Comprehensive Clinical Psychology [Volume 7]

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Comprehensive Clinical Psychology

Comprehensive Clinical Psychology. Volume 7 Copyright © 2000 Elsevier Science Ltd. All rights reserved. Editors-in-Chief: Alan S. Bellack and Michel Hersen Table of Contents Volume 7: Clinical Geropsychology Close Preface Contributors 7.01 Physiological Aspects of Aging: Relation to Identity and Clinical Implications, Pages 1-24, Susan K. Whitbourne SummaryPlus | Chapter | PDF (382 K) 7.02 Cognition and Geropsychological Assessment, Pages 25-53, Boo Johansson ÅKe Wahlin SummaryPlus | Chapter | PDF (410 K) 7.03 Social Relationships and Adaptation in Late Life, Pages 55-72, Frieder R. Lang Carstensen Laura L. SummaryPlus | Chapter | PDF (319 K) 7.04 Sexuality, Pages 73-93, Susanne Zank SummaryPlus | Chapter | PDF (371 K) 7.05 Bereavement, Pages 95-112, Dale A. Lund SummaryPlus | Chapter | PDF (322 K) 7.06 Understanding Decisional Capacity of Older Adults, Pages 113-131, Lori Frank Michael Smyer SummaryPlus | Chapter | PDF (343 K) 7.07 Neuropsychological Assessment of the Elderly, Pages 133-169, John R. Crawford and Annalena Venneri Ronan E. O'Carroll SummaryPlus | Chapter | PDF (477 K) 7.08 Anxiety Disorders, Pages 171-191, Melinda A. Stanley J. Gayle Beck SummaryPlus | Chapter | PDF (362 K) 7.09 Mood Disorders in Late Life, Pages 193-229, Amy Fiske, Julia E. Kasl-Godley and Margaret Gatz SummaryPlus | Chapter | PDF (470 K)

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7.10 Cognitive Development in Alzheimer's Disease: Charting the Decline Process, Pages 231-245, Brent J. Small Agenta Herlitz Lars Bäckman SummaryPlus | Chapter | PDF (262 K) 7.11 Suicidal Behavior in Late Life, Pages 247-266, Jane L. Pearson SummaryPlus | Chapter | PDF (358 K) 7.12 Personality Disorders, Pages 267-289, Daniel L. Segal and Frederick L. Coolidge SummaryPlus | Chapter | PDF (373 K) 7.13 Schizophrenia and Related Conditions in Late Life, Pages 291-305, Philip D. Harvey SummaryPlus | Chapter | PDF (263 K) 7.14 Sleep Disorders, Pages 307-326, Sonia Ancoli-Israel, Ruth Pat-Horencyzk and Jennifer Martin SummaryPlus | Chapter | PDF (319 K) 7.15 Aging with Intellectual Disabilities and Later-life Family Caregiving, Pages 327-347, Tamar Heller SummaryPlus | Chapter | PDF (361 K) 7.16 Falls Among Older Adults, Pages 349-369, Barry A. Edelstein and Lisa W. Drozdick SummaryPlus | Chapter | PDF (365 K) 7.17 Wandering, Pages 371-412, Donna L. Algase SummaryPlus | Chapter | PDF (495 K) 7.18 Agitated and Aggressive Behavior, Pages 413-431, Jane E. Fisher, Diane N. Swingen and Colleen M. Harsin SummaryPlus | Chapter | PDF (316 K) 7.19 Incontinence, Pages 433-454, John F. Schnelle SummaryPlus | Chapter | PDF (359 K) 7.20 Community Mental Health Services in the United States and the United Kingdom: A Comparative Systems Approach, Pages 455-475, Bob G. Knight and Brian Kaskie Bob Woods Emily Phibbs SummaryPlus | Chapter | PDF (360 K) 7.21 Nursing Home Care and Interventions, Pages 477-497, Jacob Lomranz and Liora Bartur SummaryPlus | Chapter | PDF (361 K) 7.22 Family Caregiving: Research Findings and Clinical Implications, Pages 499-523, Steven H. Zarit, Adam Davey, Anne B. Edwards, Elia E. Femia and Shannon E. Jarrott SummaryPlus | Chapter | PDF (366 K)

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7.23 Rehabilitation in Old Age: Psychosocial Issues, Pages 525-550, Clemens TeschRömer Hans-Werner Wahl SummaryPlus | Chapter | PDF (409 K) 7.24 Interdisciplinary Health Care Teams in Geriatrics: An International Model, Pages 551-570, Antonette M. Zeiss Ann M. Steffen SummaryPlus | Chapter | PDF (339 K)

Preface Volume 7 In 1900 the average life expectancy in the USA was 49 years. There was relatively little need at that time for a psychology of aging, much less a clinical psychology of aging. That situation has dramatically changed over the past century and will continue to do so for many years. Today, adults 65 years of age and older comprise approximately 12.7% of the US population. In 1994 there were 33.2 million individuals in this age group and this number is expected to increase to 35.3 million by the year 2000 (Association for the Advancement of Retired Persons [AARP], 1995). Though the growth in number of older adults is expected to slow somewhat during the 1990s due to the decrease in births during the Great Depression of the 1930s, a rapid increase is expected as baby boomers reach the age of 65. According to estimates by the AARP (1995), there will be approximately twice as many older adults in 2030 as there were in 1990, representing approximately 20% of the total population. With increasing age comes increased risks of physical health problems. In 1993, 8% of the US population under the age of 65 years rated their health as fair or poor, in contrast to 28% of adults 65 years and older. Approximately 80% of older adults suffer from at least one chronic health problem (Knight, Santos, Teri, & Lawton, 1995), with arthritis, hypertension, and heart disease being among the most prevalent (AARP, 1995). Mental health problems continue to be experienced as we age. Older adults suffer from the same psychological problems as younger adults, although the prevalence of the various disorders varies somewhat across the lifespan. Gatz, Kasl-Godley, and Karel (1996) have estimated that approximately 23% of adults 65 years of age and older meet diagnostic criteria for some mental disorder. The authors note that this proportion is approximately the same for younger adults (National Advisory Mental Health Council, 1993) and individuals under the age of 18 (Kazdin & Kagan, 1994). Many older adults are also potentially more vulnerable than younger adults to develop psychological problems resulting from factors associated with increasing age, such as retirement, loss of friends and family members, diminishing cognitive skills, and changes in living situations. The psychological and physical health problems of older adults have significant implications beyond the individuals experiencing the problems, as their caregivers often experience significant mental health problems arising from the stress of caregiving (Stone, Cafferata, & Sangl, 1987; see also Chapters 15 and 22, this volume). Knight, Santos, Teri, and Lawton (1995) have identified several factors that collectively reveal the urgency and importance of addressing the mental health needs of older adults. "These include the file:///D|/1/CCP/07/00.htm (3 of 15)17.10.06 11:00:33

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numbers of elderly adults involved, the growing proportion of individuals and families affected the emotional, functional, and social disabilities related to these problems, and their overwhelming impact on our social service and health care delivery systems" (p. 2). Clinical psychologists have met the challenge presented by older adults through the years, often without the benefit of specialized knowledge and skills. Ample evidence of these contributions are well documented at least back to the early 1900s (see Knight, Kelly, & Gatz, 1992, for a historical account). In more recent years the relatively new field of clinical geropsychology has emerged, with the clear understanding that to be most effective in dealing with the mental health problems of older adults, one must have "special knowledge of the aging process and the unique characteristics and situations of older adults," coupled with "additional training, the degree of which will depend on the types of clinical issues with which the practitioner will be dealing" (Niederehe, 1995, p. 3). By 1981 the training of psychologists to work with older adults was viewed as sufficiently important and pressing to warrant a training conference in Boulder, Colorado devoted to the topic (known as the Older Boulder Conference). A second training conference, co-sponsored by the National Institute of Mental Health and the American Psychological Association and chaired by Linda Teri, was held in 1992 and entitled "The 1992 National Conference on Clinical Training in Psychology: Improving Psychological Services for Older Adults." 1993 saw the initiation of a Section on Clinical Geropsychology within the Clinical Division (12) of the American Psychological Association. Most recently, in 1997, the new section and Division 20 submitted an application to the American Psychological Association for the recognition of clinical geropsychology as a proficiency within clinical psychology. Clinical geropsychology has come to be defined as "the growing area of practice that applies the knowledge and techniques of clinical psychology to help older persons and their families maintain well-being, overcome problems, and achieve maximum potential during later life" (Petition for the Recognition of a Proficiency in Psychology, 1997, p. 1). The field of clinical geropsychology continues to evolve as more researchers and clinicians begin to address the mental health needs of our increasing older adult population. The Current Volume The principal goal of this volume was to assemble the contributions of a group of international experts whose work has focused on the psychology of aging and the field of clinical geropsychology. The chapters in this volume survey many of the significant contributions to our knowledge of the mental health problems of older adults, their clinical assessment, and the empirical support for our clinical interventions. Chapter 1 is a very thoughtful consideration of the many physiological changes that occur with aging. In this chapter Whitbourne emphasizes the importance of considering a variety of psychological disorders (e.g., depression, anxiety) in light of the changes occurring within the body as one ages. Moreover, she emphasizes the distinction between chronic diseases often associated with aging and normal age-related changes in the body. A person's identity, sense of self over time, is discussed with the aging process conceptualized as a constant challenge to the maintenance of a stable identity. Whitbourne then introduces a multiple threshold model of aging that comprises physical changes to

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identity, coping processes, adaptational outcomes, and age-related control behaviors. Whitbourne ends with a discussion of changes in the major systems of the body and the clinical implications of changes in each. In Chapter 2, Johansson and Wahlin offer the reader an understanding of age-related changes in memory and cognition, two extremely important domains of functioning that are often assessed by clinical geropsychologists. Aging is conceptualized as an interaction between biological, psychological, and social processes. The authors take an idiographic approach, emphasizing the patterns of aging that are unique to each individual. Learning, memory, and intellectual functioning are discussed, followed by a consideration of how older adults cope with cognitive change. Finally, the authors address the transition from the basic research laboratory to the "real world," followed by a brief discussion of what is known about cognition in everyday life. Overall, the authors do a stunning job of reviewing relevant research with an eye to bridging the more basic experimental literature and the questions that might be faced by the clinical geropsychologist. In Chapter 3, Lang and Carstensen address the role of social relationships in late-life adaptation. Normative changes in the characteristics of social relationships and social networks across adulthood are discussed with a focus on friendships and family relationships. The authors review the healthrelated functions of social relationships, including the negative outcomes of negative social interactions. Finally, the findings regarding social relationships, age, and health are considered in light of recent theoretical perspectives on adaptive social behaviors. Zank explores issues of older adult sexuality in Chapter 4, beginning with an enlightening discussion of the previous reviews of sexual behavior among older adults. The results of various epidemiological studies of sexual behavior are discussed followed by a very thoughtful critique addressing methodological and theoretical problems. Zank then reviews the physiological changes related to sexual functioning that are associated with aging in females and males. Age-related diseases and psychological disorders that can affect sexual functioning are also addressed. Finally, Zank reviews the literature on the treatment of sexual disorders. In Chapter 5, Lund examines the complexities of the bereavement process, beginning with a discussion of bereavement experiences, with particular emphasis on bereavement in later life. He emphasizes the multidimensional context of bereavement, which can impact family life, social interactions, life satisfaction, and even the financial stability of the bereaved. Theories and models of bereavement are briefly discussed, ranging from psychoanalytic to stress, appraisal, and coping theories. Of particular importance is the discussion of predictors of bereavement adjustment in which the author, dispelling the myth that time heals the wound of grief, addresses the importance of active coping. This chapter ends with a review of promising methods for working with the bereaved. In Chapter 6, Frank and Smyer explore psychological and legal issues associated with the decisional capacity of older adults. The doctrine of informed consent is briefly reviewed, followed by a discussion of issues surrounding competence to provide informed consent and its psychological assessment. A particularly important element of this chapter is the contrasting of forensic and cognitive psychological views of competence. Advance directives are discussed in light of the Patient Self-determination Act, which has reinforced older adults' rights to self-determination and

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substantially influenced the relationship between caregivers and those for whom care is being provided. This chapter is the most thorough and thoughtful presentation of issues surrounding decision-making capacity to date. In Chapter 7, Crawford, Venneri, and O'Carroll offer an unusually thorough consideration of the many issues associated with the neuropsychological assessment of older adults. For many clinical geropsychologists, neuropsychological assessment represents the most substantial element of their practices. For others, it is an essential first step in the broader assessment of individuals whose problems range from depression to difficulties accomplishing activities of daily living. The authors of this chapter begin by noting the changes in neuropsychological assessment over the past two decades from a focus on differential diagnosis and lesion localization to the identification of cognitive and behavioral consequences of cerebral dysfunction. The authors go on to a consideration of specific assessment issues, the neuropsychological interview, and basic psychometric issues. This latter consideration is particularly important in light of the potential consequences of neuropsychological assessment, which can range from rehabilitation recommendations to legal determinations ranging from competence to the settlement of civil disputes. From the perspective of the average clinical geropsychologist, the section on screening tests for mental status is particularly important, as this is a key ingredient in the assessment of older adults by non-neuropsychologists. Finally, very specific recommendations are made regarding the interpretation of various psychological tests and their use in differential diagnosis. In Chapter 8, Stanley and Beck explore the relatively under-researched area of anxiety disorders among older adults. Anxiety disorders are the most prevalent of the many psychiatric disorders among older adults, even more prevalent than clinical depression, which is often mistakenly thought to be particularly prevalent among older adults. The authors appropriately qualify their discussion by noting the lack of well-established measures of anxiety for older adults and the limitations of studies due to the failure to use strict diagnostic criteria. The prevalence of anxiety disorders among older adults, their onset and associated risk factors are initially discussed, with particular attention to gender and ethnicity. The psychopathology of anxiety disorders and their differential diagnosis follows, with appropriate attention to problems of many older adults that complicate the diagnostic picture (e.g., medical problems, sleep disturbances, depression, and cognitive impairment). The paucity of support for measures of anxiety and the attendant psychometric limitations of most measures is well documented. Finally, the authors discuss the general issue of older adults' utilization of mental health services followed by a discussion of pharmacological and psychosocial interventions. The authors end with an appeal for more research addressing the durability of treatment response. In Chapter 9, Gatz, Fiske, and Kasl-Godley provide an overview of mood disorders in late life. The authors initially address diagnostic issues with particular attention to the adequacy of our current diagnostic system for the affective disorders of older adults. Prevalence rates are then discussed with appropriate caveats regarding the definitional problems that cloud our understanding of the prevalence and etiology of affective disorders. Different diagnostic classification systems are discussed as an illustration of this problem. One of the more interesting and important topics addressed is the difference in symptom presentation between younger and older adults. The authors provide an excellent review of factors associated with depression among older adults. They have also done a marvelous job of addressing the assessment of affective disorders with careful attention to the file:///D|/1/CCP/07/00.htm (6 of 15)17.10.06 11:00:33

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psychometric properties of current measurement instruments. Finally, the course, treatment, and prevention of depression are addressed. Small, Herlitz, and B•man examine dementia in Chapter 10, with particular emphasis on Alzheimer's disease, its development and cognitive course. The authors begin with an interesting discussion of preclinical cognitive markers of dementia, proceeding through the detection of dementia, its staging, and the progression of decline in cognitive functioning. The authors make a compelling case for the predictability of changes accompanying dementia, specifically addressing predictors of dementiarelated differences and changes. Pearson provides an exceptionally thorough review of the literature on suicide among older adults in Chapter 11. This is a particularly important topic for clinical geropsychologists, as the suicide rate among older adults, particularly those aged 85 years and older, surpasses that of all other age groups. Pearson begins with the epidemiology of suicidal behavior in late life and then examines the correlates of suicide completions among older adults. She also reviews studies of suicide attempters, followed by an exploration of older adult subgroups who are at increased risk for suicide. Pearson then addresses some of the more difficult bioethical issues associated with suicide, including physician-assisted suicide, competency assessment of depressed older adults, and the need for bioethical research. This section of the chapter is particularly timely in light of the increasing publicity and public concern regarding passive and active euthanasia, advance directives, and physician-assisted suicide. Finally, she explores a variety of clinical resources for the suicidal older adult, followed by a brief discussion of psychotherapeutic approaches for suicidal older adults. Segal and Coolidge explore the literature on personality disorders among older adults in Chapter 12. The authors very thoughtfully place their initial discussion of personality disorders in the historical context of personality disorders as they evolved through the various versions of the Diagnostic and statistical manual of mental disorders (DSM). Interestingly, the DSM-IV was the first of these to specifically consider the developmental issues of aging with regard to personality disorders. The authors briefly present various theories regarding the etiologies of personality disorders and the relevance of these theories for older adults. Segal and Coolidge have worked at a considerable disadvantage in preparing this chapter in light of the paucity of literature on personality disorders among older adults, and the inconsistencies of epidemiological information regarding incidence and prevalence. The more prominent personality assessment measures are discussed followed by discussions of their applications to older adults. Finally, the treatment of personality disorders is addressed, again with the disadvantage of the lack of relevant literature for older adults. Overall, the authors have done a noteworthy job of addressing this topic in spite of the paucity of literature and theoretical considerations of this age group. Schizophrenia, which was once thought to be a disorder arising only among younger adults, is competently discussed by Harvey in Chapter 13. The author approaches the diagnosis of schizophrenia and related conditions in late life with the goals of informing the reader regarding the impact of these disorders on older adults, and encouraging the development of new treatments specifically targeting older adults. He does a particularly good job of explaining the differences between individuals with early- and late-onset schizophrenia. Harvey offers an in-depth discussion of cognitive functioning in late-life schizophrenia and the resulting impairment in adaptive behavior. Finally, he notes the lack of any specialized literature on the treatment of late-life schizophrenia, file:///D|/1/CCP/07/00.htm (7 of 15)17.10.06 11:00:33

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noting that we have no evidence that our current therapeutic practices would be ineffective with lateonset schizophrenia. In Chapter 14, Ancoli-Israel, Martin, and Pat-Horencyzk discuss sleep and its disorders among older adults. Older adults spend more time in bed than younger individuals but sleep less. Moreover, they are more easily aroused from sleep and experience decreases in slow wave sleep. The authors address these points and review what constitutes sleep, how it is measured, the major theories of sleep, and then the changes that occur in sleep as one ages. Sleep disorders (e.g., sleep-disordered breathing, periodic limb movements in sleep, and insomnia) are reviewed in considerable depth, followed by a discussion of dementia and sleep. For each of the disorders, the authors describe prevalence, symptoms, evaluation, and treatment of the disorder. This is not only a useful guide for clinicians, but also a very thorough and up-to-date review of the state of our knowledge regarding the assessment and treatment of sleep disorders among older adults. Finally, the authors dispel two common myths of sleep among older adults, noting that aging does not cause sleep problems and older adults do not need less sleep than younger individuals. In Chapter 15, Heller addresses the very complication issue of later life caregiving for intellectually disabled individuals. Many of us do not stop to think that intellectually disabled individuals require care throughout their lifespan and the families of these individuals are the caregivers for almost 80% of these individuals. Heller examines caregiving of intellectually disabled individuals from a lifecourse perspective that takes into account social trends and changes in service patterns. As the number of older adults with intellectual disabilities increases, so do the demands on the social system in general and their caregivers in particular. Heller addresses the reasons for increased life expectancy of intellectually disabled individuals, age- related changes, and trends in services and supports. She also reviews theories of family caregiving over the lifespan and discusses the empirical support for these theories. The roles of mothers, fathers, and siblings are addressed along with the need for future planning and possible placement of the intellectually disabled individuals who have or will lose their caregivers to poor health, death, or other factors that preclude continued care. Heller ends with several excellent recommendations for future research. Edelstein and Drozdick address falls among older adults in Chapter 16, initially noting that a significant percentage of older adults fall each day, with approximately 50% of long-term residents falling every year. The authors begin with a discussion of the conceptual and methodological issues that have plagued this area of research, followed by a discussion of the physical, psychological, and economic consequences of falls. Internal and external risk factors for falls are discussed in depth, with particular attention to the variability in findings across studies. Finally, the authors describe approaches to the prevention of falls, including medical, rehabilitative, and environmental strategies. The authors end on an optimistic note, indicating that numerous risk factors have been identified that can be changed through a variety of interventions. In Chapter 17, Algase offers an extraordinarily comprehensive review of the literature on wandering among older adults, a very significant problem for cognitively-impaired individuals and their caregivers. The author begins with a discussion of various conceptual schemes and typologies of wandering, noting that few empirical descriptions or characterizations exist. Epidemiological data are presented, including potential contributors to and consequences of wandering behavior. Perhaps the

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most interesting element of this chapter is the very thoughtful discussion of etiologic theories and factors, culminating in a multifactorial explanation for wandering. Extraordinarily detailed reviews and discussions of assessment methods, assessment instruments, and interventions fill the remainder of the chapter. Algase ends with an extensive set of important research questions. Chapter 18 is a very thorough review of the assessment and treatment of agitated and aggressive behavior among older adults. Fisher, Swingen, and Harsin address the rather frequent and quite significant problems among cognitively impaired older adults. These behaviors increase the likelihood of one being institutionalized and experiencing physical and/or pharmacological restraint. They are the bane of psychologists consulting in long-term care facilities and the source of considerable suffering among caregivers. The authors initially address definitional issues, prevalence, and etiological factors associated with aggressive and agitated behavior. Assessment of these behaviors is thoughtfully considered, including discussions of the psychometric properties of various assessment instruments. Finally, a broad array of interventions are critically evaluated. This chapter is an excellent critical review of the literature and an excellent resource for the practicing clinical geropsychologist. In Chapter 19, Schnelle offers an exceptionally thorough treatment of incontinence among older adults, a problem that affects 30% of individuals over the age of 60 years and over 50% of residents of nursing facilities. The author also discusses how and why psychologists should be involved in the management of incontinence among older adults. Schnelle begins with an overview of the prevalence, morbidity, and consequences of incontinence. This is followed by in-depth discussions of the various types of urinary incontinence, the assessment of incontinence, and treatment options. Interventions include the use of drugs, surgery, and a variety of behavioral interventions. Of substantial utility is a very thoughtful and thorough discussion of how to implement an incontinence management program in a nursing home, including methods of assessment, determination of candidates for various interventions, and staff management issues that can influence the effectiveness of continence programs. Finally, future directions are addressed with respect to both communitydwelling and nursing home populations. Knight, Kaskie, Woods, and Phibbs offer an interesting and unique comparison between US and UK systems of mental health for older adults in Chapter 20. The authors highlight the similarities and differences in community mental health services for older adults and explore the development of these systems. The authors initially explore the many systems in which older adults with mental health problems are embedded and explain how such systems are confusing and characterized by numerous gaps in service because of the conditions under which each of the services developed. A broad array of community-based services are described, beginning with long-term institutional psychiatric care. Community-based care in the UK and USA are described and contrasted. Finally, the histories of development of clinical geropsychology in the UK and USA are contrasted, ending with an appeal to training programs to rethink their training goals for the twenty-first century. In Chapter 21, Lomranz and Bar-Tur address the topic of mental health care in the nursing home. The authors describe the effects of institutionalization and the mental health of residents in light of their transition and adaptation to a nursing home. Mental disorders common among nursing home residents are discussed, followed by a discussion of a proposed model of clinical geropsychological services. The model proposed, which is quite impressive for its innovativeness and file:///D|/1/CCP/07/00.htm (9 of 15)17.10.06 11:00:33

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comprehensiveness, is currently operative in Israel. In Chapter 22, Zarit, Davey, Edwards, Femia, and Jarrott inform us that families are caring for disabled older adults more often and for longer periods of time than ever before. It is clear from their presentation that we must be as concerned about the mental health and well-being of the caregivers as we have been with the recipient of the care. These authors review the research findings on family caregiving and discuss the clinical implications. They begin with a very lucid presentation of several basic issues in family caregiving, followed by a presentation of the various stages of caregiving or careers assumed by caregivers as those under their care progressively change. What follows are discussions of a variety of caregiving topics including caregiving stress, the family context of caregiving, the perspective of the care recipient, normative family relationships in later life, health and mental health outcomes of caregiving, current clinical research and services, and the consequences of institutionalization. In Chapter 23, Tesch-R r and Wahl provide a very broad and comprehensive survey of the rehabilitation of older adults with particular attention to the psychosocial issues involved. The authors discuss issues of assessment, restoration of functional independence, and a variety of strategies for accomplishing this. Motivation and compliance are addressed as key factors in the success of any rehabilitation program. Rehabilitation of specific client groups (e.g., stroke patients, arthritis patients, sensory im paired patients) is discussed from a multidisciplinary perspective. Finally, the authors address various practical issues and ethical problems associated with rehabilitation efforts. This chapter is an excellent overview of the many problem areas in which geropsychological knowledge and skills can play significant roles in the rehabilitation of older adults. In the last chapter Zeiss and Steffen advocate an interdisciplinary health care team approach to the assessment and treatment of older adults residing in medical facilities. The authors build a strong case for the use of such teams, with much of their rationale based upon two characteristics of geriatric patients: their problems are complex and chronic. The heterogeneity of capacities and problems of older adults argue for interdisciplinary teams, which the authors distinguish from unidisciplinary, intradisciplinary, and multidisciplinary teams. Because the interdisciplinary team as a whole takes responsibility for team effectiveness and function, it functions quite differently from teams that are hierarchically organized. Advantages and disadvantages of such teams are considered, followed by a discussion of the natural history of team development. In closing I would like to take this opportunity to thank George Niederehe for his many thoughtful suggestions for chapter topics and potential authors. Margy Gatz was also very helpful with this project, particularly through her suggestions for international authors. Finally, I wish to thank Angela Greenwell at Elsevier, who consistently provided answers to all of my often odd questions and who repeatedly offered assistance in motivating chapter authors. References Association for the Advancement of Retired Persons (1995). A profile of older Americans. Washington, DC: Author. Gatz, M., Kasl-Godley, J. E., & Karel, M. J. (1996). Aging and mental disorders. In J. E. Birren & K. file:///D|/1/CCP/07/00.htm (10 of 15)17.10.06 11:00:33

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W. Schaie (Eds.), Handbook of the psychology of aging (4th ed., pp. 365¯382). New York: Academic Press. Kazdin, A. E., & Kagan, J. (1994). Models of dysfunction in developmental psychopathology. Clinical Psychology: Science and Practice, 1, 35¯52. Knight, B. G., Santos, J., Teri, L., & Lawton, M. P. (1995). The development of training in clinical geropsychology. In B. G. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults (pp. 1¯8). Washington, DC: American Psychological Association. Knight, B., Kelly, M., & Gatz, M. (1992). Psychotherapy with the elderly. In D. K. Freedheim (Ed.), The history of psychotherapy. Washington, DC: American Psychological Association. National Advisory Mental Council (1993). Health care reform for Americans with severe mental illnesses. Report of the National Advisory Mental Health Council. American Journal of Psychiatry, 150, 1447¯1465. Niederehe, G. (1995). Progress and prospects in clinical geropsychology. The Clinical Psychologist, 48, 3¯4. Petition for the Recognition of a Proficiency in Psychology (1997). Unpublished manuscript. Stone, R., Cafferata, G. L., & Sangl, J. (1987). Caregivers of the frail elderly: A national profile. The Gerontologist, 27, 616¯626.

