Helping seniors accept dependence with hope
Eight ways to maximize patient autonomy
By Ruth Davidhizar, RN, DNS, CS, FAAN
Dean of Nursing
Ruth Shearer, RN, MN, MSN
Assistant Professor of Nursing
Bethel College, Mishawaka, IN
Loss of autonomy is a source of significant trauma and stress for many older Americans. After a lifetime of independence and productivity, the elderly often must adjust to loss of personal control over activities of daily living and cognitive function.
This loss of autonomy often is accompanied by a loss of self-esteem. The health care system is often too large, intimidating, and foreign for the average elderly client to have a complete understanding of his or her health care options. Case managers must advocate for elderly clients to maximize their autonomy at all times and at all levels of the health care system.
Personal control over decisions has a positive influence on the elderly client's physical and emotional well-being. A level of personal choice is a powerful predictor of quality of life and survival for patients who receive long-term care.
Here are eight methods case managers can use to help elderly clients cope with loss of autonomy:
1. Assess the client's current level of autonomy. A variety of assessment tools exist for assessing functional disability and cognitive impairment in the elderly.
Case managers should assess the client's ability to perform activities of daily living and skills such as handling money and shopping. They also should conduct a physical assessment. (For a comprehensive list of geriatric assessment tools, see Case Management Advisor, March 1998, p. 53.)
Assessment of the elderly requires special skills, including the ability to listen, allow for pauses, observe minute details, obtain data from all available sources, and recognize changes due to the normal aging process.
Evaluate deficit areas realistically
Many times, an exact assessment of cognitive impairment is difficult because the elderly often develop coping mechanisms to overcome certain deficits. In addition, mental and physical capacity tend to vary and fluctuate over time and in different settings.
Determining the client's level of functioning helps case managers develop an individualized treatment plan that maximizes their clients' remaining abilities. Understanding areas of deficit helps case managers form realistic expectations and reduce frustration among elderly clients.
2. Assess the client's reaction to loss of autonomy. Case managers also should assess their elderly clients for situational losses. A client who recently has experienced multiple losses may be reacting more to the losses in his or her environment than to losses of physical and cognitive functioning.
Feelings of loneliness, grief, isolation, and depression may occur in response to situational losses and contribute to feelings of loss of autonomy. For example, a loss of physical mobility that forces an elderly woman to stop working in her garden may cause a grief reaction and even depression, if her garden was once a source of great pride.
Case managers must include psychological care for elderly clients, if necessary. Therapeutic intervention including counseling and medication may be necessary to help clients cope with situational losses.
3. Assess the client for possible suicide risk. An elderly client who is experiencing a loss of autonomy is at high risk for depression and suicide. At any given time, from 10% to 65% of all elderly Americans are evaluated as depressed. In addition, the severity of depression is often higher in the elderly than in other populations.
Case managers should observe elderly clients closely for clues of suicidal thoughts and intent. Listen for telling statements, such as the following:
· "I don't have any reason left to live."
· "It would be better for my children if I were dead."
A suicidal client needs close observation, careful protection, and prompt therapy. If an elderly client is depressed, the depression should be treated. Depression should not be considered an inevitable part of the aging process.
Case managers also should evaluate the client's medication. Many drugs - including antihypertensives, cardiac medications, and hormones - can cause depression.
4. Facilitate discussion about loss of autonomy. Encourage your clients to express feelings about their loss of autonomy. Some examples of statements that case managers can use to facilitate discussion about loss include:
· "It must be hard for you to not be as independent as you were. How do you feel about having to use a walker?"
· "I imagine that with all the things you are used to doing, not being able to get out of bed by yourself is a difficult adjustment for you."
· "It must be a difficult adjustment not to be able to drive anymore."
An emotional reaction to loss is normal and should not be denied. In normal grief, an individual immediately evaluates the meaning of the loss and experiences shock followed by sadness.
Talking about loss often helps the elderly client accept feelings of loss. Case managers must assist their elderly clients to realistically evaluate the cause of altered performance and the potential for improvement. Specific strategies to improve performance may be possible. Case managers also should encourage their clients to discuss changes and concerns with family members and assist clients in negotiating with their families for necessary help.
5. Use positive reminiscing to promote a positive outlook. Memories can promote ego and hope in the elderly. Sharing pleasant memories of the past helps the elderly recapture previous strengths and feelings of self-worth. Memories also can help put recent changes in better perspective.
Appreciation of past accomplishments by family members and significant others can be supportive for your elderly client. Examples of such positive memories include:
· "Dad, I appreciate all the times you took me fishing when I was young. I have such good memories about those times we spent together."
· "Dad, I remember when you helped coach my Little League team. I was so proud to have my dad as one of my coaches."
· "Mom, I'll never forget the great holiday meals we had at our house. It was so special to have all our aunts, uncles, and cousins with us on the holidays."
Case managers should suggest that family members help surround the elderly with mementos that recall past accomplishments. For example, pictures of happy family outings and awards received for successes in sports, clubs, or careers help promote positive reminiscing.
6. Treat the client as an individual. Case managers must treat elderly clients as individuals in order to promote a sense of personal autonomy and respect in spite of limitations. Calling clients by name and talking about their family members by name not only helps orient clients but also shows them you are personally involved in their well-being.
7. Discuss the future with hope. Death of spouses or friends and recognition of declining function make the elderly aware of their own approaching death. Case managers should encourage elderly clients to look forward to upcoming events to help them find meaning in the present and hope for the future. Examples of events that may give elderly clients causes for hope include:
· a child's marriage;
· a grandchild's graduation;
· a special anniversary;
· the birth of a grandchild or great-grandchild;
· an upcoming visit from a family member.
8. Give control over decision-making whenever possible. Functionally independent elderly clients have the right to choose to access or forgo health care and social services. Case managers should give elderly clients the right to choose whether or not to use available services. Always treat the elderly as partners in their own health care selection and encourage them to use services that seem appropriate without coercing them.
Don't exclude clients from decisions
Case managers must carefully present the pros and cons of each available service. Excluding the elderly from decisions about important lifestyle changes has been related to hastening death and decreasing quality of life. When big decisions are too difficult, case managers should encourage the elderly to become involved in making smaller ones. Some examples of those decisions include:
· "Would you like me to invite your family to visit you this Sunday?"
· "Would you like to have the home health nurse help you out of bed in the morning?"
If elderly clients no longer are able to assume control for themselves, case managers may be able to shift to a model of shared control. In a shared control model, the case manager and the client mutually identify problems, goals, needed actions for goal attainment, and expected outcomes. This type of interaction model contributes to feelings of satisfaction in individuals unable to provide total care for themselves.
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