aware of the terminal condition and can talk about it, although the nearness of death may not be established.  Now the senior can reminisce and conduct life review.  He/she can give treasured possessions to the right person.  He/she can be in control of his/her situation to a greater degree as he/she finishes important work and makes plans for and says farewells to the family.  He/she learns how family members perceive their coming loss; his/her death.  He/she can share his/her feelings of loss as he/she anticipates death.  The anguish is not reduced, but it can be faced together.

The staff will also be more involved with the senior as he/she talks to them about his/her death.  The staff may find it more difficult to care for the person who knows.  Staff cannot hide behind clichés.  They have to involve something of the self and see him/her as a person, not a thing.  The senior or family may request extra privileges, which the rule-bound nurse finds difficult to fulfill.  He/she may wish to die at home, and the family and staff may work together to set up care at home and secure the help of a home health agency. The senior who knows, may quietly but firmly, convey that he/she wishes to be granted privacy and dignity, both of which may be difficult to obtain.

4. SEQUENCE OF REACTIONS TO APPROACHING DEATH

Dr. E. Kubler-Ross describes a series of reactions that the person and family go through as death approaches.

These stages are:

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

1. Denial

Denial and isolation are the initial and natural reactions when the senior becomes ill or learns of a terminal diagnosis:  “It can’t be true; I don’t believe it”.  Denial is more likely in the person who is told too quickly or abruptly by the doctor.  Denial may be manifested by minimizing or refusing to acknowledge his/her illness or diagnosis or that the diagnosis may change his/her lifestyle.

The senior may make overly optimistic comments about his/her condition, refuse to follow doctor’s orders, seek other doctors’ opinions, try home remedies or delay hospital admission.  He/she may even begin unrealistic plans or projects that will be finished in the far distant future.  However, denial does not usually last when pain, fatigue or weakness interfere with activity.  As the senior becomes aware of his/her condition, either because of the extent of his/her symptoms or because he/she is repeatedly told by others, he/she may use emotional isolation as a defense.  He/she talks about his/her illness and even the possibility of death intellectually, without emotion, as if the topic referred to someone else.  Isolation enables the person to carry on practical activities of life that are necessary in order to prepare for hospitalization, prolonged illness or eventual death.

2. Anger

Anger is the second reaction and it occurs with acknowledgement of the reality of the prognosis.  As denial and isolation decrease, anger, envy and resentments toward the living are felt.  In America, direct expressions of anger are unacceptable.  Therefore, angry feelings are likely to be displaced onto the doctor, nurse, family or even the food.  Angry demands are a way to avoid neglect and to feel a sense of control over an uncontrollable event.  The person feels that he/she does not deserve to be sick, let alone die.  He/she can be bitter and hard to manage as he/she thinks, “Why me?”.

3. Bargaining

Bargaining, the third reaction may be difficult to observe unless you care for the elderly person regularly.  The person tries to enter some kind of agreement which may postpone death.  He/she tries to be on his/her best behavior in order to be granted the special wish of longer life, preferable without pain.  Bargaining may be life-promoting.  The person is hopeful and he/she expresses faith in God and the future.  The body’s physical defenses may be enhanced by mental or emotional processes yet unknown, and a bargaining attitude may account for the not-so-uncommon cases in which the person has a prolonged, unexpected remission from a disease process.  The senior who has a negative self-concept or is alone and isolated, lacks a sense of hope and is not likely to bargain.  He/she feels that he/she has nothing to bargain for.

During this stage, the senior vacillates between doubt and hope.  Sources of doubt include new and unexpected symptoms.  Any additional or unexpected stressor related to treatment, financial concerns or the temporary absence of the doctor or primary nurse.  When the source of stress is relieved, so is the doubt.  Hope arises when the senior hears the medical personnel say “We can help you”.  Hope also arises when the senior is encouraged to be actively involved in his/her treatment, by working with doctors and nurses against the disease, by being treated at a leading medical center, and by overtly hopeful attitudes of the staff.

4. Depression

Depression, the fourth reaction to his/her condition, occurs when the person gets weaker, needs more treatment or pain medication and worries about realistic mounting medical costs and even obtaining necessities.  Role reversal and related problems add to the depression.  The senior feels shame about his/her condition and guilt about being a burden on others.  He/she may feel that they are being punished for past misdeeds.  He/she may think about past losses and his/her present condition and he/she worries about the future.  He/she feels hopeless.  He/she fears being alone, losing independence, being disfigured, having pain or losing his/her sanity.  The mild depression that is frequently present in the senior is worsened when he/she anticipates death.  The senior may lay with his/her face to the wall; answer slowly, if at all; speak with an expressionless voice; talk in short and muddled sentences; or stare out of the window (Rogers 1976).  Preparatory depression differs from reactive depression.  He/she now grieves for the impending losses he/she will endure.  Not only will his/her loved ones lose him/her, but he/she is losing all significant relationships and things.  He/she will not be able to do some things that he/she wanted to do.