Volume 7 Contributors ALGASE, D. L. (University of Michigan, Ann Arbor, MI, USA) Wandering ANCOLI-ISRAEL, S. (University of California and Veterans Affairs Medical Center, San Diego, CA, USA) *Sleep Disorders B•KMAN, L. (Stockholm Gerontology Research Center, Sweden and G borg University, Sweden) *Cognitive Development in Alzheimer’s Disease: Charting the Decline Process BAR-TUR, L. (The Herczeg Institute on Aging, Tel Aviv University, Israel) *Nursing Home Care and Interventions BECK, J. G. (State University of New York at Buffalo, NY, USA) *Anxiety Disorders CARSTENSEN, L. L. (Stanford University, CA, USA) *Social Relationships and Adaptation in Late Life COOLIDGE, F. L. (University of Colorado, Colorado Springs, CO, USA) *Personality Disorders

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CRAWFORD, J. R. (University of Aberdeen, UK) *Neuropsychological Assessment of the Elderly DAVEY, A. (Pennsylvania State University, University Park, PA, USA) *Family Caregiving: Research Findings and Clinical Implications DROZDICK, L. W. (West Virginia University, Morgantown, WV, USA) *Falls Among Older Adults EDELSTEIN, B. A. (West Virginia University, Morgantown, WV, USA) *Falls Among Older Adults EDWARDS, A. B. (Pennsylvania State University, University Park, PA, USA) *Family Caregiving: Research Findings and Clinical Implications FEMIA, E. E. (Pennsylvania State University, University Park, PA, USA) *Family Caregiving: Research Findings and Clinical Implications FISHER, J. E. (University of Nevada at Reno, NV, USA) *Agitated and Aggressive Behavior FISKE, A. (University of Southern California, Los Angeles, CA, USA) *Mood Disorders in Late Life FRANK, L. (MEDTAP International, Bethesda, MD, USA) *Understanding Decisional Capacity of Older Adults GATZ, M. (University of Southern California, Los Angeles, CA, USA) *Mood Disorders in Late Life HARSIN, C. M. (University of Nevada at Reno, NV, USA) *Agitated and Aggressive Behavior HARVEY, P. D. (Mount Sinai School of Medicine, New York, NY, USA) Schizophrenia and Related Conditions in Late Life HELLER, T. (University of Illinois at Chicago, IL, USA) Aging with Intellectual Disabilities and Later-life Family Caregiving HERLITZ, A. (Stockholm Gerontology Research Center, Sweden and Stockholm University, Sweden) *Cognitive Development in Alzheimer’s Disease: Charting the Decline Process JARROT, S. E. (Pennsylvania State University, University Park, PA, USA) file:///D|/1/CCP/07/00.htm (12 of 15)17.10.06 11:00:34

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*Family Caregiving: Research Findings and Clinical Implications JOHANSSON, B. (Institute of Gerontology and Centre for Psychology, University College of Health Sciences, J••ng, Sweden) *Cognition and Geropsychological Assessment KASKIE, B. (University of Southern California, Los Angeles, CA, USA) *Community Mental Health Services in the United States and the United Kingdom: A Comparative Systems Approach KASL-GODLEY, J. E. (University of Southern California, Los Angeles, CA, USA) *Mood Disorders in Late Life KNIGHT, R. G. (University of Southern California, Los Angeles, CA, USA) *Community Mental Health Services in the United States and the United Kingdom: A Comparative Systems Approach LANG, F. R. (Freie Universit•Berlin, Germany) *Social Relationships and Adaptation in Late Life LOMRANZ, J. (The Herczeg Institute on Aging, Tel Aviv University, Israel) *Nursing Home Care and Interventions LUND, D. A. (University of Utah, Salt Lake City, UT, USA) Bereavement MARTIN, J. (University of California and Veterans Affairs Medical Center, San Diego, CA, USA) *Sleep Disorders O’CARROLL, R. E. (University of Stirling, UK) *Neuropsychological Assessment of the Elderly PAT-HORENCZYK, R. (University of California and Veterans Affairs Medical Center, San Diego, CA, USA) *Sleep Disorders PEARSON, J. L. (National Institute of Mental Health, Rockville, MD, USA) Suicidal Behavior in Late Life PHIBBS, E. (University College London, UK) *Community Mental Health Services in the United States and the United Kingdom: A Comparative Systems Approach SCHNELLE, J. F. (University of California, Los Angeles, CA, USA)

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Incontinence SEGAL, D. L. (University of Colorado, Colorado Springs, CO, USA) *Personality Disorders SMALL, B. J. (Stockholm Gerontology Research Center, Sweden and Karolinska Institute, Stockholm, Sweden) *Cognitive Development in Alzheimer’s Disease: Charting the Decline Process SMYER, M. (Boston College, Chestnut Hill, MA, USA) *Understanding Decisional Capacity of Older Adults STANLEY, M. A. (University of Texas Medical School, Houston, TX, USA) *Anxiety Disorders STEFFEN, A. (University of Missouri at St. Louis, MO, USA) *Interdisciplinary Health Care Teams in Geriatrics: An International Model SWINGEN, D. N. (University of Nevada at Reno, NV, USA) *Agitated and Aggressive Behavior TESCH-R•ER, C. (Ernst Moritz Arndt University, Greifswald, Germany) *Rehabilitation in Old Age: Psychosocial Issues VENNERI, A. (University of Aberdeen, UK) *Neuropsychological Assessment of the Elderly WAHL, H.-W. (German Center for Research on Aging at the University of Heidelberg, Germany) *Rehabilitation in Old Age: Psychosocial Issues WAHLIN, • (Stockholm Gerontology Research Center and Karolinska Institute, Stockholm, Sweden) *Cognition and Geropsychological Assessment WHITBOURNE, S. K. (University of Massachusetts–Amherst, MA, USA) Physiological Aspects of Aging: Relation to Identity and Clinical Implications WOODS, R. (University of Wales, Bangor, UK) *Community Mental Health Services in the United States and the United Kingdom: A Comparative Systems Approach ZANK, S. (Freie Universit•Berlin, Germany) Sexuality

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Comprehensive Clinical Psychology

ZARIT, S. H. (Pennsylvania State University, University Park, PA, USA) *Family Caregiving: Research Findings and Clinical Implications ZEISS, A. M. (VA Palo Alto Health Care System, CA, USA) *Interdisciplinary Health Care Teams in Geriatrics: An International Model

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

7.01 Physiological Aspects of Aging: Relation to Identity and Clinical Implications SUSAN K. WHITBOURNE University of Massachusetts±Amherst, MA, USA 7.01.1 INTRODUCTION

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7.01.2 IDENTITY AND PHYSICAL CHANGES IN LATER LIFE

2 2 3 4

7.01.2.1 Identity Processes 7.01.2.2 A Multiple Threshold Model 7.01.2.3 Physical Identity and Aging 7.01.3 THE EFFECTS OF AGE ON APPEARANCE AND MOBILITY

5 5 5 5 6 6 6 6 6 7 7 7 8

7.01.3.1 Skin 7.01.3.1.1 Age changes 7.01.3.1.2 Clinical implications 7.01.3.2 Hair 7.01.3.2.1 Age changes 7.01.3.2.2 Clinical implications 7.01.3.3 Body Build 7.01.3.3.1 Age changes 7.01.3.3.2 Clinical implications 7.01.3.4 Mobility 7.01.3.4.1 Age changes 7.01.3.4.2 Clinical implications 7.01.4 THE EFFECTS OF AGE ON VITAL FUNCTIONS

9 9 9 9 10 10 11

7.01.4.1 Cardiovascular System 7.01.4.1.1 Age changes 7.01.4.1.2 Clinical implications 7.01.4.2 Respiratory System 7.01.4.2.1 Age changes 7.01.4.2.2 Clinical implications 7.01.5 THE EFFECTS OF AGE ON REGULATORY SYSTEMS

11 11 11 12 12 12 12 13 13 13

7.01.5.1 Excretory System 7.01.5.1.1 Age changes 7.01.5.1.2 Clinical implications 7.01.5.2 Digestive System 7.01.5.2.1 Age changes 7.01.5.2.2 Clinical implications 7.01.5.3 Immune System 7.01.5.3.1 Age changes 7.01.5.3.2 Clinical implications 7.01.6 AGE CHANGES IN THE REPRODUCTIVE SYSTEM AND SEXUALITY

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7.01.6.1 Female Reproductive System 7.01.6.2 Male Reproductive System

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications 7.01.6.3 Clinical Implications

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7.01.7 THE NERVOUS SYSTEM

15 15 15 15 16 16 16

7.01.7.1 Central Nervous System 7.01.7.1.1 Age changes 7.01.7.1.2 Clinical implications 7.01.7.2 Autonomic Nervous System 7.01.7.2.1 Age changes 7.01.7.2.2 Clinical implications 7.01.8 AGE CHANGES IN SENSORY FUNCTIONING

17 17 17 17 18 18 18 19 19 19

7.01.8.1 Vision 7.01.8.1.1 Age changes 7.01.8.1.2 Clinical implications 7.01.8.2 Hearing 7.01.8.2.1 Age changes 7.01.8.2.2 Clinical implications 7.01.8.3 Balance 7.01.8.3.1 Age changes 7.01.8.3.2 Clinical implications 7.01.9 CONCLUDING OBSERVATIONS

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7.01.10 REFERENCES

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7.01.1 INTRODUCTION Understanding the normal physiological changes associated with aging is of essential importance to clinical psychologists who work with the elderly. Issues related to depression, anxiety, and other psychological disorders are seen from new perspectives when interpreted in terms of the changes within the body that older clients are likely to experience. Of particular importance is the necessity of distinguishing between the processes of normal aging and alterations in functioning that are the result of specific diseases. Although it is true that older individuals are at heightened risk of developing chronic health problems such as arthritis, cardiovascular disease, cancer, and diabetes, these are diseases rather than normal agerelated changes. Clinicians should be aware that they need to persist in the treatment of an elderly client rather than assume that the symptoms of chronic disease represent inevitable losses due to aging. After reading this chapter, it should be clear that the physical changes associated with the aging process are complex, multifaceted, and multidirectional. Individuals age in their own unique ways, due to their genetic inheritance and lifestyle choices. Clinicians can be of tremendous help to an older person by being aware of expectable age-related changes that affect the aging population as a whole but also by planning interventions that take into account the individual's unique characteristics, life history, and resources. In general, with regard to physical functioning, it is beneficial to advocate the ªuse it or lose itº principle; that is, the individual maximizes functioning by maintaining maximum levels of

activity. This philosophy gives the clinician concrete tools to design treatment plans and helps to communicate a sense of optimism rather than hopelessness about aging. Furthermore, this approach often results in demonstrable gains in the older individual's daily functioning. However, the clinician is best advised to tailor the application of this principle to the client's preferences, lifestyle, and resources. It is of little help to prescribe an exercise regimen for an individual who has no access to supervised exercise facilities, has never had an interest in exercise, and who cannot afford even the proper pair of sneakers. Apart from such restrictions, however, clinicians may expect to encounter resistance of a different nature when proposing lifestyle changes to older clients. Those who have incorporated into their own identities the belief that there is in fact nothing they can do to alter their own aging will not be led by even the most effective clinician down the activity path unless this resistance can be approached and sensitively overcome. Therefore, in this chapter, a perspective incorporating the notion of identity will be discussed in regard to physical changes. With this perspective, clinicians can target interventions that take into account the ways that older individuals incorporate views about aging into their identities. 7.01.2 IDENTITY AND PHYSICAL CHANGES IN LATER LIFE 7.01.2.1 Identity Processes The construct of identity has been used in the area of adult development to refer to the individual's sense of self over time. It is

Identity and Physical Changes in Later Life conceptualized as incorporating various content areas, including physical functioning, cognition, social relationships, and experiences in the world. In this model (Whitbourne, 1986, 1996a), identity is theorized to form an organizing schema through which the individual's experiences are interpreted. The affective content of identity, for psychologically healthy adults, takes the positive self-referential form encapsulated in the expression ªI am a competent, loving, and good person;º that is, competent at work, loving in family life, and good in the sense of being morally and ethically righteous. In this model, such self-attributions are seen as contributing to the individual's emotional well-being. The developmental imperative for normal, nondepressed adults to regard themselves as having these qualities may be seen as providing a driving force in development in the adult years. The individual's experiences, both past and present, are postulated to relate to identity through processes of assimilation and accommodation. Identity assimilation is defined as the interpretation of life events relevant to the self in terms of the cognitive and affective schemas that are incorporated in identity. The events and experiences to which the assimilation function applies can include major life events, cumulative interactions with the environment over time, or minor incidents that can have a potential impact on identity. Each type of experience can have different meanings depending on the nature of the individual's current self-conceptualizations in identity. The process of identity accommodation, by contrast, involves changing identity in response to identity-relevant experiences. An event that reflects unfavorably on identity is likely to be processed first through assimilation and, only after such efforts prove unsatisfactory, will identity accommodation follow (Brandtstadter & Renner, 1990). As a general principle, it is theorized that a healthy state of emotional adaptation involves a balance or equilibrium between the two identity processes so that the individual maintains a sense of consistency over time but is able to change when there are large discrepancies between the self and experiences (Kiecolt, 1994). The aging process is a constant challenge to the maintenance of a stable sense of identity over time. Events caused by physical aging are qualitatively different from other experiences that are of a more transitory or fleeting nature. An unpleasant encounter in a chance meeting with a stranger that reflects unfavorably upon one's social identity will fade through time as it is dismissed through identity assimilation as lacking direct personal relevance. Aging, how-

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ever, is a process that does not fade with time but may in fact grow with importance as the individual must find ways to integrate agerelated changes into identity throughout adulthood.

7.01.2.2 A Multiple Threshold Model Integrating these factors into a comprehensive framework is a ªmultiple threshold modelº of aging (Whitbourne, 1996a, 1996b), that relates age changes to identity, coping processes, adaptational outcomes, and age-related control behaviors. The term ªthresholdº in this model refers to the point at which an age-related change is recognized by the individual. Before this threshold is reached, the individual does not think of the self as ªagingº or ªold,º or even perhaps as having the real potential to be ªagingº or ªold.º After crossing the threshold, the individual recognizes the possibility that functions may be lost through aging (or disease), and begins to accommodate to this possibility by changing identity accordingly. The term ªmultipleº in this model refers to the fact that the aging process involves potentially every system in the body, so that there is in actuality no single threshold leading to the view of the self as aging. The individual may feel ªoldº in one domain of functioning, such as in the area of mobility, but feel ªnot old,º ªmiddle-aged,º or possibly ªyoungº in other domains, such as in the area of sensory acuity or intellectual functioning. Whether a threshold is crossed depends in part on the actual nature of the aging process and whether it has affected a particular area of functioning. However, it is also the case that individuals vary widely in the areas of functioning that they value. Mobility may not be as important to an individual whose major source of pleasure is derived from sedentary reading activities. Changes in the area of mobility will not have as much relevance to the individual's direct adaptation to the environment or to identity as would be the case for losses in vision or memory. In the multiple threshold model, it is assumed that changes in areas important to adaptation and competence have the greatest potential for affecting identity. Not only are changes in central functions likely to have a greater impact on adaptation and identity, but it is possible to assume further that changes in these functions are watched for most carefully by the individual and early signs of age-related changes will be noticed in these areas. For example, the individual who takes great pride in a full and vibrant head of hair will be on the lookout for gray hairs and thinning,

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

and the individual who values intellectual skills will scrutinize performance on activities involving memory for signs of deterioration. The increased vigilance for areas of functioning central to identity will theoretically heighten the impact of age changes. On the other hand, with increased vigilance may come increased motivation to take advantage of control activities that reduce the impact of aging. The adult who values being in peak physical shape will work devotedly each day to avoid loss of muscle strength and aerobic capacity. Having valued these qualities, he or she will be more likely to hold onto them into old age. This situation presents a double-edged sword, in which heightened vigilance leads to behavior that offsets the aging process, thus reducing the dreaded outcomes, but also leads the individual to become acutely sensitive to signs that loss has occurred. It may be in this situation, then, that identity accommodation becomes important. The individual who recognizes that he or she is aging is less likely to become discouraged and frustrated at evidence that certain age-related changes cannot be completely reversed. The assimilative individual who desperately attempts to hang onto a youthful identity has the potential to be demolished when an event occurs that makes it abundantly clear that the aging process has taken its inevitable toll. The multiple threshold concept is most easily viewed as a set of linear processes, with the outcome of passing through a threshold an alteration in the individual's level of well-being. The process is, however, cyclical. Each time a threshold is passed, the individual's identity has the potential to be altered through identity accommodation. When this happens, the crossing of the threshold serves as an event relevant to the self that becomes integrated into identity. The resulting change in identity then alters the individual's subsequent vigilance regarding future age-related in changes in other areas of functioning and the behaviors relevant to the threshold just crossed.

7.01.2.3 Physical Identity and Aging The substantive content of identity incorporates the domains of physical, psychological, and social functioning. Within the domain of physical functioning are the attributes of appearance, competence, and health (Whitbourne & Primus, 1996). Physical identity may be regarded as one of the fundamental, yet overlooked, areas within psychological gerontology. For example, in a preliminary test of the multiple threshold model, it was found

that the aspect of physical functioning in particular that seems to trigger the crossing of a threshold with regard to aging is the recognition of loss of physical competence, an area that is generally not given a great deal of attention by clinicians (Whitbourne, 1996b). Individuals who use identity assimilation tend to deny as much as possible the importance of age-related changes in valued aspects of physical functioning. For these individuals, it might be speculated that changes in functioning that are related to age are not acknowledged as a result of the aging process, but instead are attributed to transitory states of health or health-related behaviors. This type of denial may be seen as an effort to preserve and protect the individual's sense of the self as competent and consistent over time. Those older adults who rely more or less exclusively on identity accommodation overreact to small events or experiences and draw overly broad and sweeping conclusions from one instance or situation. With regard to aging, they may conclude prematurely that they are ªover the hillº and fail to take preventative actions (Woodward & Wallston, 1987) because they adopt the self-image of being too weak or feeble to continue to maintain their participation in activities that were formerly rewarding to them (Janelli, 1993). As a result, they can become unduly depressed and hopeless (Parmalee, Katz, & Lawton, 1991). In a test of the multiple threshold model (Whitbourne, 1996b), identity accommodation was found to predict awareness of age-related physical changes. Thus, individuals who are highly responsive to their experiences and do not have a firm sense of self are more likely to be sensitive to the effects of normal aging on their bodies. Greater sensitivity to age-related changes, in turn, appears to be predictive of lower selfesteem. A balanced approach to adapting to agerelated changes in valued aspects of physical functioning involves taking precautions and attempting to preserve functions for as long as possible, and adapting to them when they occur by finding ways to compensate for losses. The individual may find a compromise between assimilation and accommodation by recognizing the reailty of aging, but not letting this knowledge interfere with daily functioning or future plans. There may be emotional costs involved in the recognition of impending losses, but individuals who maintain a balanced approach rebound from setbacks with renewed vigor and optimism (Labouvie-Vief, HakimLawson, & Hobart, 1987; Ryff, 1989). With this model as a backdrop, research on the physical aspects of aging will now be

The Effects of Age on Appearance and Mobility

5

summarized. The concepts of the multiple threshold model and the identity processes of assimilation and accommodation will be used as the basis for suggesting clinical implications. The underlying assumption is not that the aging process must or should be slowed, but that the individual's adaptation to the aging process can be maximized by working with the assimilative or accommodative functions of identity. Ultimately, the value of these interventions can be measured in terms of improved physical health and in terms of an improved or perhaps more realistic outlook on the part of the individual toward the aging process.

Age-related alterations also occur in the coloring of the skin. There are fewer melanocytes, and those that remain develop irregular areas of dark pigmentation. Under the skin surface, capillaries and small arteries become dilated, creating small irregular colored lines. Varicose veins may also form, creating an uneven surface of knotty, bluish, and cordlike irregularities. The loss of capillaries means that fair-skinned people look paler, and in general the blood vessels and bones can be seen more easily under what is a more transparent skin surface.

7.01.3 THE EFFECTS OF AGE ON APPEARANCE AND MOBILITY

7.01.3.1.2 Clinical implications

7.01.3.1 Skin 7.01.3.1.1 Age changes A variety of changes contribute to the phenomena of wrinkling and sagging, the most apparent age-related effects on the skin. The epidermis, the outer layer of the skin, becomes flattened (Kligman, Grove, & Bolin, 1985), and as cells in the epidermis are replaced through cell renewal processes, their patterns become less organized and their arrangment less regular. These changes at the microscopic level are reflected in visible changes of the geometric furrows visible on the surface of exposed areas of the skin (Lavker, Kwong, & Kligman, 1980). Wrinkling and sagging can be explained in large part by changes in the middle, dermal layer of the skin, notably a decrease in the connective tissue collagen (Kligman et al., 1985). Elastin fibers become more brittle so that the ability of the skin to conform to movement of the bones is compromised. The subcutaneous fat on the limbs decreases and instead collects in areas of fatty deposits, such as around the waist and hips. A decrease in muscle mass, as will be discussed later, further adds to the loss of firmness in the skin's appearance. There are also significant changes in the sweat and oil-producing glands within the dermis that maintain body temperature and lubricate the skin surface (Bolin & Pratt, 1989; Kurban & Bhawan, 1990). In areas such as the palms and underarms, the sweat glands become less active. The sebaceous glands that lubricate the skin with their secretions diminish in activity, and consequently the skin becomes rougher, dryer, and more vulnerable to surface damage. These changes lead to heightened risk of medical problems such as dermatitis (Grove, 1989) and pruritis (excessive itching), as well as to general discomfort (Kligman, 1989).

Age-related changes in the skin and skinrelated structures alter the skin's protective functions as well as its appearance. There is less insulation provided against extremes of temperature, and less of a barrier against environmental agents that can irritate the skin and cause dermatitis (Grove, 1989). Even if the individual is not particularly concerned about the effects of age on appearance, these changes in comfort level can trigger the crossing of an aging threshold. However, for many individuals, particularly in middle age (Whitbourne, 1996a, 1996b), age changes in the skin that lead to wrinkling are very noticeable and can have an impact on the individual's identity. In particular, comparisons of present appearance with pictures or memories of early adulthood can trigger identity accommodation in a negative way to older people who valued their youthful image (Fenske & Albers, 1990; Kleinsmith & Perricone, 1989) Having crossed this threshold in terms of appearance, there are many steps that older individuals can take to slow, compensate for, or correct the changes in appearance caused by aging of the skin. The primary method of prevention is for fair-skinned people to avoid direct exposure to the sun and to use sunblocks when exposure cannot be avoided (Gilchrest, 1989). There are also many ways for the individual to compensate for age-related changes in the skin once they have become manifest. To counteract the fragility, sensitivity, and dryness of the skin, the individual can use sunscreens, emollients, and fragrance-free cosmetics (O'Donoghue, 1991). If a client raises concerns about these aspects of appearance, interventions here, as with hair color (see below), must attempt to strike a judicious balance between intrusiveness into matters of personal taste and the concerns of preventive practice.

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

7.01.3.2 Hair 7.01.3.2.1 Age changes With increasing age in adulthood, for men and women, the hair on the head and body loses pigmentation and takes on a white appearance due to a decrease in melanin production in the hair follicles. The rate at which hair color changes varies from person to person due to variations in the timing of onset and rate of melanin production decrease across the surface of the scalp. Interestingly, although gray hair is thought to be a universal feature of aging, the degree of hair grayness is not as reliable an indicator of a person's age as is the extent to which hair on the body (axillary and pubic) has turned gray (Kenney, 1989). Gradual and general thinning of scalp hair occurs in both sexes over the years of adulthood, although loss of hair is popularly regarded as a concern of men. Hair loss results from destruction or regression of the germ centers that produce the hair follicles underneath the skin surface. However, in men with pattern baldness, the hair follicles do not actually die but change the type of hair they produce from coarse terminal hair to fine translucent vellus hair. Men may also experience thinning of the hairs in their whiskers, and a growth of coarse hair on the eyebrows and inside the ear. Patches of coarse terminal hair may develop on the face of women, particularly around the chin. 7.01.3.2.2 Clinical implications As is true for wrinkles, the threshold for agerelated changes in the hair, at least for graying, appears to be crossed at some point in the 30s or 40s (Whitbourne, 1996b). Compared to wrinkles, gray hairs are relatively easy to detect; however, unlike wrinkles, gray hairs can be returned to virtually their original state through the use of hair dye. Changes in hair thickness, however, are not so easily reversed. The desire to disguise or stop the apparent signs of aging through surgery or the wearing of hairpieces is widespread, as is evident in the many advertisements for hair loss replacement processes. There are many ways in which clinical intervention can be of use when changes in hair amount and color becomes a concern. Apart from providing information about commercial products that can be used if the individual chooses to try to combat the aging process, interventions can focus on ways the individual can learn to reframe age changes in the hair's appearance, particularly with regard to hair thinning, in a manner that allows for a balance between identity assimilation and accommodation. Since there are no practical

implications of hair loss or hair graying, interventions in this area can be entirely at the discretion of the client and clinician. Unlike cardiovascular functioning, in which denial of age-related changes can prove fatal, the denial of changes in the hair does not have severe health consequences. The only exception is when the individual is at risk of ostracism or ridicule by others due to inappropriate attempts to maintain what he or she thinks is a youthful head of hair. In these cases, the accommodation process may need to be brought to bear on the situation so that the individual can accept that patch of skin on the top of the head or can find a hair dye that does not attempt to recreate the look of a 20-year-old. Of course, these issues quickly become matters of taste and preference, and short of major concerns or problems, should ultimately be left to the individual's discretion. 7.01.3.3 Body Build 7.01.3.3.1 Age changes It is a well-established fact that over the course of adulthood there is a consistent pattern of a reduction in standing height, occurring at a greater rate after the 50s and particularly pronounced in women (Shephard, 1978). The major cause is loss of bone mineral content in the vertebrae, which leads them to collapse and cause compression in the length of the spine (Garn, 1975). Changes in the joints and flattening of the arches of the feet can further contribute to height loss (Kenney, 1989). Total body weight increases from the 20s until the mid-50s, after which total body weight declines. Most of the weight gain in middle adulthood is due to an accumulation of body fat, particularly around the waist and hips. The weight loss that occurs in the later years of adulthood is not due to a slimming of the torso but to a loss of lean body mass consisting of muscle and bone (Chien et al., 1975; Ellis, Shukla, Cohn, & Pierson, 1974). Consequently, very old adults may have very thin extremities but fatty areas in the chin, waist, and hips. Middle-aged and older women are particularly likely to experience this accumulation of body fat around the torso, with a gain of abdominal girth amounting to 25±35% across the adult years compared to 6±16% for men over a comparable time period (Shephard, 1978). However, contemporary changes in lifestyle and improved nutrition may be altering this trend, with current cohorts of older women showing a decrease rather than an increase in body fat (Rico, Revilla, Hernandez, GonzalezRiola, & Villa, 1993).

The Effects of Age on Appearance and Mobility 7.01.3.3.2 Clinical implications Changes in body fat that lead to the appearance of a sagging or heavier body shape can result in increased identification of the self as moving away from the figure of youth. The development of ªmiddle-aged spreadº is one of the first occurrences to trigger identity accommodation of the self as aging, perhaps even before the first gray hairs have sprouted. Indeed, awareness of changes in body composition can occur surprisingly early in adulthood, perhaps by the 30s (Whitbourne, 1996b). Fortunately, the crossing of the body fat threshold may be readily compensated, and before the individual gives up on trying to slow down this particular process, there are many activities that the clinician can promote if this is an area of concern for the individual. It is well established that participation in active sports and exercise activity can offset the deleterious effects of aging on body fat accumulation. For instance, endurance athletes do not gain weight and they maintain their muscular physiques throughout adulthood for as long as they continue to train (Suominen, Heikkinen, Parkatti, Forsberg, & Kiiskinen, 1977). Participation in exercise training programs can even be of value for middle-aged and elderly adults who were sedentary throughout their lives. By engaging in vigorous walking, jogging, or cycling for 30±60 minutes a day for 3±4 days a week, the sedentary adult can expect to achieve positive results in a period as short as 10±20 weeks (Whitbourne, 1996a). Furthermore, the same activities that a middle-aged person might engage in to combat body fat changes can also have very positive cardiovascular and general health benefits. Thus, vanity might actually serve a protective function in this area. Changes in body height are less easily compensated, but identity processes are also less likely to be engaged in this area unless the individual has had concerns about height from the early years and on. Clinical interventions here may focus on the maintenance of bone strength through weight resistance training and although these activities might not have an enhancing effect on height, they can be very important in promoting mobility (see below), another major concern for many older adults. 7.01.3.4 Mobility 7.01.3.4.1 Age changes The individual's ability to move around in the physical environment is a function of the integrity of the muscles, bones, joints between

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the bones, tendons and ligaments that connect muscle to bone, and contractility of flexor and extensor muscles. Mobility changes in important ways over the course of the adult years such that movement becomes more difficult, more painful, and often less effective for the older adult. Between ages 40±70 years, the loss of muscle strength amounts to approximately 10±20% with more severe losses of 30±40% after ages 70 to 80 years; losses that are more pronounced in the muscles of the lower extremities (McArdle, Katch, & Katch, 1991). This pattern of diminishing muscle strength appears to be due to atrophy of muscle fibers, particularly the ªfast twitchº fibers important in developing the rapidly accelerating powerful contractions normally associated with strength. The ªslow twitchº fibers involved in maintaining posture and muscular contractions over protacted periods of exertion remain constant over the adult years. The atrophy of fast-twitch fibers is thought to result from the loss of the motoneurons that activate the muscles. After the muscle fiber dies, it is replaced initially by connective tissue and in its final stages, by fat (Fiatrone & Evans, 1993). However, declines in muscle strength are not completely accounted for by loss of muscle mass, and there are other influences on age effects on muscle strength as yet to be determined (Kallman, Plato, & Tobin, 1990; Overend, Cunningham, Kramer, Lefeve, & Paterson, 1992). There are individual variations that can lead to important deviations from such a general pattern of decline. The extent to which aging affects loss of muscle strength depends in part on which gender is being tested, the general level of activity in which the individual has typically engaged, the particular muscle group being tested, and whether the type of muscle strength being assessed is static (isometric) or dynamic. Although the process of bone growth and remodeling continues, the overall course of bone development in adulthood is toward loss of bone strength, resulting in diminished ability of the bones to withstand mechanical pressure and to show greater vulnerability to fracture. The decrease in various measures of bone strength ranges from 5 to 12% per decade from the 20s through the 90s (McCalden, McGeough, Barker, & Court-Brown, 1993). Loss of bone strength is generally explained as a function of the loss of bone mineral content, meaning that the bone becomes increasingly porous and unable to support the loads it must bear. The extent to which bone mass decreases over the years of adulthood amounts to approximately 20±30% of total bone mineral content in women, and approximately half that amount

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

in men (Mazess, 1982; Riggs et al., 1981). The period of maximum bone loss is between the 50s and the 70s (Sparrow, Beausoleil, Garvey, Rozner, & Silbert, 1982). The explanation of the underlying process that causes loss of bone mineral content is that the rate of resorption exceeds that of new bone growth in later adulthood, giving a net result of a reduction in bone mass (Sherman et al., 1992). In part, bone density and the loss of bone mass in the later years of adulthood may be a function of genetic factors (Dargent & Breart, 1993; Kelly et al., 1993). Lifestyle also seems to play a role, however, including factors such as physical activity, smoking, alcohol use, and diet which can account for 50±60% of the variation in bone density (Krall & Dawson-Hughes, 1993). There are also hormonal influences on bone mass, as indicated by the observation that bone mineral loss in women proceeds at a higher rate in postmenopausal women who are no longer producing estrogen in monthly cycles (Nuti & Martini, 1993). Although the aging of joints is most commonly associated with the later years of life, degenerative processes that reduce the functional efficiency of the joints begin even before the individual reaches skeletal maturity. Restrictions of movement and discomfort are therefore a potential problem for adults of any age, but they occur with increasing frequency as age progresses. The decline in joint functioning can be accounted for by age losses in virtually every structural component of the joint. Starting in the 20s and 30s, the arterial cartilage begins to thin, fray, shred, and crack (Adrian, 1981). Unprotected by cartilage, the underlying bone eventually begins to wear away. At the same time, outgrowths of cartilage develop and these interfere with the smooth movement of the joint. Age-related weakening of the muscles further contributes to restrictions in range of movement due to changes in the joints themselves (Vandervoort et al., 1992). Changes at the cellular level in the structure of collagen and elastin comparable to those that occur in the dermis are thought to contribute to loss of flexibility, strength, and resiliency of connective tissue. Diminished efficiency of circulation may contribute further to deteriorative changes. Since the cartilage receives little vascular supply to begin with, any reductions in adulthood due to aging or arterial disease will further reduce its reparative ability. Furthermore, the joints are subjected to an extreme amount of trauma throughout life, including the strains and sprains encountered during everyday activities and strenuous exercise, activities that further contribute to their deterioration.

7.01.3.4.2 Clinical implications For many individuals, thresholds of aging become painfully crossed with each newlydiscovered joint ache or mobility restriction, sometimes beginning in the 40s (Whitbourne, 1996b). Changes in the structures that support movement have many pervasive effects on the individual's life, resulting in restrictions in activity and pain which can interfere with the individual's psychological adaptation and sense of well-being (Hughes, Edelman, Singer, & Chang, 1993). In part, the effects of mobility loss can be attributed to the enforced reliance on others that is created, leading to other deleterious processes such as being treated like a dependent child (Whitbourne & Wills, 1993). One of the most serious outcomes of reduced muscle strength, bone strength, and joint mobility is the heightened susceptibility of older individuals, particularly women, to falls (Dargent & Breart, 1993; Lord, Clark, & Webster, 1991). If a broken hip results, the individual is more likely to suffer long-term disability and dependency (Roberto, 1992). Unfortunately, individuals might overreact to falls by developing a ªfear of fallingº (Downton & Andrews, 1990) or lowered sense of self-efficacy regarding the ability to avoid a fall (Tinetti & Powell, 1993). As a result, they become less stable on their feet and avoid physical activities that might benefit their strength and stability. Understandably, these individuals are vulnerable to feelings of depression and anxiety. Other adults may react to falls through identity assimilation, by repressing their occurrence (Wright, Aizenstein, Vogler, Rowe, & Miller, 1990), which might maintain their sense of self-efficacy but place them at risk of further serious injury. This summary of age-related changes in mobility describes a fairly downhill process, but there are many interventions clinicians can pursue that will have practical advantages. As has been mentioned already, it is important to structure an intervention around the nature of the individual's identity processes, particularly as balanced against the individual's actual agerelated losses and possiblities for compensation. Given such an assessment, older individuals can be encouraged to participate in a variety of physical exercises that can prove to be extremely helpful in maintaining or restoring mobility. A regular program of exercise can help the middleaged and older adult compensate substantially for the loss of muscle fibers. Although there is nothing that can be done to stop the loss of muscle cells, the remaining fibers can be strengthened and work efficiency increased through exercise training even in persons as old as 90 years (Fiatrone et al., 1990). Inactivity

The Effects of Age of on Vital Functions can accelerate the loss of muscle strength, and the same is true of bone loss. Older individuals can also benefit from resistance training exercises that, within limits, increase the stress placed upon the bone (Dalsky et al. 1988; Rikli & McManis, 1990; Smith, 1981). Although degenerative changes in the joints are not reversible, it is possible for older individuals to benefit from exercise training, particularly if it is oriented toward promoting flexibility (Jirovec, 1991), strengthening the muscles that support the joints, increasing the circulation of blood to the joints thereby promoting the repair of injured tissues (Brooks & Fahey, 1984), and decreasing the risk of injury (Stamford, 1988). 7.01.4 THE EFFECTS OF AGE ON VITAL FUNCTIONS 7.01.4.1 Cardiovascular System 7.01.4.1.1 Age changes The aging process results in serious limitations of the heart's functional requirement to pump blood continuously through the circulatory system at a rate that adequately perfuses the body's cells. Although a distinct entity in terms of underlying processes, fatal cardiovascular diseases do become more probable with advancing age in adulthood. These diseases can have widespread effects on daily life in addition to providing constant sources of reminders of the individual's mortality. For example, the chest pains associated with angina, a chronic cardiac illness, are not only uncomfortable but provide clear warning signals of the heart's impending failure. The reduction in the heart's pumping capacity is due to a variety of changes affecting the structure and function of the heart muscle walls, particularly the left ventricle which becomes progressively thicker with each decade in adulthood and less elastic (Kitzman, Scholz, Hagen, Ilstrup, & Edwards 1988; Kitzman & Edwards, 1990) as the number of myocardial cells decreases and the remaining cells become hypertrophied (Olivetti, Melissari, Capasso, & Anversa, 1991). The decreased capacity of the ventricle walls to expand results in a reduced and delayed filling of the left ventricle and the ejection of less blood into the aorta. The cardiac muscle also becomes less responsive to the neural stimulation of the ªpacemakerº cells in the heart that initiate each contraction (Montamat & Davies 1989; Schulman & Gerstenblith, 1989). Effects of aging on the arteries further compromise the system's ability to distribute blood to the body's cells. Although it is difficult to separate the effects of aging from those of

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atherosclerosis (a disease in which the arteries become rigid and narrowed by fatty accumulation), the aging process itself appears to cause changes in the aorta and arteries (Shimojo, Tsuda, Iwasaka, & Inada, 1991). The wall of the aorta becomes less flexible, so that the blood leaving the left ventricle of the heart is faced by more resistance and cannot travel as far. The walls of the arteries throughout the body become thicker and less flexible. Impedence of blood flow through the arteries is further augmented by the accumulation of lipids in the blood (Heiss et al., 1980). Although age-related changes in the heart and arteries reduce the amount of blood available to the cells of the body, under normal conditions these changes are not particularly pronounced or noticable. The effects of aging of the circulatory system are most apparent while the individual is engaging in aerobic exercise, when there is a reduction both in maximum oxygen consumption (aerobic capacity) and the maximum attainable heart rate (Lakatta, 1987; Morley & Reese, 1989). Aerobic capacity decreases in a linear fashion throughout the adult years, so that the average 65-year-old individual has 30±40% of the aerobic capacity of the young adult (McArdle et al., 1991). Other functional variables decrease to a commensurate degree, such as the amount of blood pumped at each beat of the heart (Weisfeldt & Gerstenblith, 1986), and the cardiac output per minute. These decreases in the functional capacity of the heart mean that less oxygen reaches the muscles during exercise. Changes in the heart and arteries can also account, in part, for the observation that older individuals have higher levels of systolic and diastolic blood pressure, both at rest and during exercise. 7.01.4.1.2 Clinical implications Although not as apparent in its effects on identity as appearance, the functioning of the cardiovascular system is an important influence on the individual's feelings of well-being and identity. The efficiency of the cardiovascular system is essential to life so that threats to the integrity of this system are perceived as highly dangerous. Awareness of reduced cardiovascular efficiency can therefore serve as reminders of one's own personal mortality. In working with middle-aged and older adults, clinicians can turn to the wealth of research pointing to the effectiveness of exercise in slowing or reversing the effects of the aging process. The results of research on the effectiveness of exercise training have consistently revealed improved functioning in long-term endurance athletes, master athletes, exercisers,

10

Physiological Aspects of Aging: Relation to Identity and Clinical Implications

and previously sedentary adults (Whitbourne 1996a; McArdle et al., 1991). Previously sedentary adults can improve to levels that approximate the improvements achieved by younger adults (Govindasamy, Paterson, Poulin, & Cunningham 1988; Hagberg et al., 1989). Even moderate or low-intensity exercise can have beneficial effects on healthy sedentary elderly (Foster, Hume, Byrnes, Dickinson, & Chatfield 1989; Hamdorf, Withers, Penhall, & Haslam, 1992). Further, aerobic exercise training has the positive effect of lowering the heart rate and improving work load intensity and duration in submaximal exercise, (Morey et al., 1991; Poulin, Paterson, Govindasamy, & Cunningham, 1988), ultimately placing less stress upon the heart during exertion. Other benefits of exercise training are improvements in the peripheral vasculature (Blumenthal et al., 1989), lipid metabolism (Tamai et al., 1988), and blood pressure during or immediately after exertion (Webb, Poehlman, & Tonino, 1993). That exercise can have such positive effects on physical functioning in old age, even if it is begun after a lifetime of sedentary patterns, provides strong evidence in favor of the view that the rate of the aging process can be altered significantly through active lifestyle choices made by the individual. The main advantage that exercise seems to hold as a means of retaining a higher level of cardiovascular functioning is that it provides a continued potent stimulus for the muscle cells of the heart to undergo strong contractions so that they retain or gain contractile power. The greater strength of the myocardial muscle improves the functioning of the left ventricle and as a result, more blood can be ejected from the left ventricle (Ehsani, Ogawa, Miller, Spina, & Jilka, 1991). The other advantage of exercise training is that it makes it possible for the individual to ªsaveº energy during aerobic work that is less than maximal by fulfilling the demands of the work load but placing less stress on the heart. Because more blood is ejected with each cardiac muscle contraction, the same output of blood can be pumped per minute but at a lower heart rate. The effects of training on cardiac functioning under submaximal conditions are of interest in that these performance situations are closer to the conditions under which people exert themselves in their daily lives. Exercise training also has favorable effects on the body's performance by increasing the efficiency of metabolism in the working muscles (Meredith et al., 1989). In addition to the advantages of exercise training for the cardiovascular system, it is well established that adults who become involved in aerobic activities experience a variety of positive

effects on mood, anxiety levels, and particularly feelings of mastery and control, leading to enhanced feelings of self-esteem (Hill, Storandt, & Malley 1993; McAuley, Lox, & Duncan, 1993). Although some researchers have demonstrated there to be positive effects of exercise on cognitive functioning (Chodzko-Zajko, Schuler, Solomon, Heiul, & Ellis, 1992; Stevenson & Topp, 1990), this effect is not observed consistently (Hill et al., 1993). Nevertheless, it appears clear that older adults who enter exercise training programs ªfeel better,º and this improvement in mood can be clinically useful for many aging clients. A great deal has been written in the area of behavioral medicine on strategies for increasing the compliance of cardiac patients with dietary and exercise controls over the progress of their disease. In terms of the normal aging process, similar interventions might be suggested. Those individuals who deny the effects of aging through identity assimilation must be brought to recognize that they will run real risks to their lives if they either fail to engage in preventative behaviors or engage in strenuous activities without proper supervision or training. In contrast, middle-aged and older individuals who overreact to age changes in what they have heard about cardiovascular functioning, or perhaps to the appearance of slight symptoms, need to be given assurance that they can nevertheless continue to engage in exercise activities and that, indeed, such activities are necessary for the prevention of further and more serious health limitations.

7.01.4.2 Respiratory System 7.01.4.2.1 Age changes The airways in the respiratory system permit gas exchange between the blood and air, making it possible for the body's cells to receive support for their metabolic activities. Aging's primary effect is to reduce the quality of gas exchange in the lungs so that less oxygen from the outside air reaches the blood (Kenney, 1989). Aging also reduces vital capacity, the amount of air that is moved into and out of the lungs at maximal levels of exertion (Reddon, 1981), and forced expiratory volume, the amount of air that can be breathed out during a short amount of time (Smith, Cunningham, Patterson, Rechnitzer, & Koval, 1992). These reductions in respiratory functioning result from changes in pulmonary structures such that the airways, and particularly lung tissue, lose the elastic ability to resist expansion as they fill with air. The changes in

The Effects of Age on Regulatory Systems lung structures that account for decreased elastic recoil and increased compliance are alterations in the composition and structure of the elastin and collagen composition of lung tissue (Brandstetter & Kazemi, 1983; D'Errico et al., 1989). Increased rigidity of the chest wall further lower the lung's ability to be fully compressed during expiration and expanded during inspiration (Mahler, Rossiello, & Lohe, 1986). These changes mean that less than the maximal amount of air can be brought into and out of the lungs, particularly under conditions of exertion (Teramoto, Fukuchi, Nagase, Matsuse, & Orimo, 1995). The greater rigidity of the chest wall also increases the amount of work that must be performed by the respiratory muscles during the inspiratory and expiratory phases of the ventilation cycle.

7.01.4.2.2 Clinical implications Age changes in respiration can lead to feelings of dyspnea and fatigue associated with exertion, sensations that can approach the intensity of a panic attack. Adding to age effects on cardiovascular functioning, changes in the respiratory system can lead the aging individual to avoid strenuous activities, a consequence that further impairs the individual's cardiovascular and respiratory efficiency. Because both of these functions are so crucial to life, and because shortness of breath is so frightening, the individual might conclude prematurely that death is around the corner. The effects of exercise training on respiratory functioning are encouraging (Blumenthal et al., 1989) but the specific effects of exercise on respiratory functioning are not as dramatic as the effects on the cardiovascular system. Equally, if not more, beneficial to the respiratory function is the avoidance of cigarette smoking (Hermanson, Omenn, & Kronmal, 1988). Taking these factors into account, clinicians may wish to treat instances of dyspnea leading to panic as instances of overaccommodation, in which the individual may be brought to a more balanced state through recognizing the fact that some age-related changes in breathing capacity are in fact inevitable. On the other hand, for individuals who are using identity assimilation to deny the importance of factors that impede respiratory efficiency, notably cigarette smoking, steps need to be taken to increase identity accommodation and the recognition that this behavior can accelerate the deleterious effects of aging on respiratory efficiency and feelings of comfort during exercise.

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7.01.5 THE EFFECTS OF AGE ON REGULATORY SYSTEMS 7.01.5.1 Excretory System 7.01.5.1.1 Age changes It has been known for years that there are significant and widespread changes in the structure of the kidneys, changes that are reflected in cross-sectional studies in impaired efficiency across adulthood on every measure of renal functioning studied. (Rowe, Shock, & DeFronzo, 1976). An early estimate of the loss of renal functions over the adult years was a figure of 6% per decade from age 20 and continuing into the 90s, a loss that exists in longitudinal studies as well (Shock, Andres, Norris, & Tobin, 1978). The cause of aging of the kidney is loss of structure and function of the basic cell of the kidney, the nephron (McLacklan, Guthrie, Anderson, & Fulker, 1977). There are also independent losses in mechanism within the kidney responsible for concentrating urine (Rowe, 1982). Particularly challenging to the aging kidney is aerobic exercise because it diverts blood to the working skeletal muscles, and thereby causes a further reduction in the blood flow through the kidneys. Equally important, the urine concentrating mechanism begins to fail during exercise or under extreme conditions of heat when the individual begins to perspire. Fatigue, changes in body chemistry, and potentially harmful changes in bodily fluid levels occur more rapidly in the older adult who cannot conserve sodium and water adequately under these conditions. The effects of aging on the bladder are of great importance to the individual's conscious experience of aging. Adults past the age of 65 years experience a reduction in the total amount of urine they can store before feeling a need to void, and more urine is retained in the bladder after the individual has attempted to empty it. These phenomena appear to be related to age changes in the connective tissue of the bladder causing the organ to lose its expandability and contractility somewhat like that which is seen in the lung. Furthermore, recognition of the need to void may not occur until the bladder is almost or even completely filled. This means that the individual has less or perhaps no time to reach a lavatory before leakage or spillage occurs. The most significant effect of changes with age in the bladder is on patterns of urinary incontinence. The prevalence of incontinence among the population 60 years and older is estimated to be 19% for women and 8% for men (Herzog, Diokno, Brown, Normolle, & Brock, 1990) but can reach as high as 36% among community-dwelling elderly with dementia

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

(Ouslander, Zarit, Orr, & Muira, 1990). Women are more likely to suffer from stress incontinence, which refers to loss of urine at times of exertion such as when one is laughing, sneezing, lifting, or bending and is the result of weakness of the pelvic muscles. Urge incontinence, which is more prevalent in men, involves urine loss following an urge to void or lack of control over voiding with little or no warning (Diokno, Brock, Brown, & Herzog, 1986); it is related to prostatic disease or incomplete emptying of the bladder. Among the community-dwelling elderly, each of these conditions, particularly urge incontinence, is reversible and may disappear within a year or two of its initial development (Herzog et al., 1990) 7.01.5.1.2 Clinical implications Although not insignificant in terms of the body's physiological efficiency, the aging of the kidney is unlikely to have a discernible impact on everyday functioning. However, age-related changes in the bladder are another matter, and can be important threshold phenomena (Whitbourne, 1996b). Incontinence can be highly disruptive to the older individual's everyday life, causing distress and embarrassment (Hunskaar & Vinsnes, 1991; Ouslander & Abelson 1990; Wyman, Hawkins, & Fantl, 1990). Not only do such occasions involve shame, but they feed into the association in many people's minds between ªsenilityº and urinary incontinence. Other horrors of incontinence may also trigger overaccommodation, such as loss of independence and respect. Given the many associations to urinary continence, it would not be unreasonable to suppose that even a single episode of stress incontinence could create a threshold experience and overaccommodation. Unfortunately, advertisers prey on this vulnerability of older adults in commercials for adult diapers that suggest these changes to be expectable and unpreventable. Clinicians needs to work with older adult clients to dispel these myths. On the positive side, once identified, incontinence is a condition that in many cases can be managed if the individual is able to learn new behavioral strategies. Through behavioral techniques, sometimes involving only very simple exercises, the problem can be held in check if not reversed (Burgio & Engel, 1990; Burns et al., 1993). Age effects on renal functioning significantly affect the older person's ability to excrete medications, a fact that can be of great importance in a therapeutic context. When an older person is given the the same dosage of medication appropriate for a younger adult, more of the drug will remain in the bloodstream

over the period of time between doses. With repeated dosages of the drug it is more likely that toxic levels will build up in the blood. Unless the dosage is adjusted to take into account this lower rate of tubular transport, drugs may have an adverse impact instead of their intended benefits (Lamy, 1988; Montgomery, 1990). 7.01.5.2 Digestive System 7.01.5.2.1 Age changes The documented effects of aging on digestion in the empirical literature are remarkably minor compared to the lavish attention devoted by advertisers and the popular media to the supposed inefficiencies of digestive processes in older adults. One change with age that may have implications for digestive functioning is a reduction in the metabolism of certain nutrients in the stomach and small intestine, but other structures such as the esophagous, liver, pancreas, and large intestine appear to be relatively spared by the aging process (Whitbourne, 1996). More important than constipation, dyspepsia, and reduced sensory capacities for enjoying food are the beliefs that people hold as communicated through the media, the social context in which food is eaten, other physical and cognitive deficiencies, and the individual's lifelong patterns of nutrition (Costello & MoserVeillon, 1992; Fischer & Iohson 1990; Ryan, Craig, & Finn, 1992; Wedman et al., 1991). 7.01.5.2.2 Clinical implications Changes in the digestive system at the physiological level due to aging are not likely to propel the individual over an aging threshold (Whitbourne, 1996b). However, so many elders have been exposed to inaccurate conceptions in the media about the aging digestive system that clinicians have an important psychoeducational role to play. In the area of digestion and particularly elimination, embarrassment may lead the older individual to avoid discussions of anxiety-provoking issues that, if discussed and allayed, could ease these very uncomfortable feelings. Furthermore, questions about food intake are essential for clinicians to explore, as inadequate nutrition may lead to symptoms that mimic those of psychological or cognitive impairment disorders. Unchecked, a vicious cycle may be created, as depression can lead to loss of interest in food and food preparation (Rosenbloom & Whittington, 1993). Another clinical issue related to digestion concerns fecal incontinence. Older adults, particularly those who overrely on identity

Age Changes in the Reproductive System and Sexuality accommodation, may associate irregularities in defecation with feared diseases and the prospects of institutionalization in later life (Holt, 1991; Wald, 1990). Older persons who believe that ªsenilityº is an inevitable feature of aging may regard with alarm any indication that their patterns of elimination are changing, seeing in such changes a more ominous significance that can risk putting them over the threshold. The anxiety created by this concern may contribute further to gastrointestinal problems so that what originates as a temporary problem comes to have a more prolonged course. Clinicians can intervene in this process by sensitive discussion of this very personal and potentially frightening area of daily life. 7.01.5.3 Immune System 7.01.5.3.1 Age changes There is substantial evidence of reduced immune system functioning across age groups of adults. T-cells, which destroy antigens (foreign substances that enter the body), lose effectiveness over the adult years (Bloom, 1994; Globerson, Eren, Abel, & Ben-Menahem, 1990), in part due to changes in the thymus gland. Autopsy studies have revealed that deterioration of the thymus gland begins shortly after sexual maturity is reached, so that by the time the individual is 45±50 years old, the thymus retains only 5±10% of its peak mass. As a result of these changes, there are more immature T-cells present both within the thymus gland and in the bloodstream. Other immune system cells, including natural killer (NK) cells, K cells, and macrophages, do appear to retain their functioning into old age (Bloom 1994; Kutza, Kaye, & Mwasko, 1995); however, another entire line of defenses is altered in the aging process through the reduced activity of helper T-cells, increased activity of suppresser T-cells, and the increasing development of certain autoimmune diseases. 7.01.5.3.2 Clinical implications Investigations have been stimulated by progress in psychoneuroimmunology, a field in which the intricate connections are examined between affective states such as stress and depression, nervous system functioning, and operation of the immune system (O'Leary 1990; Vollardt, 1991). For example, elderly individuals with high levels of life stress have been found to experience lower T-cell functioning (McNaughton, Smith, Patterson, & Grant, 1990). Conversely, social support, at least among women, was found to be related

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positively to immune system competence measured in terms of lymphocyte numbers and response to mitogens (Thomas, Goodwin, & Goodwin, 1985). Older individuals are at least as susceptible to stress as younger adults in increases of T-suppressor cells and NK cell numbers, although not in terms of increased NK activity (Nabiloff et al., 1991). Stress also seems linked to the release of beta-endorphin, an opioid peptide released from the pituitary gland that has an analgesic effect. This process may play an important role in mediating the effects of emotions on the immune system (Antoni, 1987). Apart from changes in the immune system that interact with psychological functioning, the lowered effectiveness of the immune system in older adults has important implications for health. The aging immune system has been linked to increased vulnerability to influenza, infections, cancer, and certain age-associated autoimmune disorders such as diabetes and possibly atherosclerosis and Alzheimer's disease. A less competent immune system can put the elderly individual at higher risk at least to certain forms of cancer and influenza (Ershler, 1990; Miller, 1993). Clearly, the development of severe health problems can have significant effects on the individual's psychological wellbeing. There are many ways in which clinicians can take advantage of the potential interactions between identity and immune system functioning. The crossing of an aging threshold in any salient area of functioning, to the extent that it triggers a stressful reaction, can lead to deleterious effects on immune functioning. The individual then becomes more susceptible to immune-related conditions, further accentuating the effects of crossing the threshold. Overassimilation may have some beneficial aspects, in this regard, if the individual is not placed at risk by ignoring important physical changes. 7.01.6 AGE CHANGES IN THE REPRODUCTIVE SYSTEM AND SEXUALITY 7.01.6.1 Female Reproductive System Throughout her 40s, a woman's reproductive capacity becomes gradually reduced until, by the age of 50±55 years, it ceases altogether. Associated with the ending of the monthly phases of ovulation and menstruation is a diminution of the hormones estrogen and progesterone. Other changes in sexual functioning are related to aging of the tissues in other bodily systems. For example, sagging of the

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

breasts and torso results from decreased skin elasticity. Subcutaneous fat accumulates around the waist, leading to uneven bulges. The appearance and functioning of the genital organs also change after the menopause. The pubic hair on the mons veneris and around the vulva becomes thin and coarser. The labia majora and minora become thinner and wrinkled, the skin in the vulva atrophies, and the surface cells of the vaginal wall become thin, dry, pale, and smooth. The vagina also becomes narrower and shorter. These changes are significant not only for their effects on sexual functioning but for their effects on the woman's enjoyment of sexual intercourse. The older woman may experience discomfort during intercourse due to changes in the vagina and vulva, and the rhythmic contractions of the uterus during orgasm may become painful. Despite changes in the reproductive system, the conclusion reached by Masters and Johnson (1966) in the mid 1960s is still generally accepted: that older women are limited in their sexual gratification more by their attitudes, values, and accessibility to partners than they are by physical changes involved in aging. The sexual response cycle might be slowed down somewhat in the older woman, but the possibility of achieving orgasm is not reduced.