The person begins to separate him/herself from the world.  He/she reviews the meaning of his/her life, tries to share his/her insights with others and gradually withdraws from involvement in life around him/her.  If others continue to convey that they expect him/her to want to live, he/she may feel misunderstood and more depression, turmoil and grief.  This depression is difficult for family and staff.  However, he/she needs to be allowed to emotionally prepare for death.

The quality of life that is being left behind is defined differently by each person, depending upon:

1. Present life situation
2. Amount of pain
3. Family relationships
4. Feelings of despair and dependency
5. Work abilities
6. Amount of body mechanics
7. Religious beliefs
8. Amount of body mutilation
9. Past ability to cope with stresses
10. Feelings of loneliness and isolation
11. Loss of freedom imposed by medical care system
12. Ability to carry on usual routines
13. Sense of mastery over oneself and one’s life

.5. Acceptance

Acceptance, the final reaction, comes when the person has time to prepare for death, when he/she is given help in working through previous reactions and when he/she remains alert enough to emotionally resolve his/her death.  Now he/she is resigned to his/her fate.  He/she is withdrawn, neither angry, depressed, envious nor resentful of the living.  The person is emotionally and socially bankrupt.  Nothing of obvious importance can be added to his/her life and nothing can be regained.  Apathy rather than serenity or acceptance may be seen.

The senior cannot or will not further accommodate to the indignities of his/her diseases.  He/she has lived his/her life and does not wish to relieve it.  He/she says his/her goodbyes.  Only the senior who continues to add to the spiritual dimensions of his/her life will be able to use this time for growth emotionally and spiritually and feel that he/she is adding something to him/herself as he/she is dying.  He/she may feel and inner peace and self-possession.  He/she lives with the certainty of a limited future.  He/she plans his/her inheritance and assigns his/her treasures to others.

Unless he/she is unconscious, the senior who is dying continues to feel, think and respond to the present and limited future, to his/her illness and to those around him/her.  He/she does not just lie passively and await death.  He/she may strive to control and manipulate others; to prevent their leaving him/her or withdrawing their love.  He/she may pretend to avoid feelings of loss and despair.

The person may not proceed to acceptance.  He/she may refuse to admit he/she is dying.  He/she may show anger, bitterness and self-pity.  He/she may retaliate against others, demand, cling or berate him/herself.

The person who is dying often fluctuates between avoidance, denial, anxious hope, rejection, uneasy resignation and calm acceptance.  The person tries to maintain ties with those closest to him/her while he/she wrestles with impending extinction.

As a health professional, you must examine personal attitudes and values about life and death.  You must be committed to helping the terminally ill person live as comfortably and with as much meaning as possible until he/she dies.  Some authors feel that the elderly and the chronically or terminally ill are taking space, food, oxygen and money that could be used for technological advances to help those who are well or at least curable.

It would be easy to assume that we are helping the chronically or terminally ill and the dying person by ending their misery; putting them to sleep; with their consent, of course.  Each of us must work vigorously to prevent such an ethic from taking hold.

Do so by clearly knowing inside yourself that every person is valuable, including the dying person.  Suffering can be comforted, although a vegetative state need not be artificially prolonged.  The patient can refuse treatment.  Know clearly that unless you work to humanize care of the chronically or terminally ill person, you can predict what you will receive when you are in the situation yourself.

For selfish reasons, if not for altruistic reason, it is essential to assert your values, knowledge and skills on the side of those most vulnerable and least able to speak for themselves.  A look into yourself, and increase awareness about your values, is the first step in the right direction.3

Yet, modern methods of resuscitation that are used when lives can be saved are out of place when disease or accident has nearly ended the senior’s life.  This is especially true if resuscitation renews his/her suffering and he/she is prepared for and desirous of death.  The dying ought to be allowed to depart in peace, and after death, the body should not be immediately disturbed.  Disturbance of the dead body may have no effect on the deceased, but it robs bereaved bystanders of their peace and consolidation.

Opinions expressed in this course are those of the author.  It is recognized that there are varying opinions surrounding the topics of treating the terminally ill patient.

Next: Chapter VI  DRUG THERAPIES FOR THE ELDERLY CLIENT