7.01.6.2 Male Reproductive System Just as women gradually lose reproductive capacity, men experience a climacteric of sorts in which there is a reduction in the number of viable sperm they produce due to degenerative changes in the seminiferous tubules of the testes (Harman, 1978). With increasing age, men may experience changes in the prostate gland that lead to a reduction of the volume and pressure of semen expelled during ejaculation. Agerelated changes also include overgrowth or hypertrophy of the glandular and connective tissue in the parts of the prostate that surround the prostatic urethra. This condition, called benign prostatic hypertrophy, is increasingly prevalent in men past 50 years, rising to an estimated 50% of men 80 years and older. The adjacent penile urethra may become constricted due to this overgrowth, and urinary rentention may ensue. Discomfort and embarrassment may result from difficulties in urination and from the occurrence of involuntary penile erections (Masters & Johnson, 1966). If urinary retention becomes a chronic condition, kidney problems may develop, leading to more serious health threats. A physiological index of reproductive function that has a decidedly noticeable effect on the

older man's sense of his own sexuality is that of penile erectility. It is well documented that older men experience fewer nightly episodes of penile erections compared to younger males (Karacan, Willliam, Thornby, & Salis, 1975). By contrast, there are inconsistencies in the findings regarding increase in penile circumference during erection, with some decreases noted across age groups (Solnick & Birren, 1977), and in other research no age differences are observed (Schiavi & Schreiner-Engel, 1988). As is true for aging women, there is a general slowing down in aging men of the progression through the human sexual response cycle. Compared to young adult men, orgasm is shorter, involving fewer contractions of the prostate, and ejection of a smaller amount of seminal fluid (Masters & Johnson, 1970). These findings may carry some negative implications for the aging male's sexual relations. However, the gains for the older man's ability to enjoy sexuality are also compelling. He may feel less driven toward the pressure to ejaculate, be able to prolong the period of sensual enjoyment prior to orgasm, and have the control to coordinate his pleasure cycle to correspond more to his female partner. The main predictor of a man's pattern of sexuality in the earlier years of adulthood is by far the best predictor of his sexuality in old age (George & Weiler, 1985). The sexually active middle-aged man, given good health, has the potential to remain sexually active well into his later years.

7.01.6.3 Clinical Implications The impact of the menopause depends heavily on how the woman interprets the significance of this transition, which may be met with relief or as a reminder of the inevitability of aging and mortality. Although the aging male is likely to be less preoccupied by his diminished (but not lost) reproductive capacity, he may also find age-related changes to have a negative impact on his enjoyment of sexual relations. He may overaccommodate to aging changes, believing that his masculine prowess has failed. Furthermore, the changes he perceives in his sexual functioning may be interpreted as movement toward deterioration and death. As is true for any man regardless of age, depression, heavy alcohol use, or late-life career pressures may also interfere with the aging male's ability to enjoy sexual relations. Difficulties in adjusting to age changes in the sexual response cycle may present a problem if the partners are unfamiliar with the fact that sexual responsivity naturally becomes altered in later adulthood. The woman

The Nervous System may worry that she has lost her orgasmic capacity because it takes her longer to become aroused, excited, and stimulated. The aging male may be at high risk of developing symptoms of secondary (nonphysiological) impotence. As is true of other sensitive areas of physical functioning, the clinician's responsibility in these areas is to explore in a patient and careful manner the level of concern the individual or couple may have about their functioning. Given cohort differences in attitudes toward sexuality, it is likely that the average older person finds it difficult to discuss specific details about problems in sexual functioning. The general level of anxiety associated with sexual matters can lead to heightened potential for either identity assimilation in the form of denial, or identity accommodation in the form of overreaction. Furthermore, in this area perhaps more so than in any other, it might be necessary for the clinician's own attitudes toward sexuality in the aged to become an area of personal focus and reflection before proceeding to the level of intervention.

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and in the cerebellum (Hall, Miller, & Corsellis, 1975), the structure that regulates refined motor patterns. Age losses in these subcortical areas, however, are considered relatively minor compared to losses (as high as 50%) in the areas of the cerebral cortex responsible for processing sensory information, including the primary visual cortex (Devaney & Johnson, 1980), the primary somatosensory region (Henderson, Tomlinson, & Gibson, 1980), and the secondary auditory cortex which loses between one-third and one-half of its total number of neurons over the adult years (Brody, 1955; Henderson et al., 1980). Cells in the motor cortex show comparable losses of 20±50%, and these losses are thought to be a contributing factor to muscular stiffness, slowness, and joint pain (Scheibel, 1982). In contrast to these somewhat dramatic losses of neuron numbers is the pattern of relative stability in the prefrontal region of the cortex (Higatsberger, Budka, & Bernheimer, 1982; Huttenlocher, 1979). The stability of neurons in these regions of the cortex is important, as these are the parts of the nervous system involved in judgment, abstract thinking, and the ability to plan.

7.01.7 THE NERVOUS SYSTEM 7.01.7.1 Central Nervous System 7.01.7.1.1 Age changes In the central nervous system (CNS), as in the other major organ systems, changes that are due to aging alone are difficult to separate from changes that are the result of disease. Neurofibrillary tangles, amyloid plaques, and granulovacuolar degeneration are all deleterious changes observed in the brains of people with Alzheimer's disease, but are also thought to occur to a lesser extent in normal aging. There are thought to be decreases in acetylcholine levels in the hippocampus and a decline in the number of neurons in the hippocampus, but these are also well-known correlates of Alzheimer's disease. Similarly, decreased amounts of dopamine in the substantia nigra±basal ganglia pathway are regarded as age-related changes but are also observed in Parkinson's disease. It is not clear whether these losses occur normally in later life and are exaggerated in the case of disease, or whether they constitute discrete phenomena. Keeping in mind the distinction between normal aging and disease processes, there is documentation that areas of the brain are differentially affected by neuronal loss in later adulthood. There appear to be signficiant losses of neurons from the hippocampus, the area affected by Alzheimer's disease and involved in short-term memory (Mouritzen Dam, 1979),

7.01.7.1.2 Clinical implications Aging of the CNS has direct effects on a variety of sensory, motor, and cognitive capacities and behaviors including perception, short-term memory, fine motor coordination, and large muscle control. However, the view of the aging brain as a degenerating system does not take into account what is known about the compensatory processes of redundancy and plasticity (Buell & Coleman, 1979; Flood, Buell, Horowitz, & Coleman 1987; Flood & Coleman, 1988). The impact of these processes is most likely to occur in the association areas of the cerebral cortex, where higher order abstract thinking processes are mediated. In fact, these abilities may improve in the later years of adulthood as the individual stores more experiences into the long-term memory association areas on which decisions and judgment are based. Furthermore, it is important to emphasize once again that there is tremendous variation among adults in the ways in which the aging process (apart from disease) affects CNS functions. Some of these functions in later adulthood are, in addition, affected by the extent to which the individual developed and used them during the adult years. Exposure to stimulation in the areas of perception, cognition, and motor activity through mental and physical exercise can influence, throughout old age, the degree to which the abilities that depend

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

on these functions are maintained. The importance placed by the individual on mental and physical abilities contributes further to the personal meaning of age changes in any of these areas and whether a threshold is crossed in this domain. Clinically, of course, it is essential that those working with the elderly are knowledgable about and sensitive to the symptoms of Alzheimer's disease, particularly as these differ from other forms of cognitive impairment or depression. Clinicians must also be aware of the extent to which elders fear the onset of Alzheimer's disease and interpret even minor changes in cognitive functions as signs that the end is in sight. Overaccommodation in the cognitive domain can prove extremely damaging to the older adult's identity as a sentient being, and vigilance in this area toward any signs of deterioration is likely to be high. This risk is perhaps greater than that of overassimilation, except when an individual who really does have early symptoms of Alzheimer's disease denies the memory or judgment problems that are interfering with daily life activities. Media attention to Alzheimer's disease, although positive in the sense of educating the public, may backfire in this domain, leaving many elders (and clinicians) with the erroneous impression that the disease is an inevitable outcome of the aging process. 7.01.7.2 Autonomic Nervous System 7.01.7.2.1 Age changes Although in many aspects the autonomic nervous system (ANS) operates without significant age-related alterations throughout adulthood, there are important effects of aging on two functions served by the ANS that have a considerable impact on the individual's daily life: bodily temperature control and sleep patterns. It is well established both through population health statistics and experimental studies that individuals over the age of 65 years have impaired adaptive responses to extremely hot and cold outside temperatures. The diminished response of the elderly to cold appears to be due to a diminished perception that the core body temperature is low, and to an impaired ability to raise core temperature when the body's peripheral temperature becomes lowered. Responses to extremes of heat are impaired due to decreased secretion by the sweat glands in the skin. In the area of sleep regulation, older adults spend more time in bed relative to time spent asleep due to longer time taken to fall asleep, more periods of wakefulness during the night,

and time spent lying awake before arising in the morning. The primary causes of sleep disturbance include sleep apnea (Ancoli-Israel & Kripke, 1991), periodic leg movements, heartburn, and frequent needs to urinate (Freidman, Bliwise, Tauke, & Salom, 1992). EEG sleep patterns show some corresponding age alterations, including a rise in Stage 1 sleep (drowsiness without actual sleep), and a large decrease in Stage 4 sleep (slow wave or heavy sleep). By the 60s and 70s, REM sleep starts to diminish as well, as do the observable behaviors associated with REM sleep. 7.01.7.2.2 Clinical implications The knowledge gained from personal experience and media exposure that one's aging body is less adaptable to outside temperatures means that adults living in geographical areas with cold winters will restrict their outdoor activities and spend more time at home. They will also limit their outdoor exposure during the summer. Overaccommodation to the threshold experience of aging in this regard can reduce the wellbeing of the older adult who may feel forced to remain indoors unnecessarily even on days when the temperature would not pose a threat. Conversely, overassimilation can have deleterious effects when the older adult does not take precautions during physical exertion or when venturing out into a very hot or very cold day. Fortunately, the changes in the ANS described here occur gradually over a period of years. Consequently, there are many opportunities for the individual to learn to adjust to the effects of aging and find new behavioral accommodations as these become necessary. Clinicians can play an important role in this process through helping their clients establish a favorable balance between overreaction and denial of aging-related changes in temperature regulation. Similarly, the function of sleep in everyday life is clearly crucial to the individual's sense of well-being and there is a strong relationship between quality of sleep and psychological symptoms (Bliwise, 1992). Given the sensitivity of sleep patterns to psychological distress, this is an area where identity±age change relationships might very profitably be discussed in therapy. Older adults who overreact through accommodation to slight sleep change patterns are perhaps the ones fated to experience the most significant changes in their ability to get a good night's sleep. They need to be given the information that a night's sleep need not consist of more than seven hours and that the longer the time spent in bed awake, the harder it will be for the individual to develop a normal nightly

Age Changes in Sensory Functioning rhythm based on this more realistic sleep requirement. The clinician can also advise the client to avoid daytime naps and to follow good sleep habits. 7.01.8 AGE CHANGES IN SENSORY FUNCTIONING 7.01.8.1 Vision 7.01.8.1.1 Age changes The optical structures in the eye focus light reflected from stimuli in the environment onto the sensory cells of the retina. Many, if not all, age effects on visual functions can be explained in terms of the effects of normal aging on these optical structures (Scheie & Albert, 1977). One effect of these changes is to reduce the clarity of the visual image reaching the retina. The image reaching the retina is clouded by increased density and opacity of the lens (Spector, 1982), and by the formation of opacities in the vitreous. Adding to these structural changes are changes in the retina itself, including declines in the number of photoreceptors (rods and cones) (Ordy, Brizzee, & Johnson, 1982), the accumulation of debris in the outermost layer of the retina (Marmor, 1980), and detachment of the vitreous from the surface of the retina (Scheie & Albert). The amount of light reaching the retina is diminished by the condition known as senile meiosis, reduction in the size of the pupil due to atrophy of the iris dilator (Carter, 1982). In addition to these changes that reduce the quality of the visual image on the retina are changes in the lens that decrease its capacity to accommodate to necessary changes in focus as objects move closer or further away from the individual. In addition to becoming denser, the lens fibers become harder and less elastic (Paterson, 1979). The loss of accommodative power of the lens due to these changes is referred to as presbyopia, and it is a condition that typically requires correction between the ages of 40 to 50 years. By the age of 60 years, the lens is completely incapable of accommodating to focus on objects at close distance (Moses, 1981). The lens also becomes yellowed due to an accumulation of yellow pigment, and as a result the older adult is less able to discriminate colors in the green±blue±violet end of the spectrum (Mancil & Owsley, 1988). These structural changes in the eye result in altered refractive power leading to hypermetropia (farsightedness), a condition that cannot be compensated by greater focusing of the lens due to presbyopia. There is a reduction in visual acuity which is especially severe at low levels of illumination, such as driving at night, and when

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tracking moving objects (Panek, Barrett, Sterns, & Alexander, 1977; Richards, 1977). Dark adaptation is reduced so that older adults have greater difficulty adjusting to movement from bright to dim lighting, and have lower absolute levels of ability to see in the dark (McFarland, Dorney, Warren, & Ward, 1960). There is also a reduction in the individual's ability to react to scotomatic glare, or sudden exposure to bright light, such as a flashbulb or the headlights of an oncoming car at night (Wolf & Gardiner, 1965). Although there are only minimal data on depth perception, there appear to be reductions in stereopsis, the perception of three-dimensional space resulting from the varying input that reaches the two eyes (Bell, Wolf, & Bernholz, 1972). 7.01.8.1.2 Clinical implications Given the centrality of vision to many activities, changes with age in the eye's basic functions can have profound psychological effects. One set of problems relates to discomfort and frustration caused by poorer acuity and reduced focusing power. Even if visual problems can be corrected with glasses or contact lenses, there are residual symptoms that may remain in special circumstances such as when the individual overworks or is trying to read small print. Older adults report experiencing as problems sensitivity to glare, difficulty seeing in dim light, and problems focusing on near objects (Kosnik, Winslow, Kline, Rasinski, & Sekuler, 1988). When these problems become more persistent, they may propel the individual toward a threshold experience. Presbyopia, although reached after a gradual process of changes in the lens, is often perceived with relative suddenness by the individual (Carter, 1982). The immediacy of this apparent change, given the association that many people have between presbyopia and the infirmities of age, makes it more likely that the change will be negatively interpreted. The necessity of wearing bifocals adds the complication of requiring the individual to adjust to a new and awkward way of using corrective lenses. Difficulties in depth perception and dark adaptation can heighten the older adult's vulnerability to falls (Felson et al., 1989; McMurdo & Gaskell, 1991), adding to the tendency to overaccommodate due to concerns about bone fragility and stiffness. Visual losses can increase the individual's dependence on others (Hakkinen, 1984), interfering with the older adult's ability to complete basic tasks of living such as driving, housekeeping, grocery shopping, and food preparation (Branch, Horowitz, & Carr 1989; Rudberg, Furner,

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

Dunn, & Cassel, 1993). Apart from the practical implications, these changes can further erode the individual's physical identity. Finally, age changes in vision can detract from the older adult's ability to enjoy leisure and esthetic activities, and even to choose appropriate clothes (Morgan, 1988). Although not a serious problem compared with difficulties in driving, such changes can be annoying and perhaps lead to derision by others. Other leisure activities involving the perception of color and fine detail may be interfered with, such as needlepoint, gardening, word puzzles, and painting. Loss of the ability to enjoy these activities add further to the threshold experience which may be crossed each time a new visual function is altered or affected by aging. A number of changes in visual functioning can, fortunately, be compensated by corrective lenses, increases in the ambient lighting, and efforts to reduce glare and heighten contrast between light and dark. Corrective surgery for cataracts can have a number of widespread positive effects on daily life (Brenner, Curbow, Javitt, Legro, & Sommer, 1993). The success of these efforts depends on the individual's willingness to persist in trying new ideas when the old methods no longer work, a process that might be enhanced through clinical intervention. Nevertheless, a point may be reached within each sphere of functioning in which the individual's range of movement becomes compromised. Furthermore, the situation may not permit compensation, as is true for night driving. Again, clinical sensitivity plays an important role in helping the older person accommodate to this age-related change in a valued function. 7.01.8.2 Hearing 7.01.8.2.1 Age changes Presbycusis, the general term used to refer to age-related hearing loss, actually includes several specific subtypes reflecting different changes in the auditory structures. The most common form of hearing loss reduces sensitivity to high-frequency tones earlier and more severely than sensitivity to low-frequency tones (Van-Rooij & Plomp, 1990). The loss of highfrequency pitch perception is particularly pronounced in men (Lebo & Reddell, 1972). Speech perception is affected both by the various forms of presbycusis operating at the sensory level and by changes in the central processing of auditory information at the level of the brain stem and above (Van-Rooij & Plomp, 1992). Translated into speech discrimination, this means that older adults suffering from presbycusis have

greater dificulty perceiving sibilants, such as the ªsº in plurals. In addition to the effects of aging on speech discrimination due to the loss of high-pitched tone sensitivity are the effects of aging on the ability to hear when there is interference or distraction. Age effects begin to appear even as early as 40 years in the understanding of sentences under a variety of distorting conditions, particularly when the speech signal is interrupted (Bergman et al., 1976). Other conditions known to impair speech perception in the aged include higher rate of presentation, deletion of parts of the message, competition from background noise or competing messages, and reverberation (Neils, Newman, Hill, & Weiler, 1991).

7.01.8.2.2 Clinical implications Hearing deficits interfere greatly with interpersonal communication, leading to strained relationships and greater caution by the elderly in an attempt to avoid making inappropriate responses to uncertain auditory signals. They also reduce the older person's ability to hear noises such as a siren or a door knock (Gatehouse, 1990). These changes are almost impossible to avoid noticing (Slawinski, Hartel, & Kline, 1993), and it is perhaps for this reason that hearing loss forms a threshold for a large percentage of individuals over the age of 70 years and particularly those in their 80s (Whitbourne, 1996b). There is evidence linking hearing loss to impaired physical functioning (Bess, Lichenstein, Logan, & Burger, 1989) and psychological difficulties including loneliness (Christian, Dluky, & O'Neill, 1989) and depression (Kalayam, Alexopoulos, Merrell, & Young, 1991). Those who interact with hearing-impaired elders can benefit from learning ways to communicate that lessen the impact of agerelated changes (Slawinski et al., 1993). Modulating one's tone of voice, particularly for women, so that it is not too high, and avoiding distractions or interference, can be important aids to communicating clearly with older adults. The clinician can also use observations of the elderly client's reaction to communication difficulties in therapy as the basis for clinical recommendations. For example, identity accommodation can be encouraged in a client who denies the existence of an obvious hearing deficit; a client who has no apparent hearing deficit but appears preoccupied with this particular threshold will need to develop a more balanced approach to this area of functioning.

Concluding Observations 7.01.8.3 Balance 7.01.8.3.1 Age changes The effects of age on the vestibular organs involve the losses occurring in the sensory structures as well as in the pathways to the higher levels of the nervous system (Johnsson & Hawkins, 1972; Rosenhall & Rubin, 1973). There are also reductions in the numbers of Purkinje cells in the cerebellum (Hall, Miller, & Corsellis, 1975) which could result in lowering of reflexive abilities to adjust the body's posture to changes in position. The apparent results of these changes in the vestibular system are increased dizziness and vertigo in older adults (Toglia, 1975). Not only are these sensations unpleasant, but they can increase the likelihood of accidental falls. However, structural changes in the vestibular system do not account entirely for the phenomena of dizziness and vertigo. There is considerable plasticity within the vestibular system so that loss of receptor cells may be compensated by the activity of structures in other sensory systems (Teasdale, Stelmach, & Breunig, 1991). For example, the positional receptors in the somesthetic system appear to be less vulnerable to aging effects (Babin & Harker, 1982). Conversely, the loss of information from more than one sensory system, such as the visual and the vestibular systems, can make it difficult for the older person to compensate successfully (Manchester, Woollacott, Zederbauer-Hylton, & Marin, 1989). Slowing of central integrative processes responsible for maintaining postural stability can also contribute to increased likelihood of falls. It may take longer for the older adult to integrate information from the vestibular, visual, and somesthetic systems, resulting in less efficient control of posture under changing body positions (Teasdale et al., 1991). 7.01.8.3.2 Clinical implications Balance is an essential element of moving about effectively in the environment. Aging of the vestibular system brings with it the potential for the individual to feel insecure in moving, particularly under conditions that are less than ideal, such as sloping, steep, or uneven surfaces. Fear of falling due to other changes in mobility can increase the individual's anxiety and perhaps exacerbate any true deficits in vestibular functioning. Conversely, individuals who through identity assimilation ignore signs of dizziness and vertigo may place themselves in danger as they may not be able to avoid a fall when and if they do lose their balance. There are social consequences of aging of the vestibular system as well. The older adult who

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experiences dizziness and vertigo may fear appearing disoriented in front of other people, perhaps due to concern about appearing intoxicated or mentally confused. A desire to avoid such embarrassment may lead the individual to avoid leaving the home, creating unnecessary limitations on social opportunities. Nevertheless, it remains the case that vestibular dysfunction is not an inevitable consequence of the aging of the vestibular system. Furthermore, compensation is possible if the individual is able to adapt other sensory systems to make up for vestibular losses (Lord, Clark, & Webster, 1991). Such compensation seems to be more likely to occur if the individual is able to react in a balanced manner to the experience of dizziness or vertigo. The clinician can encourage the older client to benefit from the coping strategies that involve seeking other cues, such as those provided by the somesthetic system. During episodes of dizziness or vertigo, the individual can learn to pay attention to stance and bodily orientation, learning to judge the position of the lower body limbs to make better use of feedback in adjusting posture (Hu & Woollacott 1994a, 1994b; Meenwsen, Sawicki, & Stelmack, 1993).

7.01.9 CONCLUDING OBSERVATIONS In this chapter, a number of age-related changes have been described that occur throughout the body's organ systems and sensory processes. The multiple threshold model postulates that an individual's reactions to these changes varies according to how central the area of functioning is to identity as well as according to whether the individual approaches the age change through identity assimilation or accommodation. The problems involved in using overaccommodation or overassimilation have also been described. Clinicians can learn from this approach to pay greater attention to the subtle and not-sosubtle cues that elderly clients give regarding the concerns they have about the functioning of their bodies. Assessments of older adults in particular, but also adults in middle age, can benefit from detailed history-taking not only of ªhealthº problems but also of the individual's appraisal of and reaction to normal age-related changes in physical and sensory functioning. Such questions are particularly important for the clinician to raise because older clients are likely to be reticent in raising delicate and potentially embarrassing concerns about how their bodies are aging. Clinicians should also be encouraged to narrow their questions as specifically as possible to particular areas of

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Physiological Aspects of Aging: Relation to Identity and Clinical Implications

functioning rather than explore issues related to ªagingº or ªhealthº in general. Such general questions are easily disregarded, as most older individuals tend to report that they are in good health even if they have a number of specific age-related limitations (Heidrich & Ryff, 1993). Authors in the field of clinical geropsychology have, for years, advised clinicians to examine their own age biases and attitudes toward elderly people. This admonition definitely applies with regard to the aging of the body, as clinicians who are a product of Western culture have undoubtedly acquired a number of negative attitudes toward the loss of functioning that is so generally associated with old age. Less well recognized, though, is the need for the clinician to examine his or her own personal aging thresholds. To the extent that the clinician harbors concern about how aging will affect his or her own appearance, physical mobility, or cognitive functioning, that clinician might approach in a defensive and unhelpful way an elderly client with apparent deficits in that area. Finally, it is crucial for clinicians to recognize the independence, autonomy, and vitality of spirit seen in many elders, even those with severe losses or age-related limitations. The older adults seen in therapy are ªsurvivorsº who have managed to reach this point in life through resiliency and an indefatigible ability to adapt to change. They are coping daily with physical changes that would daunt individuals many years their junior. Therapists who condescend to the elderly or patronize them (perhaps as a result of their own fears of aging) are missing important treatment opportunities as well as important opportunities to learn from the wisdom of their clients. 7.01.10 REFERENCES Adrian, M. J. (1981). Flexibility in the aging adult. In E. L. Smith & R. C. Serfass (Eds.), Exercise and aging: The scientific basis (pp. 45±58). Hillsdale, NJ: Enslow. Ancoli-Israel, S., & Kripke, D. F. (1991). Prevalent sleep problems in the aged. Biofeedback and Self Regulation, 16, 349±359. Antoni, M. H. (1987). Neuroendocrine influences in psychoimmunology and neoplasia: A review. Psychology and Health, 1, 3±24. Babin, R. W., & Harker, L. A. (1982). The vestibular system in the elderly. Otolaryngolic Clinics of North America, 15, 387±393. Balin, A. K., & Pratt, L. A. (1989). Physiological consequences of human skin aging. Cutis, 43, 431±436. Bell, B., Wolf, E., & Bernholtz, C. D. (1972). Depth perception as a function of age. Aging and Human Development, 3, 77±81. Bergman, M., Blumenfeld, V. G., Cascardo, D., Dash, B., Levitt, H., & Margulies, M. K. (1976). Age-related decrement in hearing for speech: Sampling and longitudinal studies. Journal of Gerontology, 31, 533±538. Bess, F. H., Lichtenstein, M. J., Logan, S. A., & Burger, M. C. (1989). Hearing impairment as a determinant of

function in the elderly. Journal of the American Geriatrics Society, 37, 123±128. Bliwise, N. G. (1992). Factors related to sleep quality in healthy elderly women. Psychology and Aging, 7, 83±88. Bloom, E. T. (1994). Natural killer cells, lymphokineactivated killer cells, and cytolytic T lymphocytes: Compartmentalization of age-related changes in cytolytic lymphocytes? Journal of Gerontology: Biological Sciences, 49, B85±92. Blumenthal, J. A., Emery, G. F., Madden, D. J., George, L. K., Coleman, R. E., Riddle, M. W., McKee, D. C., Reasoner, J., & Williams, R. S. (1989). Cardiovascular and behavioral effects of aerobic exercise training in healthy older men and women. Journal of Gerontology: Medical Sciences, 44, M147±157. Branch, L. G., Horowitz, A., & Carr, C. (1989). The implications for everyday life of incident self-reported visual decline among people over age 65 living in the community. Gerontologist, 29, 359±365. Brandtstadter, J., & Renner, G. (1990). Tenacious goal pursuit and flexible goal adjustment: Explication and age-related analysis of assimilative and accommodative strategies in coping. Psychology and Aging, 5, 58±67. Brandstetter, R. D., & Kazemi, H. (1983). Aging and the respiratory system. Medical Clinics of North America, 67, 419±431. Brenner, M. H., Curbow, B., Javitt, J. C., Legro, M. W., & Sommer, A. (1993). Vision change and quality of life in the elderly: Response to cataract surgery and treatment of other chronic ocular conditions. Archives of Ophthalmology, 5, 680±685. Brody, H. (1955). Organization of cerebral cortex. III. A study of aging in the human cerebral cortex. Journal of Comparative Neurology, 102, 511±556. Brooks, G. A., & Fahey, T. D. (1984). Exercise physiology: Human bioenergetics and its applications. New York: Wiley. Buell, S. J., & Coleman, P. D. (1979). Dendritic growth in the aged human brain and failure of growth in senile dementia. Science, 206, 854±856. Burgio, K. L., & Engel, B. T. (1990). Biofeedback-assisted behavioral training for elderly men and women. Journal of the American Geriatrics Society, 38, 338±340. Burns, P. A., Pranikoff, K., Nochajski, T. H., Hadley, E. C., Levy, K. J., & Ory, M. G. (1993). A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older communitydwelling women. Journal of Gerontology: Medical Sciences, 38, M167±174. Carter, J. H. (1982). The effects of aging on selected visual functions: Color vision, glare sensitivity, field of vision, and accommodation. In R. Sekuler, D. Kline, & K. Dismukes (Eds.), Aging and human visual function . New York: Alan R. Liss. Carter, J. H. (1982). Predicting visual responses to increasing age. Journal of the American Optometric Association, 53, 31±36. Chien, S., Peng, M. T., Chen, K. P., Huang, T. F., Chang, C., & Fang, H. S. (1975). Longitudinal studies on adipose tissue and its distribution in human subjects. Journal of Applied Physiology, 39, 825±830. Chodzko-Zajko, W. J., Schuler, P., Solomon, J., Heinl, B., & Ellis, N. R. (1992). The influence of physical fitness on automatic and effortful memory changes in aging. International Journal of Aging and Human Development, 35, 265±285. Christian, E., Dluhy, N., & O'Neill, R. (1989). Sounds of silence: Coping with hearing loss and loneliness. Journal of Gerontological Nursing, 15(11), 4±9. Costello, R. B., & Moser-Veillon, P. B. (1992). A review of magnesium intake in the elderly. A cause for concern? Magnesium Research, 5, 61±67. Dalsky, G. P., Stocke, K. S., Ehsani, A. A., Slatopolsky,

References E., Lee, W. C., & Birge, S. J. (1988). Weight-bearing exercise, training, and lumbar bone mineral content in post-menopausal women. Annals of Internal Medicine, 108, 824±828. Dargent, P., & Breart, G. (1993). Epidemiology and risk factors of osteoporosis. Current Opinions in Rheumatology, 5, 339±345. D'Errico, A., Scarani, P., Colosimo, E., Spina, M., Grigioni, W. F., & Mancini, A. M. (1989). Changes in the alveolar connective tissue of the ageing lung. An immunohistochemical study. Archives of Pathology Anatomy and Histopathology, 415, 137±144. Devaney, K. O., & Johnson, H. A. (1980). Neuron loss in the aging visual cortex in man. Journal of Gerontology, 35, 836±841. Diokno, A. C., Brock, B. M., Brown, M. B., & Herzog, A. R. (1986). Prevalence of urinary incontinence and other urological syptoms in the noninstitutionalized elderly. Journal of Urology, 136, 1022±1025. Downton, J. H., & Andrews, K. (1990). Postural disturbance and psychological symptoms amongst elderly people living at home. International Journal of Geriatric Psychiatry, 5, 93±98. Ehsani, A. A., Ogawa, T., Miller, T. R., Spina, R. J., & Jilka, S. M. (1991). Exercise training improves left ventricular systolic function in older men. Circulation, 83, 96±103. Ellis, F. P., Shukla, K. K., Cohn, S. H., & Pierson, R. N. (1974). A predictor for total-body potassium in man based on height, weight, sex, and age: Application in metabolic disorders. Journal of Laboratory and Clinical Medicine, 83, 716±727. Ershler, W. B. (1990). Influenza and aging. In A. L. Goldstein (Ed.), Biomedical advances in aging (pp. 513±521). New York: Plenum. Felson, D. T., Anderson, J. J., Hannan, M. T., Milton, R. C., Wilson, P. W., & Kiel, D. P. (1989). Impaired vision and hip fracture: The Framingham Study. Journal of the American Geriatrics Society, 37, 495±500. Fenske, N. A., & Albers, S. E. (1990). Cosmetic modalities for aging skin: what to tell patients. Geriatrics, 45(9), 59±67. Fiatrone, M. A., & Evans, W. J. (1993). The etiology and reversibility of muscle dysfunction in the aged. Journal of Gerontology, 48 (Special issue), 77±83. Fiatrone, M. A., Marks, E. C., Ryan, N. D., Meredith, C. N., Lipsitz, L. A., & Evans, W. J. (1990). High-intensity strength training in nonagenarians. Effects on skeletal muscle. Journal of the American Medical Association 263, 3029±3034. Fischer, J., & Johnson, M. A. (1990). Low body weight and weight loss in the aged. Journal of the American Dietetic Association, 90, 1697±1706. Flood, D. G., Buell, S. J., Horwitz, G. J., & Coleman, P. D. (1987). Dendritic extent in human dentate gyrus granule cells in normal aging and senile dementia. Brain Research, 402, 205±216. Flood, D. G., & Coleman, P. D. (1988). Cell type heterogeneity of changes in dendritic extent in the hippocampal region of the human brain in normal aging and in Alzheimer's disease. In T. L. Petit & G. O. Ivy (Eds.), Neural plasticity: A lifespan approach (pp. 265±281). New York: Alan R. Liss. Foster, V. L., Hume, G. J. E., Byrnes, W. C., Dickinson, A. L., & Chatfield, S. J. (1989). Endurance training for elderly women: Moderate vs low intensity. Journal of Gerontology: Medical Sciences, 44, M184±188. Friedman, L. F., Bliwise, D. L., Tanke, E. D., & Salom, S. R. (1992). A survey of self-reported poor sleep and associated factors in older individuals. Behavior, Health, and Aging, 2(1), 13±20. Garn, S. M. (1975). Bone loss and aging. In R. Goldman & M. Rockstein (Eds.), The physiology and pathology of

21

aging (pp. 39±57). New York: Academic Press. Gatehouse, S. (1990). Determinants of self-reported disability in older subjects. Ear and Hearing, 11 (Suppl.), 57S±65S. George, L. K., & Weiler, S. J. (1985). Sexuality in middle and late life. In E. Palmore, J. Nowlin, E. Busse, I. Siegler & G. Maddox (Eds.), Normal aging III . Durham, NC: Duke University Press. Gilchrest, B. A. (1989). Skin aging and photoaging: an overview. Journal of the American Academy of Dermatology, 21(3, Pt. 2), 610±613. Globerson, A., Eren, R., Abel, L., & Ben-Menahem, D. (1990). Developmental aspects of T lymphocytes in aging. In A. L. Goldstein (Ed.), Biomedical advances in aging (pp. 363±373). New York: Plenum. Govindasamy, D., Paterson, D. H., Poulin, M., & Cunningham, D. A. (1988). The time course of cardiorespiratory adaptations in elderly men. Canadian Journal of Sport Sciences, 13, 53±54. Grove, G. L. (1989). Physiologic changes in older skin. Clinics in Geriatric Medicine, 5, 115±125. Hagberg, J. M., Graves, J. E., Limacher, L., Woods, D. R., Leggett, S. H., Cononie, C., Gruber, J. J., & Pollock, M.L. (1989). Cardiovascular responses of 70± to 79±yrold men and women to exercise training. Journal of Applied Physiology, 66, 2589±2594. Hakkinen, L. (1984). Vision in the elderly and its use in the social environment. Scandanavian Journal of Social Medicine, 35, 5±60. Hall, T. C., Miller, A. K. H., & Corsellis, J. A. N. (1975). Variations in the human Purkinje cell population according to age and sex. Neuropathology and Applied Neurobiology, 1, 267±292. Hamdorf, P. A., Withers, R. T., Penhall, R. K., & Haslam, M. V. (1992). Physical training effects on the fitness and habitual activity patterns of elderly women. Archives of Physical Medicine and Rehabilitation, 73, 603±608. Harman, S. M. (1978). Clinical aspects of the male reproductive system. In E. L. Schneider (Ed.), Aging: Vol. 4. The aging reproductive system. New York: Raven Press. Heidrich, S. M., & Ryff, C. D. (1993). The role of social comparisons processes in the psychological adaptation of elderly adults. Journal of Gerontology: Psychological Sciences, 48, 127±136. Heiss, G., Tamir, I., Davis, C. E., Tyroler, H. A., Rifkind, B. M., Schonfeld, G., Jacobs, D., & Frantz, I. D. (1980). Lipoprotein-cholesterol distributions in selected North American populations: The Lipid Research Clinics Program Prevalence Study. Circulation, 61, 302±315. Henderson, G., Tomlinson, B., & Gibson, P. H. (1980). Cell counts in human cerebral cortex in normal adults throughout life using an image analysing computer. Journal of the Neurological Sciences, 46, 113±136. Hermanson, B., Omenn, G. S., & Kronmal, R. A. (1988). Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease. New England Journal of Medicine, 24, 1365±1369. Herzog, A. R., Diokno, A. C., Brown, M. B., Normolle, D. P., & Brock, B. M. (1990). Two±year incidence, remission, and change patterns of urinary incontinence in noninstitutionalized older adults. Journal of Gerontology: Medical Sciences, 45, M67±74. Higatsberger, M. R., Budka, H., & Bernheimer, H. (1982). Neurochemical investigations of aged human brain cortex. In S. Hoyer (Ed.), The aging brain: Physiological and pathophysiological aspects. New York: Springer. Hill, R. D., Storandt, M., & Malley, M. (1993). The impact of long-term exercise training on psychological function in older adults. Journal of Gerontology: Psychological Sciences, 48, P12±17. Holt, P. R. (1991). General perspectives on the aged gut. Clinics in Geriatric Medicine, 7, 185±189.

22

Physiological Aspects of Aging: Relation to Identity and Clinical Implications

Hu, M.-H., & Woollacott, M. H. (1994a). Multisensory training of standing balance in older adults: I. Postural stability and one-leg stance balance. Journal of Gerontology: Medical Sciences, 49, M52±61. Hu, M.-H., & Woollacott, M. H. (1994b). Multisensory training of standing balance in older adults. II. Kinematic and electromyographic postural responses. Journal of Gerontology: Medical Sciences, 49, M62±71. Hughes, S. L., Edelman, P. L., Singer, R. H., & Chang, R. W. (1993). Joint impairment and self-reported disability in elderly persons. Journal of Gerontology: Social Sciences, 48, S84±92. Hunskaar, S., & Vinsnes, A. (1991). The quality of life in women with urinary incontinence as measured by the Sickness Impact Profile. Journal of the American Geriatrics Society, 39, 378±382. Huttenlocher, P. (1979). Synaptic density in human frontal cortexÐdevelopmental changes and effects of aging. Brain Research, 163, 195±205. Janelli, L. M. (1993). Are there body image differences between older men and women? Western Journal of Nursing Research, 15, 327±339. Jirovec, M. M. (1991). The impact of daily exercise on the mobility, balance and urine control of cognitively impaired nursing home residents. International Journal of Nursing Studies, 28, 145±151. Johnsson, L. G., & Hawkins, J. E., Jr. (1972). Sensory and neural degeneration with aging, as seen in microdissections of the human inner ear. Annals of Otolaryngology, Rhinology, and Laryngology, 81, 179±193. Kalayam, B., Alexopoulos, G. S., Merrell, H. B., & Young, R. C. (1991). Patterns of hearing loss and psychiatric morbidity in elderly patients attending a hearing clinic. International Journal of Geriatric Psychiatry, 6, 131±136. Kallman, D. A., Plato, C. C., & Tobin, J. D. (1990). The role of muscle loss in the age±related decline of grip strength: Cross-sectional and longitudinal perspectives. Journal of Gerontology: Medical Sciences, 45, M82±88. Karacan, I., Williams, R. L., Thornby, J. I., & Salis, P. J. (1975). Sleep-related penile tumescence as a function of age. American Journal of Psychiatry, 132, 932±937. Kelly, P. J., Nguyen, T., Hopper, J., Pocock, N., Sambrook, P., & Eisman, J. (1993). Changes in axial bone density with age: a twin study. Journal of Bone Mineral Research, 8, 11±17. Kenney, A. R. (1989). Physiology of aging (2nd ed.). Chicago, IL: Yearbook Medical. Kiecolt, K. J. (1994). Stress and the decision to change oneself: A theoretical model. Social Psychology Quarterly, 57, 49±63. Kitzman, D. W., & Edwards, W. D. (1990). Age-related changes in the anatomy of the normal human heart. Journal of Gerontology: Medical Sciences, 45, M33±39. Kitzman, D. W., Scholz, D. G., Hagen, P. T., Ilstrup, D. M., & Edwards, W. D. (1988). Age-related changes in normal human hearts during the first ten decades. Part II (Maturity): A quantitative anatomic study of 765 specimens from subjects 20 to 99 years old. Mayo Clinic Proceedings, 63, 137±146. Kleinsmith, D. M., & Perricone, N. V. (1989). Common skin problems in the elderly. Clinics in Geriatric Medicine, 5, 189±211. Kligman, A. M. (1989). Psychological aspects of skin disorders in the elderly. Cutis, 43, 498±501. Kligman, A. M., Grove, G. L., & Balin, A. K. (1985). Aging of human skin. In C. E. Finch & E. L. Schneider (Eds.), Handbook of the biology of aging (2nd ed. ). New York: Van Nostrand Reinhold. Kosnik, W., Winslow, L., Kline, D., Rasinski, K., & Sekuler, R. (1988). Visual changes in daily life throughout adulthood. Journal of Gerontology: Psychological Sciences, 43, P63±70. Krall, E. A., & Dawson-Hughes, B. (1993). Heritable and

life-style determinants of bone mineral density. Journal of Bone Mineral Research, 8, 1±9. Kurban, R. S., & Bhawan, J. (1990). Histologic changes in skin associated with aging. Journal of Dermatology and Surgical Oncology, 16, 908±914. Kutza, J., Kaye, D., & Murasko, D. M. (1995). Basal natural killer cell activity of young versus elderly humans. Journal of Gerontology: Biological Sciences, 50A, B110±116. Labouvie-Vief, G., Hakim-Larson, J., & Hobart, C. J. (1987). Age, ego level, and the life-span development of coping and defense processes. Psychology and Aging, 2, 286±293. Lakatta, E. G. (1987). Why cardiovascular function may decline with age. Geriatrics, 42, 84±94. Lamy, P. P. (1988). Actions of alcohol and drugs in older people. Generations, 12(4), 9±13. Lavker, R. M., Kwong, F., & Kligman, A. M. (1980). Changes in skin surface patterns with age. Journal of Gerontology, 35, 348±354. Lebo, C. P., & Reddell, R. C. (1972). The presbycusis component in occupational hearing loss. Laryngoscope, 82, 1399±1409. Lord, S. R., Clark, R. D., & Webster, I. W. (1991). Postural stability and associated physiological factors in a population of aged persons. Journal of Gerontology: Medical Sciences, 46, M69±76. Lord, S. R., Clark, R. D., & Webster, I. W. (1991). Physiological factors associated with falls in an elderly population. Journal of the American Geriatrics Society, 39, 1194±1200. Mahler, D. A., Rossiello, R. A., & Loke, J. (1986). The aging lung. Clinics in Geriatric Medicine, 2, 215±225. Manchester, D., Woollacott, M., Zederbauer-Hylton, N., & Marin, O. (1989). Visual, vestibular and somatosensory contributions to balance control in the older adult. Journal of Gerontology: Medical Sciences, 44, M118±127. Mancil, G. L., & Owsley, C. (1988). `Vision through my aging eyes' revisited. Journal of the American Optometric Association, 59, 288±294. Marmor, M. F. (1980). Clinical physiology of the retina. In G. A. Reyman, D. R. Sanders, & M. F. Goldberg (Eds.), Principles and practice of opthalmology (Vol. 2, pp. 823±856). Philadelphia: Saunders. Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston, MA: Little, Brown. Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. Boston, MA: Little, Brown. Mazess, R. B. (1982). On aging bone loss. Clinical Orthopaedics and Related Research, 165, 239±252. McArdle, W. D., Katch, F. I., & Katch, V. L. (1991). Exercise physiology: Energy, nutrition, and human performance (3rd ed.). Philadelphia: Lea & Febiger. McAuley, E., Lox, C., & Duncan, T. E. (1993). Long-term maintenance of exercise, self-efficacy, and physiological change in older adults. Journal of Gerontology: Psychological Sciences, 48, P218±224. McCalden, R. W., McGeough, J. A., Barker, M. B., & Court-Brown, C. M. (1993). Age-related changes in the tensile properties of cortical bone. The relative importance of changes in porosity, mineralization, and microstructure. Journal of Bone and Joint Surgery, 75, 1193±1205. McFarland, R. A., Domey, R. G., Warren, A. B., & Ward, D. C. (1960). Dark adaptation as a function of age: I. A statistical analysis. Journal of Gerontology, 15, 149±154. McLachlan, M. S. F., Guthrie, J. C., Anderson, C. K., & Fulker, M. J. (1977). Vascular and glomerular changes in the ageing kidney. Journal of Pathology, 121, 65±78. McMurdo, M. E., & Gaskell, A. (1991). Dark adaptation and falls in the elderly. Gerontology, 37, 221±224. McNaughton, M. E., Smith, L. W., Patterson, T. L., & Grant, I. (1990). Stress, social support, coping resources,

References and immune status in elderly women. Journal of Nervous and Mental Disease, 178, 460±461. Meeuwsen, H. J., Sawicki, T. M., & Stelmach, G. E. (1993). Improved foot position sense as a result of repetitions in older adults. Journal of Gerontology: Psychological Sciences, 48, P137±141. Meredith, C. N., Frontera, W. R., Fisher, E. C., Hughes, V. A., Herland, J. C., Edwards, J., & Evans, W. J. (1989). Peripheral effects of endurance training in young and old subjects. Journal of Applied Physiology, 66, 2844±2849. Miller, R. A. (1993). Aging and cancerÐAnother perspective. Journal of Gerontology: Biological Sciences, 48, B8±9. Montamat, S. C., & Davies, A. O. (1989). Physiological response to isoproterenol and coupling of beta-adrenergic receptors in young and elderly human subjects. Journal of Gerontology: Medical Sciences, 44, M100±105. Montgomery, S. A. (1990). Depression in the elderly: Pharmacokinetics of antidepressants and death from overdose. International Clinical Psychopharmacology, 5(Suppl. 3), 67±76. Morey, M. C., Cowper, P. A., Feussner, J. R., DiPasquale, R. C., Crowley, G. M., Kitzman, D. W., & Sullivan, R. J., Jr. (1991). Two-year trends in physical performance following supervised exercise among community-dwelling older veterans. Journal of the American Geriatrics Society, 39, 986±992. Morgan, M. W. (1988). VIsion through my aging eyes. Journal of the American Optometric Association, 59, 278±280. Morley, J. E., & Reese, S. S. (1989). Clinical implications of the aging heart. The American Journal of Medicine, 86, 77±86. Moses, R. A. (1981). Accommodation. In R. A. Moses (Ed.), Adler's physiology of the eye. St. Louis, MO: Mosby. Mouritzen Dam, A. (1979). The density of neurons in the human hippocampus. Neuropathology and Applied Neurobiology, 5, 249±264. Naliboff, B. D., Benton, D., Solomon, G. F., Morley, J. E., Fahey, J. L., Bloom, E. T., Makinodan, T. et al. (1991). Immunological changes in young and old adults during brief laboratory stress. Psychosomatic Medicine, 53, 121±132. Neils, J., Newman, C. W., Hill, M., & Weiler, E. (1991). The effects of rate, sequencing, and memory on auditory processing in the elderly. Journal of Gerontology, 46(2), 71±75. Nuti, R., & Martini, G. (1993). Effects of age and menopause on bone density of entire skeleton in healthy and osteoporotic women. Osteoporosis International, 3, 59±65. O'Donoghue, M. N. (1991). Cosmetics for the elderly. Dermatology Clinics, 9, 29±34. O'Leary, A. (1990). Stress, emotion, and human immune function. Psychological Bulletin, 108, 363±382. Olivetti, G., Melissari, M., Capasso, J. M., & Anversa, P. (1991). Cardiomyopathy of the aging human heart. Myocyte loss and reactive cellular hypertrophy. Circulation Research, 68, 1560±1568. Ordy, J. M., Brizzee, K. R., & Johnson, H. A. (1982). Cellular alterations in visual pathways and the limbic system: Implications for vision and short±term memory. In R. Sekuler, D. Kline, & K. Dismukes (Eds.), Aging and human visual function. New York: Alan R. Liss. Ouslander, J. G., & Abelson, S. (1990). Perceptions of urinary incontinence among elderly outpatients. Gerontologist, 30(3), 369±372. Ouslander, J. G., Zarit, S. H., Orr, N. K., & Muira, S. A. (1990). Incontinence among elderly community-dwelling dementia patients: Characteristics, management, and impact on caregivers. Journal of the American Geriatrics

23

Society, 38, 440±445. Overend, T. J., Cunningham, D. A., Kramer, J. F., Lefcoe, M. S., & Paterson, D. H. (1992). Knee extensor and knee flexor strength: Cross-sectional areas ratio in young and elderly men. Journal of Gerontology: Medical Sciences, 47, M204±210. Panek, P. E., Barrett, G. V., Sterns, H. L., & Alexander, R. A. (1977). A review of age changes in perceptual information ability with regard to driving. Experimental Aging Research, 3, 387±449. Parmelee, P. A., Katz, I. R., & Lawton, M. P. (1991). The relation of pain to depression among institutionalized aged. Journal of Gerontology: Psychological Sciences, 46, P15±21. Paterson, C. A. (1979). Crystalline lens. In R. E. Records (Ed.), Physiology of the human eye and visual system. New York: Harper & Row. Poulin, M., Paterson, D. H., Govindasamy, D., & Cunningham, D. A. (1988). Endurance training of elderly men. Responses to submaximal exercise. Canadian Journal of Sport Sciences, 13, 78±79P. Reddan, W. G. (1981). Respiratory system and aging. In E. L. Smith & R. C. Serfass (Eds.), Exercise and aging: The scientific basis (pp. 89±107). Hillside, NJ: Enslow. Richards, O. W. (1977). Effects of luminance and contrast on visual acuity ages 16 to 90 years. American Journal of Optometry and Physiological Optics, 54, 178±184. Rico, H., Revilla, M., Hernandez, E. R., Gonzalez-Riola, J. M., & Villa, L. F. (1993). Four-compartment model of body composition of normal elderly women. Age and Aging, 22, 265±268. Riggs, B. L., Wahner, W. H., Dunn, W. L., Mazess, R. B., Offord, K. P., & Melton, L. J. (1981). Differential changes in bone mineral density of the appendicular and axial skeleton with aging. Journal of Clinical Investigation, 67, 328±335. Rikli, R. E., & McManis, B. G. (1990). Effects of exercise on bone mineral content in postmenopausal women. Research Quarterly in Exercise of Sport, 61, 243±249. Roberto, K. (1992). Coping strategies of older women with hip fractures: Resources and outcomes. Journal of Gerontology: Psychological Sciences, 47, 21±26. Rosenbloom, C. A., & Whittington, F. J. (1993). The effects of bereavement on eating behaviors and nutrient intakes in elderly widowed persons. Journal of Gerontology: Social Sciences, 48, S223±229. Rosenhall, U., & Rubin, W. (1973). Degenerative patterns in the aging human vestibular neuroepithelia. Acta Otolaryngolica, 76, 208±220. Rowe, J. W. (1982). Renal function and aging. In M. E. Reff & E. L. Schneider (Eds.), Biological markers of aging. Bethesda, MD: National Institutes of Health, Publication No. 82±2221. Rowe, J. W., Shock, N. W., & DeFronzo, R. A. (1976). The influence of age on the renal response to water deprivation in man. Nephron, 17, 270±278. Rudberg, M. A., Furner, S. E., Dunn, J. E., & Cassel, C. K. (1993). The relationship of visual and hearing impairments to disability: An analysis using the longitudinal study of aging. Journal of Gerontology: Medical Sciences, 48, M261±265. Ryan, A. S., Craig, L. D., & Finn, S. C. (1992). Nutrient intakes and dietary patterns of older Americans: A national study. Journal of Gerontology: Medical Sciences, 47, M145±150. Ryff, C. D. (1989). In the eye of the beholder: Views of psychological well-being among middle-aged and older adults. Psychology and Aging, 4, 195±210. Scheibel, A. B. (1982). Age-related changes in the human forebrain. Neurosciences Research Progress Bulletin, 20, 577±583. Scheie, H. G., & Albert, D. M. (1977). Textbook of opthalmology. (9th ed.). Philadelphia: Saunders.

24

Physiological Aspects of Aging: Relation to Identity and Clinical Implications

Schiavi, R. C., & Schreiner-Engel, P. (1988). Nocturnal penile tumescence in healthy aging men. Journal of Gerontology: Medical Sciences, 43, M146±150. Schulman, S. P., & Gerstenblith, G. (1989). Cardiovascular changes with aging: The response to exercise. Journal of Cardiopulmonary Rehabilitation, 9, 12±16. Shephard, R. J. (1978). Physical activity and aging. Chicago, IL: Yearbook Medical. Sherman, S. S., Tobin, J. D., Hollis, B. W., Gundberg, C. M., Roy, T. A., & Plato, C. C. (1992). Biochemical parameters associated with low bone density in healthy men and women. Journal of Bone and Mineral Research, 7, 1123±1130. Shimojo, M., Tsuda, N., Iwasaka, T., & Inada, M. (1991). Age-related changes in aortic elasticity determined by gated radionuclide angiography in patients with systemic hypertension or healed myocardial infarcts and in normal subjects. American Journal of Cardiology, 68, 950±953. Shock, N. W., Andres, R., Norris, A. H., & Tobin, J. D. (1978). Patterns of longitudinal changes in renal function, Proceedings XII International Congress of Gerontology, Tokyo, August 20±25 (pp. 525±527). Amsterdam: Excerpta Medica. Slawinski, E. B., Hartel, D. M., & Kline, D. W. (1993). Self-reported hearing problems in daily life throughout adulthood. Psychology and Aging, 8, 552±561. Smith, E. L. (1981). Physical activity: A preventive and maintenance modality for bone loss with age. In F. J. Nagle & H. J. Montoye (Eds.), Exercise in health and disease (pp. 196±202). Springfield, IL: Charles C. Thomas. Smith, W. D. F., Cunningham, D. A., Patterson, D. H., Rechnitzer, P. A., & Koval, J. J. (1992). Forced expiratory volume, height, and demispan in Canadian men and women aged 55±86. Journal of Gerontology: Medical Sciences, 47, M40±44. Solnick, R. L., & Birren, J. E. (1977). Age and male erectile responsiveness. Archives of Sexual Behavior, 6, 1±9. Sparrow, D., Beausoleil, N. I., Garvey, A. J., Rosner, B., & Silbert, J. E. (1982). The influence of cigarette smoking and age on bone loss in men. Archives of Environmental Health, 37, 246±249. Spector, A. (1982). Aging of the lens and cataract formation. In R. Sekuler, D. Kline, & K. Dismukes (Eds.), Aging and human visual function. New York: Alan R. Liss. Stamford, B. A. (1988). Exercise in the elderly. In K. B. Pandolf (Ed.), Exercise and Sports Sciences Reviews, 16, 341±379. Stevenson, J. S., & Topp, R. (1990). Effects of moderate and low intensity long-term exercise by older adults. Research in Nursing and Health, 13, 209±218. Suominen, H., Heikkinen, E., Parkatti, T., Forsberg, S., & Kiiskinen, A. (1977). Effect of lifelong physical training on functional aging in men. Scandanavian Journal of the Society of Medicine, 14 (Suppl.), 225±240. Tamai, T., Nakai, T., Takai, H., Fujiwara, R., Miyabo, S., Higuchi, M., & Kobayashi, S. (1988). The effects of physical exercise on plasma lipoprotein and apolipoprotein metabolism in elderly men. Journal of Gerontology: Medical Sciences, 43, M75±79. Teasdale, N., Stelmach, G. E., & Breunig, A. (1991). Postural sway characteristics of the elderly under normal and altered visual and support surface conditions. Journal of Gerontology: Biological Sciences, 46, B238±244. Teramoto, S., Fukuchi, Y., Nagase, T., Matsuse, T., & Orimo, H. (1995). A comparison of ventilation components in young and elderly men during exercise. Journal of Gerontology: Biological Sciences, 50A, B34±39. Thomas, P. D., Goodwin, J. M., & Goodwin, J. W. (1985). Effect of social support on stress-related changes in

cholesterol, uric acid level, and immune function in an elderly sample. American Journal of Psychiatry, 142, 735±737. Tinetti, M. E., & Powell, L. (1993). Fear of falling and low self-efficacy: A cause of dependence in elderly persons. Journal of Gerontology, 48 (Special Issue), 35±58. Toglia, J. U. (1975). Dizziness in the elderly. In W. Fields (Ed.), Neurological and sensory disorders in the elderly. New York: Grune & Stratton. Vandervoort, A. A., Chesworth, B. M., Cunningham, D. A., Paterson, D. H., Rechnitzer, P. A., & Koval, J. J. (1992). Age and sex effects on mobility of the human ankle. Journal of Gerontology: Medical Sciences, 47, M17±21. Van-Rooij, J. C., & Plomp, R. (1990). Auditive and cognitive factors in speech perception by elderly listeners: II. Multivariate analyses. Journal of the Acoustical Society of America, 88, 2611±2624. Van-Rooij, J. C., & Plomp, R. (1992). How much do working memory deficits contribute to age differences in discourse memory? Special Issue: Cognitive gerontology. Journal of the Acoustical Society of America, 91, 1028±1033. Vollardt, L. T. (1991). Psychoneuroimmunology: A literature review. American Journal of Orthopsychiatry, 61, 35±47. Wald, A. (1990). Constipation and fecal incontinence in the elderly. Gastroenterology Clinics of North America, 19, 405±418. Webb, G. D., Poehlman, E. T., & Tonino, R. P. (1993). Dissociation of changes in metabolic rate and blood pressure with erthrocyte Na±K pump activity in older men after endurance training. Journal of Gerontology: Medical Sciences, 48, M47±52. Wedmann, B., Schmidt, G., Wegener, M., Coenen, C., Ricken, D., & Althoff, J. (1991). Effects of age and gender on fat-induced gallbladder contraction and gastric emptying of a caloric liquid meal: a sonographic study. American Journal of Gastroenterology, 86, 1765±1770. Weisfeldt, M. L., & Gerstenblith, G. (1986). Cardiovascular aging and adaptation to disease. In J. W. Hurst (Ed.), The heart. New York: Macmillan. Whitbourne, S. K. (1996a). The aging individual: Physical and psychological perspectives. New York: Springer. Whitbourne, S. K. (1996b). Identity processes and perceptions of physical functioning in adults: A test of the multiple threshold model. American Psychological Association 104th Annual Meeting. Toronto, Ontario, Canada. Whitbourne, S. K. (1986). The me I know: A study of adult identity. New York: Springer. Whitbourne, S. K., & Primus, L. A. (1996). Physical identity in later adulthood. In J. E. Birren (Ed.), Encyclopedia of aging. San Diego, CA: Academic Press. Whitbourne, S. K., & Wills, K.-J. (1993). Psychological issues in institutional care of the aged. In S. B. Goldsmith (Ed.), Long-term care administration handbook (pp. 19±32). Gaithersburg, MD: Aspen. Wolf, E., & Gardiner, J. S. (1965). Studies on the scatter of light in the dioptric media of the eye as a basis of visual glare. Archives of Opthalmology, 74, 338±345. Woodward, N. J., & Wallston, B. S. (1987). Age and health care beliefs: Self-efficacy as a mediator of low desire for control. Psychology and Aging, 3±8. Wright, B. A., Aizenstein, S., Vogler, G., Rowe, M., & Miller, C. (1990). Frequent fallers: Leading groups to identify psychological factors. Journal of Gerontological Nursing, 16(4), 15±19. Wyman, J. F., Harkins, S. W., & Fantl, J. A. (1990). Psychosocial impact of urinary incontinence in the community-dwelling population. Journal of the American Geriatrics Society, 38(3), 282±288.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

7.02 Cognition and Geropsychological Assessment BOO JOHANSSON Institute of Gerontology and Centre for Psychology, University College of Health Sciences, JoÈnkoÈping, Sweden and AÊKE WAHLIN Stockholm Gerontology Research Center and Karolinska Institute, Stockholm, Sweden 7.02.1 INTRODUCTION

26

7.02.2 NONCOGNITIVE INFLUENCES ON MEMORY AND COGNITION IN AGING

26

7.02.2.1 Types of Aging 7.02.2.1.1 Primary aging 7.02.2.1.2 Secondary agingÐphysical health 7.02.2.1.3 Summary 7.02.2.2 The Individual 7.02.2.2.1 Coping and self-attributions 7.02.2.2.2 Psychological well-being 7.02.2.2.3 Summary 7.02.2.3 Sociocultural Context 7.02.2.3.1 Cohort and period effects 7.02.2.3.2 Sociocognitive development 7.02.2.3.3 Summary 7.02.2.4 Cognitive Demands and Everyday Functioning 7.02.2.4.1 Cognitive mechanisms and tasks 7.02.2.4.2 Tests of functional abilities 7.02.2.4.3 Summary

26 27 28 29 29 29 31 32 33 33 34 34 35 35 36 36

7.02.3 MEMORY AND OTHER COGNITIVE ABILITIES

36 36 37 37 37 38 39 39 40 41 45

7.02.3.1 Learning and Memory 7.02.3.1.1 Types of learning 7.02.3.1.2 Models of memory 7.02.3.1.3 Episodic memory 7.02.3.1.4 Memory tests and cognitive support 7.02.3.1.5 Summary 7.02.3.2 Intellectual Abilities 7.02.3.2.1 Intelligence and aging 7.02.3.2.2 Specific cognitive abilities 7.02.3.2.3 Summary 7.02.4 COPING WITH COGNITIVE CHANGE IN AGING: PERSPECTIVES OF THE AGING INDIVIDUAL AND THE GEROPSYCHOLOGIST

25

45

26

Cognition and Geropsychological Assessment 7.02.4.1 ªFrom Lab to Lifeº 7.02.4.1.1 Individual differences 7.02.4.1.2 Ecological validity 7.02.4.1.3 Complex cognitive processing 7.02.4.1.4 Everyday life experiences and learning 7.02.4.1.5 Current knowledge and extralaboratory cognition 7.02.4.1.6 Cognitive aging and the individual: an integrative model 7.02.4.1.7 Cognitive reserves and plasticity 7.02.4.2 General Assessment Guidelines 7.02.4.3 Future Prospects and Cohorts

7.02.5 REFERENCES

7.02.1 INTRODUCTION Understanding age-related changes, as well as stability, in highly integrated cognitive functions is of fundamental importance for the geropsychologist since memory and cognitive abilities are often focused in an assessment setting. The geropsychologist may be confronted with elderly individuals who seek help because of worries and experiences of cognitive failures, or who are referred to an assessment by family or health professionals due to impairments in memory and thinking. A fundamental issue for an unbiased assessment of memory and other cognitive abilities is the geropsychologist's expertise in considering strengths or preserved ability as well as weaknesses or impaired ability relative to previous functioning, as well as the cognitive demands that are imposed in everyday life and how this relates to outcomes of cognitive testing. Other issues refer to the application of theoretical guidelines for analyzing performance, including the mechanisms involved, taking into account individual factors and the sociocultural context for cognitive functioning in aging. This chapter discusses various aspects of cognitive functioning in aging in a context that is intended to correspond to that of the clinical geropsychologist, where considerations are based on detailed information about the individual in the assessment setting as well as outside the clinic. Other chapters in this volume address reasons for assessment of elderly people, including principles and methods. The present chapter provides a solid base for these more applied contributions. Given the limitation of a single chapter for discussing cognitive aspects of aging, the reader is directed to consult recent reviews for detailed information on current research on memory (e.g., Kausler, 1994), cognitive aging (e.g., Craik & Salthouse, 1992), and clinical geropsychology, including relevant chapters in the Handbook of the psychology of aging (Birren & Schaie, 1996 and previous editions).

45 45 45 46 46 46 47 47 48 49 49

This chapter is organized into subsections based on the heuristic scheme presented in Figure 1. The general idea with this scheme is that cognitive functioning must be understood and consequently analyzed within the context of noncognitive factors. The emphasis will be on aspects of memory and intellectual abilities that are likely to be addressed in an assessment setting (the term assessment is used throughout in its broadest sense and includes assessment in clinical settings as well as research approaches to various aspects of memory and cognitive aging). The noncognitive factors depicted in Figure 1 are first discussed with reference to general aspects of memory and cognition. An overview of these domains of functioning follows, based on what is considered to be of relevance for the geropsychologist. The final section comprises an integration of cognitive aspects of aging, including messages to the geropsychologist.

7.02.2 NONCOGNITIVE INFLUENCES ON MEMORY AND COGNITION IN AGING 7.02.2.1 Types of Aging Psychological aging is a complex interaction process involving influences from biological and social factors. In addition, the aging process is characterized by change as well as continuity and becomes manifest in a multidimensional and multidirectional manner. The former refers to the differential view on aging in which various abilities are affected differently, while the latter refers to the observation that certain abilities may deteriorate gradually, whereas still others remain stable or even improve. The cascade metaphor of aging, proposed by Birren and Cunningham (1985), represents a heuristic simplification in the context of geropsychological assessment. The metaphor is based on the separation of primary, secondary,

Noncognitive Influences on Memory and Cognition in Aging

A. Types of aging

27

B. The individual

– primary aging – secondary aging – tertiary aging

– demographics, skills and knowledge – coping and self-attributions – psychological well-being

E. Learning and memory F. Intellectual abilities

C. Sociocultural context – cohort and period effects – sociocognitive development

D. Cognitive demands – cognitive testing – everyday life tasks

Figure 1 An analytical scheme for understanding and assessment of cognitive functioning in aging.

and tertiary aging patterns. Primary aging refers to intrinsic sources producing irreversible changes but otherwise a healthy or normal aging trajectory. Secondary aging refers to changes due to illnesses or pathology, adding to the inevitable primary aging. Tertiary aging refers to factors increasing the mortality risk and the pattern of terminal decline that becomes manifest preceding death. At the individual level this may be seen as a ªcurvilinearº dramatic drop while at the group level as a linear decline (cf. Berg, 1996). It could easily be argued that it is impossible fully to separate the three theoretical aging types. However, in an assessment it is usually required that the geropsychologist concludes whether an observed impairment is to be diagnosed in terms of dysfunction or whether the impairment is to be considered within the borders of ªnormal aging.º The phenomenon of terminal decline (e.g., Johansson & Berg, 1992) must also be taken into account, but is otherwise not an obvious diagnostic issue. 7.02.2.1.1 Primary aging With increasing age we can expect less primary aging and more secondary and tertiary aging. Although the likelihood of sole primary aging decreases substantially with age because of increased morbidity, primary aging constitutes the bottom line for our understanding of cognitive aging. Primary aging is, in practice, defined as the lack of illnesses that potentially could be diagnosed. In a population-based random sample of nondemented community-dwelling

individuals aged 75 to 96 years, Wahlin et al. (1993) had to exclude 38% of the participants in order to meet their health criteria. Of these, 19% were excluded because of a Mini-Mental State score (MMSE) below 25 (Folstein, Folstein, & McHugh, 1975), 4% due to psychiatric disease and/or medication, and 15% due to values of serum vitamin B12 or thyroid-stimulating hormone indicative of disease. Primary cognitive aging is principally characterized by a reduction in the speed at which information is processed in the cognitive system (e.g., Light, 1991; Salthouse, 1993). This slowing affects all cognitive processes where speed of behavior is an essential component, for example, in problem solving or executive functioning. In many tests, time limits are therefore more disadvantageous for an elderly person as compared to a younger individual. A conceptual distinction within primary aging is that between usual and successful aging. According to Rowe and Kahn (1987), usual aging refers to normal aging heightened by the effects of extrinsic factors, both physical and psychosocial. In successful aging, these extrinsic influences have a neutral or positive role in maintaining functioning. As emphasized by Rowe and Kahn, the elucidation of factors that explain success is of great value for potential interventions, including preventive efforts, aiming at successful aging. Hill, Wahlin, Winblad, and BaÈckman (1995) followed this route and examined the predictive strength of demographic and life-style variables for memory performance and ability to utilize cognitive support in very old age. The authors concluded that among healthy elderly persons,

28

Cognition and Geropsychological Assessment

those who were younger, better educated, and more socially active not only improved more from cognitive support, but also demonstrated better overall performance. Further, level of exercise (in terms of walking or bicycling) was found to be a reliable predictor of episodic free recall performance. Although this was a cross-sectional study, and no conclusions can be drawn about causative relations, it was argued that the results are relevant for the selection of individuals who are likely to benefit from memory training programs. Identifying factors important for level of cognitive performance (such as level of social activity or exercise) may also have implications for other interventions. 7.02.2.1.2 Secondary agingÐphysical health Secondary or disease-related aging becomes significantly more important with increasing age. It is well known that age is associated with an increased prevalence of a variety of diseases that may affect cognitive and memory functioning (e.g., Brody & Schneider, 1986; Fries & Crapo, 1981). Among persons over 65, more than 80% have at least one chronic illness, and many individuals have multiple diagnoses. In addition to an even more pronounced slowing of speed (e.g., Salthouse, 1993), other intellectual abilites are also likely to become affected by various illnesses. A few examples are sufficient to illustrate the effects of secondary aging on cognitive abilities: the cardiovascular system is prone to age-related changes, the prevalence of heart disease among those 65 years of age and older in the Western world is estimated to be approximately 30% (Epstein et al., 1965), and the treatment of hypertension among elderly adults is considered by many geriatricians to be an almost normal and inevitable medication in aging. It has been demonstrated that cardiovascular disease has negative impacts on memory and cognition (e.g., Barclay, Weiss, Bond, & Blass, 1988; Grut, Forsell, Hill, BaÈckman, & Winblad, 1995). Furthermore, the negative relation between elevated blood pressure and cognitive functioning has been documented in several longitudinal investigations (e.g, Farmer et al., 1990), and performance differences may also exist as a function of blood pressure medication (e.g., Elias, Wolf, D'Agostino, Cobb, & White, 1993). Also, older people may have health-related motor impairments that interfere with performance on psychological tests. Examples include tremor associated with Parkinson's disease, or difficulties associated with severe arthritis. Obviously, it may be necessary to modify tasks that put demands on hand motor functioning.

Additional examples concern the negative relation between cognitive performance and such diverse conditions as diabetes (e.g., Bale, 1973), epilepsy (e.g., Dikman & Matthews, 1977), hyperthyroidism (Gambert, 1988), hypothyroidism (Mennemeier, Garner, & Heilman, 1993), or diseases related to vitamin deficiency (e.g., Wahlin, Hill, Winblad, & BaÈckman, in press). It is well known that visual acuity (Lerman, 1983) and hearing, especially of high-frequency tones (Ordy, Brizzee, Beavers, & Medart, 1979), decline with age. In the assessment situation, it therefore becomes neccessary first to make sure that the older person has sufficient hearing or vision abilities to meet the sensory demands of the tasks at hand. It is notable that even within normal ranges, sensory functioning seems to be a strong late-life indicator of intellectual functioning (Lindenberger & Baltes, 1994). Comprehensive health screening is rarely performed in cognitive aging studies. For the clinician, this should be kept in mind in using results from scientific reports as normative data. More recent studies of age-related effects on memory and other cognitive performance, however, have tended to screen for potentially confounded critical aspects of physical health (e.g., BaÈckman & Wahlin, 1995; Hill et al., 1995; Robins Wahlin, BaÈckman, Wahlin, & Winblad, 1993, 1996; Wahlin, BaÈckman, & Winblad, 1995). Given the complexity of the potential impact of health-related factors, it is difficult to present clear-cut recommendations to the geropsychologist. Generally speaking, it is however important to evaluate performance, keeping in mind that influences other than what is addressed by the diagnostic question must be taken under serious consideration by the geropsychologist. There exists at present no clear consensus about the differentiation between primary aging and pathology. This distinction becomes increasingly difficult with age, with the risk of both over- and underdiagnosis, that is, defining assessment results within the category of ªnormal agingº as disease/illness or ascribing an impairment to ªnormal aging.º Also, the symptoms for many diseases change and tend to be more diffuse, in addition to prevalent comorbidity in old age (Fozard, Metter, & Brant, 1990). Furthermore, a diagnosis of disease is often accompanied by certain treatment efforts and with potential side-effects on cognitive functions. For example, Berg and Dellasega (1996), examined the relationships between cognitive function and psychotropic medication use in the H70 population-based sample in Sweden over a nine-year period (see Section 7.02.3.2.1). About one-third of the

Noncognitive Influences on Memory and Cognition in Aging sample was on a drug regimen including anxiolytics, hypnotics, and antidepressant medications. The study showed that these psychotropics had a negative effect on most cognitive functions, although the effects generally were found to be moderate. The dementia syndrome represents a diagnostic category of particular relevance for cognitive aging, since dementia is the single most devastating group of illnesses in which memory disturbances and cognitive impairments are cardinal outcomes. We will only address a few issues here. Dementia is extensively discussed in Chapter 10, this volume. The prevalence of dementia increases with age and the incidence rates are considerable (e.g., Fratiglioni et al., 1991; Johansson & Zarit, 1995). Dementia also demonstrates the principal difficulties in separating primary and secondary aging at an early stage, despite findings of significant impairments already present in the earliest, preclinical stage. Johansson and Zarit (1997) examined this ªborderline issueº in a longitudinal study of a populationbased sample of people aged 84 and older. They found that nondemented subjects who were diagnosed with ªmild dysfunctionº because of their performance were 11 times more likely to develop dementia within a two-year period, and seven times more likely to become demented over a four-year period. Their results also provide further evidence for terminal decline, as the likelihood for subsequent mortality was greater among individuals diagnosed with ªmild dysfunction.º The mortality risk was three times greater over two years and five times greater over four years compared with individuals who were rated as cognitively intact (see Figure 2). The insidious onset of many diseases, like that of primary degenerative dementia (e.g., Alzheimer's disease) presents particular diagnostic problems. As pointed out by Sliwinski, Lipton, Buschke, and Stewart (1996), the identification of preclinical dementia is complicated by the overestimation of age effects on cognitive measures through an underestimation of the mean and an overestimation of variance. This notion becomes more important with increasing age, because of higher prevalence rates and increased likelihood of the incidence of dementia. Besides the neccessary criteria of impaired memory and other cognitive abilities, a functional criterion is generally employed for the definition of a clinically manifest dementia. This functional criterion, as in the case of the Diagnostic and statistical manual for mental disorders (DSM; American Psychiatric Association, 1987, 1994), requires that cognitive impairments need to be of

29

sufficient severity to interfere with social or occupational functioning. A problem, however, is that cognitive demands may vary with age. The risk of underdiagnosis tends to be greater with the oldest-old due to lower cognitive demands in everyday life which makes it less likely that impairments will be uncovered. A more detailed discussion about inputs from the sociocultural context follows in Section 7.02.2.3. 7.02.2.1.3 Summary Aging is not a unitary process but the complex outcome of numerous interactions with biological, psychological and social subprocesses. The outcome can roughly be categorized using three broad aging types: primary, secondary, and tertiary aging. The distinction between primary and secondary aging often corresponds to what is expected of the geropsychologist. A differential view of cognitive aging means that while performance in certain functions has declined and may be diagnosed as an expression of disease, for example dementia, performance in other functions may remain within the ªnormal agingº category or at the border of primary aging. This is especially the case when impairments are mild or changes are subtle and where there is lack of information on decline and course of change. 7.02.2.2 The Individual Within each type of aging pattern, described above, one can discern features unique to the individual. Such individual or subject-related factors refer to exposures that have affected the individual throughout life. Whereas certain factors reflect basic demographics like age, gender, ethnicity, and socioeconomics, others refer to various aspects of personality and mental health. An understanding of the unique constellation of these influences requires the gathering of information necessary to evaluate present functioning in light of previous ability. In addition, this notion provides arguments for an interindividual difference perspective on aging. 7.02.2.2.1 Coping and self-attributions The individual's unique repertoire of behaviors, including cognitive and emotional styles, represents another dimension to consider in an assessment. Coping and self-attributions are, in the late 1990s, more often identified as significant influences for memory and cognition. A number of coping definitions have been proposed. Most of them share the general idea

BASELINE

NO DEMENTIA

N = 218

2nd YEAR

4th YEAR

6th YEAR

N = 46 (22%)

N = 34 (27%)

N = 19 (27%)

N = 124

N = 34 (20%)

DEMENTIA

N = 97 (31%)

N = 82 (40%)

N = 71

N = 14 (15%)

N = 52 (42%)

Deceased

N = 43

N=5 (10%)

INCIDENCE*

N = 31 (42%)

Deceased

N = 44 (46%)

N = 42 (51%)

N = 26 (50%)

* Incidence was calculated by taking the percentage of new cases of dementia from among surviving subjects not diagnosed as demented at the previous time of assessment. (At Time 2 there was incomplete information for diagnosis in 14 cases, at Time 3 in 8 cases and at Time 4 in one case.) Figure 2 Prevalence of dementia and incidence of demention and mortality over a six-year period in a population-based sample of 84±90 year olds (ªEarly cognitive markers of the incidence of dementia and mortality: A longitudinal population-based study of the oldest oldº by B. Johansson and S. H. Zarit, 1997. Journal of Geriatric Psychiatry, 12, pp. 53±59. Copyright 1997 by John Wiley & Sons Ltd. Adapted with permission).

Noncognitive Influences on Memory and Cognition in Aging of Lazarus and Folkman (1984), who described coping as ªconstantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the personº (p. 14). Because appraisal is a crucial component, self-attributions and personal control come into focus. Personal control, locus of control, self-efficacy, and other similar concepts all refer to the individual's feeling of being in control or lacking control over life in general or in managing certain aspects, for example intellectual tasks (see, Baltes & Baltes, 1986). In this respect, coping and dimensions of personal control are also important for daily life adjustment and performance on certain cognitive tasks. Of particular relevance for memory and cognition in this context is metamemory and metacognition, referring to people's awareness of their own strengths and weaknesses in performing memory and other cognitive tasks. For example, less effort than necessary may be invested in performance when belief exists that one's memory and cognitive capacity is too low for a certain task, and self-attributions given to actual success or failures in performance tend to reinforce these attributions. Hayslip and Panek (1993) describe the interrelations between performance experiences, self-statements, and emotional reactions in terms of a vicious cycle (see Figure 3). Further, the relation between conceptions or self-attributions of, for example, intelligence, may be under multifactorial influence. Much of the work on conceptions of intelligence indicates that the dimensions that make up the prototypic intelligent person may vary at different periods of development and for individuals of different ages or experiental background (e.g., Siegler & Richards, 1982; Yussen & Kane, 1983). Berg and Sternberg (1992) examined whether young, middle-aged, and older adults viewed the concept of intelligence differently depending on their own age. They found that adults perceive differences in what constitutes exceptional intelligence during young, middle, and late adulthood, but also that adults' conceptions of intelligence are characterized by multidirectionality and modifiability. In a study of actual and perceived change in intellectual performance, Schaie, Willis, & O'Hanlon (1994) identified three groups: realists (individuals who accurately estimated actual change), optimists (those who overestimated actual change), and pessimists (those who underestimated change). This classification was based on self-reports and actual performance on several tests. Older individuals were

31

more realistic than younger subjects on a test of number ability, while more pessimistic about verbal meaning and reasoning tests. Section 7.02.2.2.2 examines further relations between psychological well-being, self-attributions, and cognitive performance. 7.02.2.2.2 Psychological well-being Research into the psychological well-being of elderly persons tends to emphasize prior life satisfaction and mood as important predictors. Self-attributions, in terms of subjective memory and cognition, are also concurrent markers for adjustment and well-being. Beyond normal emotional fluctuations, the interrelationships between self-reports and performance become obvious in clinical depression. An inability in the depressed person to mobilize motivation will ultimately lead to deficient performance. Depression is a prevalent and disabling mental disorder in the elderly and the symptoms tend to be more indistinguishable and often involve impairments in memory and cognition (e.g., BaÈckman & Forsell, 1994), in some cases with a severity that corresponds to depressive pseudodementia (see Katona, 1994). Severity of depression seems to be correlated with the magnitude of performance deficits in tests of memory and cognition (e.g., Cipioli, Neri, Andermarcher, Pinelli, & Lalla, 1990). Numerous studies have reported strong associations between depression and self-reports of cognitive functioning. It was, however, early recognized that complaints must be differentiated from actual performance (Kahn, Zarit, Hilbert, & Niederehe, 1979). A diagnostic scheme for different configurations of performance, complaints, and affective status was presented by Gallagher, Thompson and Levy (1980). In a meta-analysis, Burt, Zembar, and Niederehe (1995) even suggested that complaints may have a stronger association with general psychopathology than with depressive symptoms. Further studies are needed to resolve the complex interrelationships between cognitive performance, mood, and self-attributions (see Kaszniak & Ditraglia Christenson, 1995). Zarit (1979) suggested that memory complaints also reflect ªa memory and aging stereotypeº that ascribes poor memory to the elderly due to their age. Such a stereotype is likely to be internalized by the elderly. Studies on self-reports show, however, a great variation, typically in the range of 40±80%, in the extent to which older people feel that their memory performance is compromised. These discrepancies may reflect sampling differences and sociocultural values. In a population-based

32

Cognition and Geropsychological Assessment

Experience of learning or memory failure

Self-statement

Emotional reaction

Difficulty in learning new material or inability to remember names, facts, or details

“This means I am getting old, or worse still, a sign of senility”

Anxiety Depression Alarm

Primary outcomes

Secondary outcomes

Tertiary outcomes

Loss of self-confidence in learning and memory skills

Disuse of skills Avoidance of others Lowered expectations by self and others

Further difficulties in learning and memory

Figure 3 A vicious cycle in which memory failures, self-statements, and emotional reactions tend to compromise future performance (Adult Development and aging (p. 158), by B. Hayslip Jr. and P. E. Panek, 1993, New York: HarperCollins. Copyright 1993 by HarperCollins College Publishers. Adapted with permission).

sample of very old Swedish people, participants were examined four times over a six-year period, and were asked to rate their own memory and cognitive ability (Johansson, Allen-Burge, & Zarit, in press). Participants typically evaluated their abilities in a positive manner (see Table 1). A subsample of 31% were, however, excluded because of dementia, which has to be taken into account when examining the figures. These self-evaluations were scaled and further examined in relation to concurrent, prospective, and retrospective performance on a battery of memory and cognitive tasks (Johansson et al., 1997). Individuals who evaluated their memory more positively showed significantly better concurrent test performances. In addition, they also reported less depression. The study interestingly revealed that self-evaluations predicted subsequent decline in test performance, as well as onset of dementia within the next two to four years. In the retrospective analysis, more negative self-evaluations were found in individuals who two years later reported that they had experienced declining memory. The actual strength in the associations between test scores and self-evaluations were, however, quite weak. This suggests that self-

evaluations are influenced by factors not covered by performance on tests. The few existing studies on the relationships between self-rated intellectual abilities and performance on intelligence and practical problem-solving tasks also show weak associations (e.g., Cornelius, 1990). 7.02.2.2.3 Summary Present functioning should always be related to the individual's prior level of functioning. This will obviously present difficulties as we seldom have baseline information or any other detailed information about the individual's past function at the level of various abilities in focus in an assessment. It is also necessary to consider influences from demographics and to take into account the individual's own perception of memory and cognitive functioning, as well as other expressions of psychological well-being that may exert an impact on the effort invested in a certain performance. Although self-reports are closely related to psychological well-being, self-evaluations may also be formed by experiences of success and failure in performing cognitive tasks in daily life.

Noncognitive Influences on Memory and Cognition in Aging Table 1

33

Self-evaluations of memory in a population-based sample of 84±90 year olds in Sweden.

Self-evaluation Good Rather good Neither good nor bad Rather bad Bad

No problems Minor problems Major problems

On the whole, how would you rate your memory? (%)

On the whole, how would you rate your thinking and problem solving? (%)

44% 34% 8% 5% 9%

53% 33% 7% 6% 1%

Do you experience memory failures in everyday life that makes life more difficult? (%)

Do you experience problems in remembering what to do and say at a later occasion (prospective memory)? (%)

82% 17% 1%

66% 32% 2%

Have you experienced any changes with your memory in the last two years? (%) Better now No change Somewhat worse now Worse now

1% 50% 44% 5%

Source: Johansson et al. (1997).

7.02.2.3 Sociocultural Context

7.02.2.3.1 Cohort and period effects

Aging is certainly not a context-free process (see Blanchard-Fields & Abeles, 1996). On the contrary, health status and level of functioning in later life are dependent on cumulative outcomes from numerous sources, including influences from the sociocultural context (e.g., dietary habits, transportation, and physical mobility, or the coverage and inputs by health care institutions like dentistry or preventive pediatrics). A list of potential factors would be very extensive. The differential exposure to environmental influences generally makes people different, and it is often claimed that interindividual differences increase with age (e.g., Krauss, 1980; Nelson & Daneffer, 1992). This is still an unresolved issue, but in assessing elderly persons, attending to sociocultural influences seems as important as attending to ethnicity or social class.

Cohort is a concept often used in the aging literature. Cohort generally refers to people born during a certain time and therefore exposed to similar experiences that tend to make them more alike than generations of people born earlier or later (see Rosow, 1978). Thus, age differences should be interpreted taking cohort effects into account. This was noticed early when age differences found in cross-sectional studies could be ascribed to significant cohort effects. The classical example is a study by Birren and Morrison (1961), who found higher correlations between certain tests of intelligence and years of formal schooling, than with age. The important role of education has since been identified in many studies (e.g., Inouye, Albert, Mohs, Sun, & Berkman, 1993). The educational system also represents an important social institution where different

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Cognition and Geropsychological Assessment

methods and content, hopefully, have longlasting but differential effects on various cohorts. Thus, the potential impact of educational differences must be considered in evaluating cognitive performance, particularly in the presence of broad age ranges. The importance of cohort is easily observed in the educational system. In elderly Swedish cohorts most individuals have six years of basic formal schooling only, compared to more than 12 years for persons in their twenties. Even at the level of brief cognitive screening, employing devices like the MMSE, it has been suggested that different cut-offs have to be used for elderly people at different educational levels (e.g., Crum, Anthony, Basset, & Folstein, 1993). Employing more sophisticated tests, cohortadjusted norms have to be appropriate for accurate interpretations. Other cohort influences may be identified in the political scene, for example the 1968 movement in Europe, corresponding to the Vietnam generation in the USA, or personal experiences of the world wars that affected people differently across ages. Period effects refer, in the context of aging, to influences that affect people throughout ages. An example is the introduction of television. Some claimed that socially and intellectually rewarding activities, such as crosswords and jigsaw puzzles, hobbies and so forth were replaced by television. The Swedish expression dumburken (ªcouch potatoesº) captures these assumed negative aspects of passive television watching. At the same time no one can deny the wealth of information and general world knowledge that is easily brought to the public through television. Although period effects tend to be pervasive across ages, certain influences may affect older persons differently from younger (see Elder, 1979). 7.02.2.3.2 Sociocognitive development Memory and other cognitive abilities develop in a sociocultural context where environmental influences tend to be normatively age-graded, that is, highly correlated with chronological age. A life-span model of intellectual development based on significant inputs from the sociocultural context was formulated by Schaie (1977±78). The model distinguishes four major developmental stages. Acquisition is the major theme in childhood and adolescence, preparing the individual with basic skills and information for later life. This basic expertise includes what society defines as essential for successful socialization and crucial for the reproduction of society. In the next stage, the young adulthood periodÐor the achieving stageÐ acquired knowledge has to be applied, whether

at work, in the family, or in other social contexts. The middle age period that follows is described basically as a stage where cognitive abilities involve more social responsibilities or executive roles. The reintegrative stage in old age is a period where one's interests, attitudes, and values become the important inputs for the individual. Personal meaningfulness is ascribed a major theme in this stage. The transitions between stages proceeds from ªWhat should I know?º through ªHow should I use what I know?º to ªWhy should I know?º In aging, the individual requires more meaning in order to be motivated to engage in a certain task. Disuse has been identified as a main source for decline in abilities that require continuous use in order to be preserved (see Kohn & Schooler, 1983; Lee, 1991). In addition to the general slowing in primary aging, disuse is generally thought of as an important input for decline in functions not practiced. Support for this hypothesis is offered by an increased performance±capacity gap with increasing age, and interventions demonstrating considerable plasticity or modifiability in primary aging (e.g., Baltes & Kliegl, 1992). Perlmutter (1986) describes a life-span view of memory in which the individual's memory capabilities reflect past experience, and where decline in capacity can be compensated for by growth in memory contents. This leads to an increasing environmental fitness and to an increasingly adapted memory system. 7.02.2.3.3 Summary In a sociocognitive development context, aging can be understood as a change of the behavior repertoire in accordance with the individual's own preferences, besides the influences of cohort and generation. Cohort effects refer to age differences due to influences that variously have affected different birth cohorts. Period effects, on the other hand, emphasize the need to consider certain sociocultural influences as more pervasive across ages. The actual impact of these influences may, however, vary depending on the age of the individual. The specific organization of society also imposes certain age-graded roles and tasks. Although a fixed stage model like Schaie's (1977±78) tends to neglect interindividual differences, it directs attention to the fact that certain tasks may be perceived quite differently depending on the differential use of intellect at different ages. This view emphasizes a need to consider what types of cognitive tasks could be employed in examining elderly people in an age-fair manner. The latter includes an ecological aspect of memory and cognition.

Noncognitive Influences on Memory and Cognition in Aging 7.02.2.4 Cognitive Demands and Everyday Functioning In cognitive aging research, age-related decline in a variety of abilities such as visuospatial functioning or episodic memory performance is well documented. In other types of task one may find that performance remains relatively stable or even improves across the adult life span. Preserved abilities are likely in tasks tapping general knowledge or languagerelated skills. Our knowledge is sparse on how this translates into everyday functioning (e.g., Salthouse, 1990; Searight & Goldberg, 1991). In clinical practice, the geropsychologist may have to resolve whether it is likely that impaired performance on, for example, tests of visuospatial ability is related to difficulties in everyday functioning. In other words, to what extent is it possible to infer, from certain test results, that an individual is incapable of performing adequately in everyday life? A patient with extensive prefrontal damage may be significantly impaired in everyday life, yet perform within the normal range on neuropsychological tests (e.g., Stuss & Benson, 1986). Another patient may score below cut-off for normal performance, but demonstrate adequate performance on a variety of everyday tasks, perhaps because these tasks are overlearned and because adequate performance is defined according to lower demands because of old age. Clearly, everyday performance has to be related to the demands of daily living and available support systems, as well as baseline capacity. One can discern two major explanations for the understanding of discrepancies between elderly people's daily-life performance and scores on test of memory and cognition. The first is based on the idea that standard tests are inadequate because they simply do not measure the relevant processes underlying daily-life functioning. Thus, the assumption is that tests and everyday life differ in terms of the mechanisms involved. The other, functional, explanation, relates to age fairness emphasizing unfamiliarity and task novelty as significant inputs for lower test performance in the elderly (e.g., Bruce, 1991). 7.02.2.4.1 Cognitive mechanisms and tasks The experimental and clinical test traditions have been criticized for their predilection for using artificial materials for remembering, or as stimuli in problem solving. The claim is that these methods have restricted relevance for the understanding of memory and cognition in everyday life (see Willis, 1996). In this vein, Neisser (1978) even suggested that naturalistic

35

studies of memory would be more productive than their laboratory counterparts. Some authors have argued that standard experimental tasks, in which elderly people demonstrate worse performance than younger ones, are not valid as indicators of everyday performance for older adults (e.g., Baltes & Willis, 1979; Berg & Sternberg, 1985; LabouvieVief, 1982, 1985). However, in spite of many efforts to develop more naturalistic measures, such as memory for texts or television programs, the results do not confirm the expected elimination of age effects or even attenuation of age differences (e.g., Denney, 1989; Hartley, 1989; Salthouse, 1983). On the contrary, performance on standard memory tasks and on more ecologically relevant tasks seem to provide similar results. It has also been claimed that certain tests may have a potential disadvantageous impact because different age groups are not equally experienced with stimulus materials or experimental and clinical tests of cognitive functions. There is, however, rather convincing evidence that differences in experience or unfamiliarity with stimulus materials cannot solely account for observed age differences (e.g., Salthouse, 1987, 1990). The claim that standard tasks do not accurately portray everyday performance led some researchers to construct tests better suited for elderly persons, so called age-fair tasks. An example is the brief battery of tests based on ideas of ecological relevance and used by Johansson, Zarit, and Berg (1992) in studies of the oldest old. The tests, Coin Test, Clock Test, and MIR (ªMemory in Realityº), were deliberately designed to minimize floor effects and to differentiate performance in cognitively impaired individuals. Age-fair testing is highly interrelated with ecological relevance, referring to naturalistic studies of memory and cognition. Both concepts emphasize the functional aspects, not that different mechanisms are involved in everyday performance compared to an experimental or clinical context. Ecological relevance refers to the congruence between task demands and demands imposed in everyday life. In other words, to what extent do the obtained pattern of results using psychometric or laboratory tasks generalize to situations in the everyday life of the individual? In a study by Cockburn and Smith (1991), subjects were tested with various measures of fluid and crystallized intelligence (see Section 7.02.3.2.1) in order to examine the predictive value of these tests for performances on a range of everyday memory problems, including analogs of situations met in daily life, such as remembering names or asking for the return of a hidden possession. Crystallized

36

Cognition and Geropsychological Assessment

intelligence showed low predictive power, while fluid intelligence was a better predictor, although the authors concluded that cognitive decline in aging involves more than a simple decline in fluid intelligence. In another study on everyday memory, West, Crook, and Barron (1992) found that a measure of crystallized intelligence, vocabulary, played a significant role for almost every memory measure examined. 7.02.2.4.2 Tests of functional abilities In some cases it may be preferable to perform a functional assessment of the client's abilities in parallel with cognitive testing. For this, clinicians have at their disposal several standardized methods measuring activities of daily living (ADL; e.g., Kane & Kane, 1981). These instruments assess functions that are associated with basic self-maintenance such as dressing, feeding, or hygiene. Furthermore, there are other instruments assessing a broader domain of more complex abilities such as managing transportation, communication, self-medication, or financial transactions. This domain of abilities is often called instrumental activities of daily living (IADL; e.g., Kuriansky & Gurland, 1976). One example is the Community Competence Scale (see Grisso, 1986). Using a multidimensional battery, Zarit, Johansson, and Berg (1993) found strong associations between cognitive impairment, ADL, and IADL in the oldest old. Results like this demonstrate that cognitive abilities are necessary prerequisites for adequate performance, although the sensitivity may be low within normal ranges of functioning.

associations with everyday functioning. The inclusion of an assessment of actual performance in everyday life, such as IADL measures, can provide additional information of value to the geropsychologist.

7.02.3 MEMORY AND OTHER COGNITIVE ABILITIES This section reviews some select research on memory and cognition in relation to current theory. Some brief outlines of models of memory, as well as processes and components involved in other cognitive abilities, will be provided. The reader is reminded of the analytical scheme (Figure 1) presented in the introductory section when critically examining reported findings and the bases for interpretations. In doing so, it is important to keep in mind the multifactorial influences on cognitive performance in old age. Furthermore, apart from noncognitive influences, it is also important to recognize that most published studies are crosssectional and consequently demonstrate age differences only, and that the bulk of research includes convenience samples recruited for studying cognitive mechanisms or potential age-related differences in various abilities. Most studies provide no detailed information concerning physical health (relating to the distinction between primary and secondary aging). To what degree the failure to do so has influenced the typical picture of cognitive aging remains yet to be elucidated. Last, few studies of memory and cognition have included individuals beyond 80 years, which limits our understanding of the very old and oldest old.

7.02.2.4.3 Summary Our understanding of memory and cognition are greatly determined by procedures and methods used in research. There seems to be no reason to believe that experimental and psychological tests measure functions other than those also constituting the basis for everyday functioning. The relation between test performance and level of functioning in daily life appears, however, to be influenced by numerous other factors such as social demands, support-systems, or the individual's level of experience. Everyday functioning of the client is of importance. In assessing elderly people, the degree to which test demands overlap with demands of daily life ought to be taken into consideration. Much effort has been invested in constructing tasks more suitable for the oldest people. Research suggests that results on various psychometric tests may show weak

7.02.3.1 Learning and Memory Learning and memory represent highly interrelated processes, and the study of either requires understanding of the other. Studies of learning tend to emphasize the acquisition of new behaviors and information, while memory refers to processes involved in the retention and retrieval of what has been acquired. Learning and memory are here treated separately from other aspects of cognition because of the wealth of information available and the extensive research in the area. This subsection provides first a framework, out of several possible, for the understanding of learning and memory. In addition, there is an examination of the significance of task properties, here defined as levels of cognitive support, for variations in episodic memory performance. Finally, some relevant research is reviewed with focus on the

Memory and Other Cognitive Abilities oldest. The review is largely restricted to episodic memory, because this memory system has proved to be most affected by age, in addition to its sensitivity to depression, dementia, and other illnesses that are prevalent in aging. 7.02.3.1.1 Types of learning Learning may mean many quite different things. It may refer to the mastering of a new skill such as learning how to ride a bicycle. The resulting procedural or motor-based memories are formed without awareness. This general area of learning and memory has been reviewed by Chiarello and Hoyer (1988) and Graf (1990). Learning may also mean acquiring and changing habits. Behavior modification is an example of this type of learning in clinical practice. Learning may further mean the acquisition of new information. This is something we all do in school. We may still remember what date World War One started, but not when that information was acquired. This is generally what we refer to as semantic memory. This subsection restricts itself to episodic memory, and learning is concerned with the remembering of personal incidents that are, in most cases, not very distant in time. Tested persons are presupposed to remember where they picked up the requested information. The typical example is a test of memory where the psychologist reads a list of words or sentences, and the client is later asked to recall as many of the words or sentences as possible of those that were presented some minutes ago. 7.02.3.1.2 Models of memory Many researchers classify memory phenomena in terms of memory systems, although the results are often analyzed in terms of various processes operating within these systems. For the clinician, the system model is perhaps the most intuitive, since it alludes to specific tasks. Before proceeding to some of the systems identified in modern experimental psychology, we choose as the point of departure a model that has exerted an enormous impact in the development of later theoretical accounts. This is the ªMultistoreº model of memory proposed by Atkinson and Shiffrin (1968). In clinical practice, their line of reasoning is perhaps still sufficient. Basically, this model of memory distinguishes between the sensory store where new information enters through sensory stimulation, the short-term store where the information is subjected to conscious mental activity, and the long-term store which is thought of as a more or less permanent store of information.

37

As a general guideline, it may be sufficient to distinguish between recent and remote memories, or between short- and long-term memory. These subdivisions are, however, somewhat complicated in terms of test materials. We therefore now turn to selected parts of the system model which are somewhat more clear for clinical purposes. For more detailed discussions, consult Baddeley (1990) or Parkin (1993). Short-term memory is analogous to primary memory in that it represents the locus of conscious mental activity. Early accounts of primary memory (e.g., Waugh & Norman, 1965) stated that this system registers and retains incoming information in a highly accessible form for a short period of time after input. This conception of primary memory has been elaborated in recent years (e.g., Baddeley, 1986). It may be useful to distinguish primary memory (holding information in consciousness) from working memory (simultaneously holding information in mind and elaborating on or using that information in combination with other incoming information). Roughly, in terms of tests, this corresponds to the difference between Digit span forward and backwards (Wechsler, 1981). The long-term store may, in terms of memory systems, be further subdivided into episodic and semantic memory. Episodic memory refers to memory of personally experienced events with a reference both in time and space, that is, we remember something we have experienced, and that memory is associated with information about when and where the information was encoded. The command ªrecall as many of the words as possible from the list I presented to you 10 minutes agoº evokes episodic memory. Semantic memory is memory for general knowledge (Tulving, 1983, 1985). The information task of the Wechsler Adult Intelligence Scale (WAIS) battery corresponds to a test of semantic memory. 7.02.3.1.3 Episodic memory Most researchers agree that age differences in performance are most likely to occur in episodic memory tasks, that is, in tasks requiring conscious retrieval of information acquired in a particular place at a particular time (see Kausler, 1994; Light, 1991; Salthouse, 1991, for reviews). However, memory performance in very old age has received relatively little empirical attention. The available evidence is mixed as to whether there are differences in episodic memory functioning among different cohorts of old and very old adults. Most studies of the late adult life span indicate a gradual decline in performance with

38

Cognition and Geropsychological Assessment

age (e.g., BaÈckman, 1991; BaÈckman & Larsson, 1992; Crook & Larrabee, 1992). There are, however, studies indicating no age differences (e.g., Cohen & Faulkner, 1989; Larsson & BaÈckman, 1993; Olofsson & BaÈckman, 1993). With reference to the previous discussion on potential impacts of health-related factors on cognitive performance, it is important to note that a careful health screening has not been performed in these memory and aging studies. This may be an essential factor underlying the contradictory findings. In studies performed by Wahlin and colleagues (e.g., BaÈckman & Wahlin, 1995; Wahlin et al., 1993, 1995), careful health screening was routinely performed. The outcome of these studies showed that performance in a variety of episodic memory tasks differs reliably in comparing elderly people between 75 and 96 years of age. This was the case in tests of episodic face recognition, free recall and recognition of random word lists, and free and cued recall of organizable words. The age-related differences were, however, relatively small in raw score numbers and more pronounced in the free recall tasks as compared to the recognition tasks. In a study of 1000 healthy participants ranging in age between 35 and 80 years, a battery of episodic and semantic memory tests (Nyberg, BaÈckman, Erngrund, Olofsson, & Nilsson, 1996) was employed. It was found that after controlling for differences in demographic (education, gender), cognitive (visuospatial ability), and health-related (blood pressure, serum vitamin B12) factors, age did not predict performance on tests of semantic memory. The impact of age on tests of episodic memory was substantially reduced when differences in the background factors were controlled for, although still significant. These authors proposed that the failure to account for the age effects on episodic memory is because it can be attributed to age-related neuronal changes. 7.02.3.1.4 Memory tests and cognitive support In addition to the many influences on cognitive and memory performance described in previous sections, performance may also vary depending on level of support provided. Some research indicates that age differences are large in unsupported tasks such as free recall, while relatively small in more supported tasks such as recognition (Craik & Jennings, 1992). Before elaborating on the concept of cognitive support, this subsection will briefly describe three types of memory tests that have dominated research on episodic memory. In these tests, the retrieval conditions vary, such that free recall represents the lowest level of support,

cued recall represents a more supportive test condition, and recognition of the information to-be-remembered (TBR) is the most supportive retrieval condition. In the free recall task, subjects are presented with the items and are then asked to recall without prompting what was previously presented. In the cued recall condition, cues of some sort are provided by the examiner, and test materials are then typically organizable in some way. Questions such as ªwhat animals do you remember?º or ªwhat kind of furniture do you remember?º constitute the cues. Finally, in the recognition tasks, the initially presented materials are presented intermixed with a number of distractors. Subjects are asked to state whether they recognize items from the presentation. Tasks may also vary in terms of presentation rate, where a slow presentation rate represents a more supportive condition as compared to a rapid presentation rate. Performance is also dependent upon the nature of the TBR materials. It is well known that stimulus dimensions like modality (i.e., items may be presented in a way that one or more of the sensory systems are stimulated during encoding), richness (e.g., items may be presented as objects or words), and organizability (i.e., it may or may not be possible to combine items in a meaningful fashion) are important to goodness of remembering (see BaÈckman, MaÈntylaÈ, & Herlitz, 1990). Further examples include the datedness of the TBR materials (e.g., items may be faces of persons who were famous 50 years ago or faces of persons who attained their fame recently). There is a consensus that performance of older adults is facilitated by increasing the support with respect to modality, richness, organizability, and prior knowledge (BaÈckman et al., 1990; Craik & Jennings, 1992) (see Figure 4). There is converging evidence from experimental research and intervention studies that episodic memory in normal aging is modifiable (BaÈckman et al., 1990; Verhaeghen, Marcoen, & Goossens, 1992). Older adults possess a substantial cognitive reserve capacity, although it seems to be less than for younger individuals (e.g., Baltes & Kliegl, 1992). However, there is no evidence for a simple relationship among cognitive support, episodic memory, and age (see BaÈckman, 1995). Also, the level of support needed for the optimization of memory performance in dementia differs considerably from that required of healthy elderly people. While in dementia, support is needed at both encoding and retrieval, normally aged adults seem to require support at either encoding or retrieval only in order to enhance their performance (e.g., Herlitz, Lipinska, & BaÈckman, 1992).

39

Memory and Other Cognitive Abilities

RECALL Level of Support Low Free recall of random words presented at 2 sec/word Study Time

Free recall of random words presented at 5 sec/word Free recall of organizable words presented at 5 sec/word

Organizability

Cued recall of organizable words presented at 5 sec/word

Retrieval Cues

High

RECOGNITION Low level of support

High Level of Support

Rapidly presented words----------------study time------------> Slowly presented words

Contemporary famous faces----------------prior knowledge------------> Dated famous faces Figure 4 Memory tasks ordered along a continuum of cognitive support.

7.02.3.1.5 Summary Learning and memory are highly interrelated and cannot be fully understood independently of each other. Most studies on memory in aging are cross-sectional and there is typically a lack of information necessary for ruling out the influence of the health status of the participants. The system model of memory employed in recent research usually distinguishes between episodic, semantic, primary, and working memory. Memory performance is seen as influenced by numerous properties acting at both encoding and retrieval stages of memory processing. Task properties may generally be recognized in terms of cognitive support (low± high), although there is no evidence of a simple relation between level of support and performance. The relatively few studies on episodic memory performance in very old age portray a gradual decline into the very late stages of the life span. 7.02.3.2 Intellectual Abilities Learning and memory represent in a sense the input and output stages of information proces-

sing, while cognition, in a broad sense, also includes processes involved in the integration and reorganization of aquired knowledge for the sake of matching behavior in an appropriate manner, that is, intelligent behavior. Certain tasks are novel and require the execution of new behavior, while others may be practiced and require less cognitive effort. The outcome of matching task demands and cognitive resources is evaluated in the relative success, or failure, to perform a task whether measured as everyday performance or by cognitive tests. This section concentrates on abilities as expressed in aging and reported in the current literature, more than on the fundamental mechanisms involved in the mental operations necessary for intelligent behavior (see Craik & Salthouse, 1992; Rybash, Hoyer, & Roodin, 1986). Studies on intelligence and aging have generally aimed at identifying normative patterns of age-related changes in the various ability components. The components are operationalized by the test battery. The following section describes such intelligence and aging patterns, while the next focuses on some of the specific cognitive components involved in intelligent behavior.

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Cognition and Geropsychological Assessment

7.02.3.2.1 Intelligence and aging The intelligence test tradition evolved at the beginning of the twentieth century as a differential psychology with focus on interindividual differences in intelligence. Age was recognized early as an important stratification variable in these studies. This psychometric tradition has since provided a basis for our understanding of normative aging and the typical age-related pattern. The most frequently used battery of tests in this research arena, as well as in the clinical setting, is the WAIS (Wechsler, 1955) and later modifications (WAIS-R, Wechsler, 1981) of this battery, encompassing tests of verbal ability (1, Vocabulary; 2, Information; 3, Comprehension), short-term learning and remembering (4, Digitspan forward and backwards), numerical abilities (5, Arithmetic), abstraction and generalizations (6, Similarities), and nonverbal abilities (7, Digit-symbol substitution; 8, Picture arrangement; 9, Picture completion; 10, Block design; 11, Object assembly). Wechsler divided the test battery into two broad categories: ªthe hold testsº (1, 2, 3, and 6) and ªthe don't hold testsº (7, 8, 9, 10, and 11) according to their resistance to age. A number of cross-sectional studies over a broad age range have consistently confirmed the ªclassic aging patternº (Botwinick, 1978), in which the verbal tests are identified as the hold tests and the nonverbal or performance tests as the don't hold tests. These findings were largely confirmed in later longitudinal studies, although the magnitude of age-related changes generally were found to be less than previously found by age differences. These design-related differences are intensively discussed in the gerontological literature and have supported the notion of including characteristics of the individual as well as recognizing influences from the sociocultural context when interpreting studies showing age effects. The classical aging pattern was partly refined in a series of studies by Horn, Catell, and Donaldsson (see Horn, 1982, for an overview) who suggested a dichotomization between crystallized and fluid intelligence. This distinction was assumed to reflect different developmental trends. The label of fluid intelligence (Gf) was attached to basic processes involved in identifying complex relations among stimulus patterns and the drawing of inferences on the basis of comprehending relationships. The tests proposed to measure this broad ability component should not be greatly aided by the breadth of previous knowledge and include tests of logical reasoning and of figural and spatial relations. Crystallized intelligence (Cc) was

defined as the cumulative end product of information acquired by the operation of fluid processes through interactions with the environment. The measurement of experience-based crystallized intelligence includes, for example, tests of vocabulary, information or general knowledge, comprehension, and arithmetic (Horn, 1982). The definition leads to expectations of preserved function, or even improvements with age. The distinction between fluid and crystallized intelligence in aging differentiates intelligence components with regard to age. While development into adulthood is characterized by a differentiation of various abilities it is followed by a dedifferentiation in late adulthood and aging (e.g., Reinert, 1970). The broad categories of fluid and crystallized intelligence correspond to a dedifferentiated pattern of formerly more independent abilities. Some researchers claim that this dedifferentiation continues, and that there remains only a broad component of basic cognitive performance in the oldest old (eg., Marsiske, Lindenberger, & Baltes, 1994). The arguments for a more rudimentary intelligence system in advanced age awaits, however, further empirical support. Although the results from some studies have been interpreted as favoring the general outcomes predicted by the fluid±crystallized dichotomy, the trend in recent research on intelligence and aging is to examine various intelligence components separately. This is consistent with the interest of a clinican when faced with separate scores for various tests. There are problems inherited in all higher-order approaches to intelligence, for example, the comparability between tests in different batteries. The greatest value, therefore, may be that higher-order approaches to intelligence can serve as heuristic frameworks for the clarification of relationships between complex abilities. The most informative data on aging and intelligence patterns emerge from longitudinal studies using multiple measurements over longer time periods (see Berg, 1996; Schaie, 1996). In the ongoing H70 study in Gothenburg, Sweden (Rinder, Roupe, Steen, & Svanborg, 1975), a random population-based sample were included at the age of 70 and then followed over the years. Interesting patterns of age-related changes, as well as continuity, emerged. In this study, the effects of tertiary aging (terminal decline) were also examined separately for different survival intervals. That is, trends of change for individuals, for example measured at Time 1, Time 2, and Time 3, and then deceased, were compared with that of individuals who survived into the assessment at the next occasion, that is, Time 4. The main finding in the H70 study was that of a

Memory and Other Cognitive Abilities robust and pervasive terminal decline pattern in which performance levels were associated with survival. Figure 5 (a) and (b) (Berg, 1987) show this for a test of verbal meaning (Synonyms; SRB:1, Dureman & SaÈlde, 1959) and reasoning (Figure logic; SRB: 2, Dureman & SaÈlde, 1959). The data from longitudinal studies typically show less change than is the case when examining age differences in cross-sectional studies. Although more accurate in providing a portrayal of intelligence and aging, longitudinal studies are affected by attrition and other selective influences that are likely to produce too optimistic a portrayal of aging trends.

7.02.3.2.2 Specific cognitive abilities The ªtop-downº intelligence and aging perspective (described above) is here supplemented with a ªbottom-upº approach focusing on specific cognitive abilites and some tests used for the measurement of these abilities. (i) Speed of behavior: perceptual and psychomotor performance Speed of behavior is a crucial ingredient in many memory and cognitive tasks because of time constraints, whether it is in everyday life, in the laboratory, or in clinical tests. While it has been argued by some that time is less important than accuracy, and that speeded tasks are unfair to elderly people, others have argued for the inclusion of speed of behavior as an important marker of intelligent behavior. The former position was supported by early assumptions that the reduced rate of processing was extrinsic or peripheral to the primary aging of the nervous system. Slowing has, however, been recognized as an intrinsic phenomenon that accompanies aging (e.g., Salthouse, 1993) caused by increased levels of noise in the nervous system (e.g., Cremer & Zeef, 1987), or broken or attenuated neural connections (MacKay & Burke, 1990). Most reseachers seem to have accepted speed as an inevitable component in various tests of intelligent behavior. Psychomotor performance was frequently studied in the early days of gerontological inquiries. The prototype experiment compared performance of young and older people on tests of simple and complex reaction time (RT). The results of numerous RT studies consistently show that when the cognitive demands are increased by the introduction of multiple stimuli and response formats, the effects of age become more pronounced (Welford, 1977). The literature on perceptual speed also demon-

41

strates a general agreement on age-related decline. Attention and decision constitute two highly interwoven components in speed of behavior. Attention has been examined using experimental paradigms for divided and selective attention, vigilance, or the ability to identify less frequent signals occurring over long time periods, or in terms of concentration and search for certain signal patterns within an array of similar signals. Tests like digit-symbol in the WAIS battery represent a way to study concentration and search. The findings from this test demonstrate marked age effects. Elderly people show worse performance in terms of items accomplished per time unit, as compared to younger people. Accuracy is, however, not impaired in the elderly. The trail-making test is a frequently used clinical test for psychomotor performance and attention. Robins Wahlin et al. (1996) administered this test in a healthy sample of individuals aged 76±93. As expected, they found that the time needed to complete the test increased significantly with age. Noteworthy, however, is that they found no age differences in accuracy. An important message is that lower speed is also related to deficient performance on a number of memory and other cognitive tasks. The pervasiveness of reduced speed of behavior in aging, thus requires that this phenomenon is taken into account in evaluating performance in tasks where speed is an ingredient (Salthouse, 1985; Stankov, 1988). Studies in which elderly individuals' slower rate of processing is compensated for by elimination of time limits still show an overall pattern of performance decline with age, identical to that found when time constraints are present. The oldest, however, seem to benefit somewhat more from eliminated time limits (e.g., Botwinick, 1977; Robins Wahlin et al., 1993), but age and other interindividual differences remain. In everyday life, however, compensatory behaviors become essential for the functioning of the individual. Performance is better when time is less of a restriction. (ii) Verbal abilities and language The spontaneous use of language, as in unrestricted speech, typically reveals experience-based learning and thereby cohort differences and other sociodemographic characteristics. That is often evident in the communication across generations where younger and older persons may find themselves using different words, grammar, and syntax. In this sense, language serves as a ªgeneration marker.º

42

Cognition and Geropsychological Assessment

(a)

20

Verbal meaning score

15

10

5 Still alive 81

Dead 75– 200 ml) postvoid residual volumes. Only residents who are candidates for specific interventions based on the results of these evaluations should be referred. Further evaluation may also be indicated for those residents who show positive stress symptoms or high wetness frequencies (two or more times per day), despite attempts to toilet two or more times a day. In these cases, either a stress or urge diagnosis is suspected, and the treatment options available for these conditions (described in Section 7.19.3) could be attempted. Given their attempts to toilet, these residents clearly have demonstrated at least the minimal cognitive capacity and motivation necessary

to be appropriate candidates for these types of treatment. Recommendations for treatment with alternative behavioral, surgical, or pharmacological interventions should be qualified by the fact that there is no strong evidence that such interventions are successful, even with carefully targeted nursing home residents. Further evaluation by a physical therapist is recommended for residents who either cannot independently perform all three mobility skills related to toileting or who do so very poorly and who are felt to have some potential for improving these skills. Based on previous work, we estimate that most incontinent residents will be in need of either a physical therapist consultation or a rehabilitative nursing exercise program designed to improve mobility, endurance, and muscle strength. Moreover, as discussed in Section 7.19.2, we reviewed data which indicates that UI and immobility problems are jointly predictive of a high rate of infection and hospitalization to treat these infections. An intervention program that addresses both risk factors is needed, even if the resident cannot attain toileting independence because of reversible physical or cognitive problems, since such a program may also prevent infections. Mobility interventions that may be effective with incontinent nursing home residents are now described. 7.19.6.6 Treatment for Mobility Problems that Limit Independent Toileting It is not known to what degree physical therapy assessment and treatment is appropriate for incontinent nursing home residents who are chronically ill, demented, and who require maximal assistance to perform the three mobility skills related to independent toileting. Two separate exercise rehabilitation trials, each lasting for nine-week periods, have not been successful in significantly improving the independence level of these very dependent residents (Schnelle, MacRae et al., 1995). However, improvements have been found in endurance, speed, and safety levels for all three mobility skills among residents capable of performing these skills independently or with minimal physical assistance (Schnelle et al., 1996; Schnelle, MacRae et al., 1995). These findings are a result of a mobility intervention utilizing a functional incidental training (FIT) technique. FIT is implemented concurrently with prompted voiding and involves two primary additions. The two additional FIT steps are done each time prompted voiding occurs when the resident is out of bed. First, the resident is encouraged to perform the toileting-related activities with minimal staff assistance. This is

Implementation of an Incontinence Management Program in Nursing Homes in contrast to standard care since, as a result of staff time constraints, aides typically provide maximal assistance to the residents in completing the prompted voiding sequence. In the absence of functional considerations, it is more efficient to provide such maximal assistance and to minimize the resident's involvement; however, the FIT intervention promotes functional activity. In the second FIT step, the resident is given repeated practice in each functional activity (e.g., standing, moving, transferring) and works toward an individualized goal, which is increased progressively as the resident demonstrates improvement. The application of the FIT protocol three times per day for nine weeks has been shown in a controlled trial to result in significant improvements in walking endurance, standing speed, wheelchair endurance, and safety measures for a group of 38 residents (Schnelle, MacRae et al., 1995). Unfortunately, only 10% of the residents showed improvement on these mobility tasks to the point where they were rated as being at a low risk for falls. A modification of the FIT protocol is currently being tested which includes resistance training designed to further improve muscle strength. There is strong evidence from several trials that even very old nursing home residents will show strength improvements with resistance training (Fiatarone et al., 1994; Mulrow, Gerety, Kanten, & Cornell, 1994). In addition, FIT is being implemented for longer time periods to explore further its potential for producing a higher level of mobility independence and a lower risk for injury and infections which may require hospitalization. However, even if these mobility interventions are successful, most residents will require routine prompting and some physical assistance to maintain continence and to maintain their improved mobility performance. A quality assurance system to assure that staff continue to provide such assistance is critical; therefore, the behavioral management skills that staff must learn to successfully implement such a system are discussed next. This behavioral management involves a system of accurately monitoring the resident incontinence status. It is in this critical arena that the role of the behavioral psychologist is most needed. 7.19.6.7 Staff Management and Continence Maintenance Three toileting tenance program

major issues must be addressed if assistance and the continence mainaspects of the prompted voiding are to be accomplished. These issues,

449

although discussed here specifically with regard to prompted voiding, are essential to any intervention requiring caregiver assistance. First, procedures are needed to target those residents who will respond well if ongoing toileting assistance is provided. Second, an information system must be developed to monitor incontinence outcomes effectively so as to facilitate quality control. Third, supervisors and direct care staff who actually implement the prompted voiding protocol must be taught how to use the outcome data to identify and correct problems. A comprehensive description of how these issues must be addressed to facilitate the implementation of prompted voiding can be found in several places (Ouslander & Schnelle, 1993; Schnelle, Ouslander, Osterwell, & Blumenthal, 1993). The methodology to target residents who can be responsive to the prompted voiding toileting program has been described earlier in this chapter; specifically a three-day run-in assessment is described for this purpose. This same three-day assessment also provides the outcome data needed to maintain the incontinence system effectively. In review, during this threeday period residents are checked for wetness and prompted every two hours. Those residents who have a 66% appropriate toileting ratio or better are designated as responsive and are recommended for ongoing maintenance. The wetness data from these responsive residents collected during the two-hour checks can now be used to generate a control chart, which is the basic information tool used to monitor the prompted voiding program, thereby addressing the need for effective quality control (Fogarty, Schnelle, & Newman, 1989; Schnelle, Newman, Fogarty, Wallston, & Ory, 1991). A control chart is a graphic display that allows the viewer visually to ascertain expected versus actual outcomes (Figure 2). The control chart in this case is constructed by graphing wetness data collected during each two-hour block during the three-day run-in period and calculating the average and standard deviation of this wetness. A warning limit is set two standard deviations above the average. This warning limit signifies unexpected variability and indicates either a failure of the prompted voiding work process to be implemented consistently or, perhaps, a change in the resident's status. For example, the control chart shown in Figure 2 was generated for a group of 22 residents. This control chart shows that 12% of the residents who showed 566% appropriate toileting rate during the three-day assessment period were found wet on the two-hour checks. A warning limit was set above this 12% average at 40%. This warning limit is two standard

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deviations above the average. An upper warning limit is established three standard deviations above the average. Supervisory nurses and direct care staff can now effectively monitor the prompted voiding program by randomly checking at least 10 residents per week for wetness. If the findings of this check, termed a control check, are within the average and two standard deviations of the expected average, the prompted voiding system can be said to be in control. If the wetness rate for the 10 patients exceeds the warning limit, then an analysis should be done to identify the causes of this excessive variability. A failure of staff to implement the prompted voiding program consistently or a deterioration in a resident's status are two potential explanations for an unusually high wetness check. Software has been developed to facilitate the analysis and interpretation of the control checks, and supervisory and direct care staff have been taught how to use the software to identify problems and to provide feedback to the staff who are implementing prompted voiding. The implementation of this computerized system has resulted in successful maintenance of high levels of resident dryness during six-month to one-year evaluation periods in eight nursing homes (Schnelle, McNees, Crooks, & Ouslander, 1995). The failure of more traditional employee training methods to sustain such improvements have been described in several places (Schnelle, Newman, & Fogarty, 1990a). Unfortunately, the staff training and management interventions that have been evaluated have only been successful as long as research staff were present to provide support and social incentives to both supervisory and direct care staff to maintain the system. The fact that maintaining resident dryness with a toileting program is more time consuming than simply changing residents when they are wet produces strong natural pressures that reduce staff motivation to maintain the program. The development of incentives to increase the motivation of nursing home staff to implement the more labor intense toileting program is an important new area to be investigated, and this is discussed in the next section.

7.19.7 FUTURE DIRECTIONS Numerous areas related to incontinence treatment that are in need of research can be identified for both community dwelling and nursing home populations. Furthermore, many of these areas have direct relevance to behavioral scientists. For example, in the case of

community dwelling populations major questions remain as to why most people with incontinence symptoms do not seek treatment. Behavioral interventions to increase people's willingness to be treated could possibly be developed if such information were available. Furthermore, such interventions to increase people's awareness of treatment options are clearly justified by the evidence that urinary incontinence is predictive of general functional decline in the community dwelling elderly. The fact that urinary incontinence is associated with a decline in measures of emotional functioning in the community dwelling elderly is also an area of interest for future behavioral research (Tinetti et al., 1995). In the case of nursing home residents, major improvements have been made with incontinence problems by utilizing the assessment, treatment, and staff management system described in this chapter. In addition, the work to date suggests future research directions that should lead to further improvements in how incontinence care might be done in nursing homes. Two of these most important future directions have direct implications for behavioral scientists. The first issue relates to the development of incentives that will motivate staff to maintain the quality control and information feedback system that is so critical to the maintenance of the prompted voiding program. The reality that maintaining continence is more time consuming than simply changing residents when they are wet contributes to the maintenance problem. However, the fact that even residents who are responsive to the prompted voiding program are not good self-advocates because of high sickness burden, dementia, or other unknown factors has not been discussed, and makes the need for incentives even more imperative. Unfortunately, most residents do not provide sufficient positive verbal feedback to nursing home staff when they provide toileting assistance so as to maintain the more labor intense toileting activities, and many residents can be convinced that they should accept their incontinence condition and a changing schedule as opposed to a prompting and toileting schedule. Several approaches could be taken in reaction to this problem. First, external incentives that link the maintenance of the prompted voiding protocol to job advancement or salary increases could be attempted. These reinforcement strategies have been used successfully with other institutional populations that are not good selfadvocates or are incapable of socially reinforcing staff for better care. A description of this behavioral research is available (Burgio & Burgio, 1990; Burgio et al., 1990).

P/V Group Control Chart, 22 Residents 04/09/95 60% Warning limit high 50% Warning limit low

% Wet

40% 30% 20%

Mean % 10% 0% 1

6

12

18

24

30

Most recent quality control checks Mean % (Lower)

Warning limits: Low (Middle) Figure 2 Sample control chart.

Warning limits: High (Upper)

36

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Incontinence

A second approach would be to develop interventions designed to make either residents or their families better advocates for their own care. With this approach, families and residents would have to be taught how to recognize good incontinence care and to interact with nursing staff in a manner so as to reinforce good care when it occurs. This form of patient/family involvement has been discussed by several consumer groups, but there have been no examples where this type of intervention has been done successfully. A second direction for future behavioral research is related to the motivation of residents to be continent. The fact that many residents (estimated 15±30%) react negatively to the prompted voiding procedures and appear to prefer to be changed as opposed to toileted has been discussed previously in this chapter. These residents are not even carried into the staff management phase of the prompted voiding program because of their unresponsiveness to the prompting procedure during the run-in evaluation period. Research to measure residents' preferences for care and to determine the factors that contribute to these preferences would be important innovations that could guide how incontinence care should be delivered. For example, are preferences to urinate in pads and be changed as opposed to toileted influenced by the residents' reduced expectations of what is possible in the nursing home, or by true preferences for changing because it is less bothersome or painful than the toileting sequence? There are reasons to believe that both hypotheses may be plausible. The fact that many residents have experienced incontinence symptoms that were untreated before they entered the nursing home has been discussed in earlier sections in this chapter. It is thus plausible to predict that many residents may have adapted to the condition and sincerely are no longer bothered by wetness. Alternatively, it is also plausible to predict that some residents may have been convinced by nursing home staff that they should accept their incontinence condition because staff do not have time to help with toileting and thus have resigned themselves to the condition. Preferences based on the patient's acceptance and adaption to the condition versus preferences created by nursing home staff persuasion would require different interventions. In the first case it is arguable if anything should be done to convince residents of their need to be concerned about toileting, whereas in the second case an intervention to reverse the dependency and low expectations about care created by nursing staff is certainly necessary. Unfortunately, we know almost nothing about how to assess accurately the

preferences of demented nursing home residents. The development of such a technology will allow us to begin the process of truly individualizing resident care according to their needs, not only in the case of incontinence care but also in other care areas. 7.19.8 REFERENCES Benvenuti, F., Caputo, G. M., Bandinelli, S., Mayer, F., Biagini, C., & Sommavilla, A. (1987). Re-educative treatment of female genuine stress incontinence. American Journal of Physical Therapy, 66, 155±168. Bo, K., Hagen, R. M., Kvarstein, B., Jorgensen, J., & Larsen, S. (1990). Pelvic floor muscle exercises for the treatment of female stress urinary incontinence. III. Effects of two different degrees of pelvic floor muscle exercises. Neurourological Urodynamics, 9(5), 489±502. Bridges, N., Denning, J., Olah, K. S., & Aorrar, D. J. (1988). A prospective trial comparing interferential therapy and treatment using cones in patients with symptoms of stress incontinence. Neurourological Urodynamics, 7(3), 267±268. Burgio, K., Whitehead, W. E., & Engel, B. T. (1985). Urinary incontinence in the elderly: Bladder±sphincter biofeedback and toileting skills training. Annals of Internal Medicine, 103, 507±515. Burgio, K. L., Matthews, K. A., & Engel, B. T. (1991). Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. Journal of Urology, 146, 1255±1259. Burgio, K. L., Robinson, J. C., & Engel, B. T. (1986). The role of biofeedback in Kegel exercise training for stress urinary incontinence. American Journal of Obstetrical Gynecology, 154(1), 58±64. Burgio, K. L., Stutzman, R. E., & Engel, B. T. (1989). Behavioral training for post-prostatectomy urinary incontinence. Journal of Urology, 141, 303±306. Burgio, L. D., & Burgio, K. L. (1990). Institutional staff training and management: a review of the literature and a model for geriatric long-term care facilities. International Journal of Aging and Human Development, 30(4), 287±302. Burgio L. D., Engel, B. T., Hawkins, A., McCormick, K., Scheve, A., & Jones, L. T. (1990). A staff management system for maintaining improvements in continence with elderly nursing home residents. Journal of Applied Behavior Analysis, 23, 111±118. Burns, P. A. Pranifoff, K., Nochajski, T. H., Hadly, E. C., Levy, K. J., & Ory, M. G. (1993, July). A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress-incontinence in older communitydwelling women. Journal of Gerontology, 48(4), 167±174. Burton, J., Pearce, L., Burgio, K. L., Engel, B. T., & Whitehead, W. E. (1988). Behavioral training for urinary incontinence in elderly, ambulatory patients. Journal of the American Geriatrics Society, 36(8), 693±698. Colling, J., Ouslander, J., Hadley, B. J., Eisch, J., & Campbell, E. (1992). The effects of patterned urge response toileting (PURT) on urinary incontinence among nursing home residents. Journal of the American Geriatrics Society, 40, 135±141. Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118, 219±223. Diokno, A. C., Brock, B. M., Brown, M. B., & Herzog, A. R. (1986). Prevalence of urinary incontinence and other urological symptoms in the non-institutionalized elderly. Journal of Urology, 136, 1022±1025. Diokno, A. C., Brock, B. M., Herzog, A. R., & Bromberg, J. (1990). Medical correlates of urinary incontinence in the elderly. Urology, 36, 129±138.

References Elia, G. & Bergman, A. (1993, February). Pelvic muscle exercises: When do they work? Obstetrical Gynecology, 81(2), 283±286. Fantl, J. A., Cardozo, L., & McClish, D. K. (1994). Estrogen therapy in the management of urinary incontinence in postmenopausal women: A meta-analysis. First report of the hormones and urogenital therapy committee. Obstetrical Gynecology, 83, 12±18. Fantl, J. A., Wyman, J. F., McClish, D. K., Harkins, S. W., Elswick, R. K., Taylor, J. R., & Hadley., E. C. (1991). Efficacy of bladder training in older women with urinary incontinence. Journal of the American Medical Association, 265(5), 609±613. Ferrie, B. G., Smith, J. S., Logan, D., Lyle, R., & Paterson, P. J. (1984). Experience with bladder training in 65 patients. British Journal of Urology, 56, 482±484. Fiatarone, M. A., O'Neill, E. F., Ryan, N. D., Clements, K. M., Solares, G. R., Nelson, M. E., Roberts, S. B., Kehayias, J. J., Lipsitz, L. A., & Evans, W. J. (1994). Exercise training and nutritional supplementation for physical frailty in very elderly people. New England Journal of Medicine, 330, 1769±1775. Flynn, L., Cell, P., & Luisi, E. (1994). Effectiveness of pelvic exercises in reducing urge incontinence among community residing elders. Journal of Gerontological Nursing, 20(5), 23±27. Fogarty, T. E., Schnelle, J. F., & Newman, D. R. (1989). Statistical quality control in nursing homes: A key indicator to evaluate patient incontinence care. Quality Review Bulletin, 15(9), 273±278. Harrison, G. L. & Memel, D. S. (1994). Urinary incontinence in women: Its prevalence and its management in a health promotion clinic. British Journal of General Practice, 44(381), 149±152. Help for Incontinent People (HIP) & the UCLA-JHA/ Anna & Harry Borun Center for Gerontological Research (1994). Managing incontinence in frail elderly dependent institutionalized and community dwelling persons: An agenda for research and care. Monograph. Holmes, D. M., Montz, F. J., & Stanton, S. L. (1989). Oxybutinin versus propantheline in the management of detrusor instability. A patient-regulated variable dose trial. British Journal of Obstetrical Gynaecology, 96(5), 607±612. Hu, T. (1994). The cost impact of urinary incontinence on health care services. Paper presented at the National Multi-Specialty Nursing Conference on Urinary Continence, Phoenix AZ. Keating, J. C., Jr., Schulte, E. A., & Miller, E. (1988). Conservative care of urinary incontinence in the elderly. Journal of Manipulative Physiological Therapy, 11(4), 300±308. McCormick, K. A., & Burgio, K. (1984). Incontinence: An update on nursing care measures. Journal of Gerontological Nursing, 10(10), 16±23. McDowell, B. J., Burgio, K. L., Dombrowski, M., Locher, J. L., & Rodriguez, E. (1992). An interdisciplinary approach to the assessment and behavioral treatment of urinary incontinence in geriatric outpatients. Journal of the American Geriatrics Society, 40, 370±374. Moore, K. H., Hay, D. M., Imrie, A. E., Watson, A., & Goldstein, M. (1990, November). Oxybutyning hydrochloride (3 mg) in the treatment of women with idiopathic detrusor instability. British Journal of Urology, 66(5), 479±485. Mouritsen, L., Frimodt, M. C., & Moller, M. (1991). Longterm effect on pelvic floor exercises on female urinary incontinence. British Journal of Urology, 68(1), 32±37. Mulrow, C. D., Gerety, M. B., Kanten, D., & Cornell, J. E. (1994). A randomized trial of physical rehabilitation for very frail nursing home residents. Journal of the American Medical Association, 271, 519±524. Murtaugh, C. M., & Freiman, M. P. (1995). Nursing home

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residents at risk of hospitalization and the characteristics of their hospital stays. The Gerontologist, 35(1), 35±43. National Kidney and Urologic Diseases Advisory Board (1994, March). Barriers to rehabilitation of persons with end-stage renal disease or chronic urinary incontinence. Workshop summary report, Bethesda, MD. Noelker, L. (1987). Incontinence in elderly cared for by family. Gerontologist, 27, 194±200. Ouslander, J. G. & Fowler, E. (1985). Management of urinary incontinence in veterans administration nursing homes. Journal of the American Geriatrics Society, 33, 33±40. Ouslander, J. G., Kane, R. L., & Abrass, I. B. (1982). Urinary incontinence in elderly nursing home patients. Journal of the American Medical Association, 248, 1194±1198. Ouslander, J. G., Morishita, L., Blaustein, J., Orzeck, S., Dunn, S., & Sayre, J. (1987). Clinical, functional and psychosocial characteristics of an incontinent nursing home population. Journal of Gerontology, 42, 631±637. Ouslander, J. G., Palmer, M. H., Rovner, B. W., & German, P. S. (1993). Urinary incontinence in nursing homes: Incidence remission and associated factors. Journal of the American Geriatrics Society, 41(10), 1083±1089. Ouslander, J. G., Schapira, M., Fingold, S., & Schnelle, J. F. (1995). Accuracy of rapid urine screening tests among incontinent nursing home residents with asymptomatic bacteriuria. Journal of the American Geriatrics Society, 43, 772±775. Ouslander, J. G., Schapira, M., & Schnelle, J. F. (1995). Urine specimen collection from incontinent female nursing home residents. Journal of the American Geriatrics Society, 43, 279±281. Ouslander, J. G., Schapira, M., Schnelle, J. F., Uman, G., Fingold, S., Tuico, S., & Nigam, J. G. (1995). Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents? Annals of Internal Medicine, 122, 749±754. Ouslander, J. G., & Schnelle, J. F. (1993). Assessment, treatment and management of urinary incontinence in the nursing home. In L. Rubenstein & D. Wieland (Eds.), Improving care in the nursing homes: Comprehensive reviews of clinical research. Newbury Park, CA: Sage. Ouslander, J. G., & Schnelle, J. F. (1995). Incontinence in the nursing home. Annals of Internal Medicine, 122, 438±449. Ouslander, J. G., Schnelle, J. F., Uman, G., Fingold, S., Nigam, J. G., Tuico, E., & Bates-Jensen, B. (1995a) Does oxybutynin add to the effectiveness of prompted voiding for urinary incontinence among nursing home residents? A placebo controlled trial. Journal of the American Geriatrics Society, 43, 610±617. Ouslander, J. G., Schnelle, J. F., Uman, G., Fingold, S., Nigam, J. G., Tuico, E., & Bates-Jensen, B. (1995b). Predictors of successful prompted voiding among incontinent nursing home residents. Journal of the American Medical Association, 273(17), 1366±1370. Ouslander, J. G., Simmons, S. F., Tuico, E., Nigam, J. G., Fingold, S., Bates-Jensen, B., & Schnelle, J. F. (1994). Use of a portable ultrasound device to measure postvoid residual volume among incontinent nursing home residents. Journal of the American Geriatrics society, 42, 1189±1192. Pengelly, A. W. & Booth, C. M. (1980). A prospective trial of bladder training as treatment for detrusor instability. British Journal of Urology, 52, 463±466. Resnick, N. M. & Yalla, S. V. (1985). Management of urinary incontinence in the elderly. New England Journal of Medicine, 313, 800±805. Riva, D. & Casolabi, E. (1984). Oxybutynin chloride in the treatment of female idiopathic bladder instability.

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Clinical Experimental Obstetrics and cynecology, 11(1±2), 37±42. Rose, M., Baigis-Smith, J., Smith, D., & Newman, D. (1990). Behavioral management of urinary incontinence in homebound older adults. Home Healthcare Nurse, 8, 10±15. Schnelle, J. F. (1991). Managing urinary incontinence in the elderly. New York: Springer. Schnelle, J. F., Keeler, E., Hays, R. D., Simmons, S. F., Ouslander, J. G., & Siu, A. L. (1995). A cost and value analysis of two interventions with incontinent nursing home residents. Journal of the American Geriatrics Society, 43(10), 1112±1117. Schnelle, J. F., MacRae, P. G., Giacobassi, K., MacRae, H. S-H., Simmons, S. F., & Ouslander, J. G. (1996). Exercise with physically restrained nursing home residents: Maximizing benefits of restraint reduction. Journal of the American Geriatrics Society, 44, 507±512. Schnelle, J. F., MacRae, P. G., Ouslander, J. G., Simmons, S. F., & Nitta, M. (1995). Functional incidental training, mobility performance, and incontinence care with nursing home residents. Journal of the American Geriatrics Society, 43(12), 1356±1362. Schnelle, J. F., MacRae, P. G., Simmons, S. F., Uman, G., Ouslander, J. G., Rosenquist, L. L., & Chang, B. (1994). Safety assessment for the frail elderly: A comparison of restrained and unrestrained nursing home residents. Journal of the American Geriatrics Society, 42, 586±592. Schnelle, J. F., McNees, P., Crooks, V., & Ouslander, J. G. (1995). The use of a computer-based model to implement an incontinence management program. The Gerontologist, 35(5), 656±665. Schnelle, J. F., Newman, D. R., Abbey, J. C., Dray, R. J., Petrilli, C. O., & Hadley, E. C. (1990). Urodynamic and behavioral analysis of incontinence in nursing home patients. Behavior, Health, and Aging, 1(1), 43±49. Schnelle, J. F., Newman, D. R., Fogarty, T. E., Wallston, K., & Ory, M. (1991). Assessment and quality control of incontinence care in long-term nursing facilities. Journal of the American Geriatrics Society, 39, 165±171. Schnelle, J. F., Newman, D. R., & Fogarty, T. E. (1990a). Management of patient continence in long-term care nursing facilities. The Gerontologist, 30(3), 373±376. Schnelle, J. F., Newman, D. R., & Fogarty, T. E. (1990b). Statistical quality control in nursing homes: Assessment and management of chronic urinary incontinence. Health Services Research, 25(4), 627±637. Schnelle, J. F., Newman, D. R., White, M., Abbey, J., Wallston, K. A., Fogarty, T., & Ory, M. G. (1993). Maintaining continence in nursing home residents through the application of industrial quality control. The Gerontologist, 33, 114±121. Schnelle, J. F., & Ouslander, J. G. (1996). Management of incontinence in long-term care. Urinary incontinence. St. Louis: MO: Mosby-Year Book. Schnelle, J. F., Ouslander, J. G., Osterweil, D., &

Blumenthal, S. (1993). Total quality management: Administrative and clinical applications in nursing homes. Journal of American Geriatrics Society, 41, 1259±1266. Schnelle, J. F., Ouslander, J. G., & Simmons, S. F. (1993). Predicting nursing home residents' responsiveness to a urinary incontinence treatment protocol. International Uro-Gynecology Journal, 4, 89±94. Schnelle, J. F., Sowell, V. A., Hu, T. W., & Traughber, B. T. (1988a). A behavioral analysis of the labor cost of managing continence and incontinence in nursing home patients. Journal of Organizational Behavior Management, 9(2), 137±153. Schnelle, J. F., Sowell, V. A., Hu, T. W., & Traughber, B. T. (1988b). Reduction of urinary incontinence in nursing homes: Does it reduce or increase cost? Journal of the American Geriatrics Society, 36, 34±39. Stewart, R. B., Moore, M. T., May, F. E., Marks, R. G., & Hale, W. E. (1992). Nocturia: a risk factor for falls in the elderly. Journal of the American Geriatric Society, 40, 1217±1220. Tapp, A. J., Cardozo, L. D., Versi, E., & Cooper D. (1990, June). The treatment of detrusor instability in postmenopausal women with oxybutynin chloride: A doubleblind placebo controlled study. British Journal of Obstetrical Gynaecology, 97(6), 521±526. Thuroff, J. W., Bunke, B., Ebner, A., Faber, P., de Geeter, P., Hannappel, J., Heidler, H., Madersbacher, H., Melchior, H., Schafer, W., Schwenzer, T., & Stockle, M. (1991). Randomized, double-blind, multicenter trial on treatment of frequency, urgency and incontinence related to detrusor hyperactivity: Oxybutynin versus propantheline versus placebo. Journal of Urology, 145(4), 813±817. Tinetti, M. E., Inouye, S. K., Gill, T. M., & Doucette, J. T. (1995). Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. Journal of the American Medical Association, 273(17), 1348±1353. United States Agency for Health Care Policy and Research (1996). Urinary incontinence in adults: Acute and chronic management. Rockville, MD: US Department of Health and Human Services, Public Health Services, Agency for Health Care Policy and Research. Warren, J. W., Damron, D., Tenney, J. H., Hoopes, J. M., Deforge, B., & Muncie, H. L., Jr. (1987). Fever, bacteremia and death as complications of bacteriuria in women with long-term urethral catheters. Journal of Infectious Diseases, 155, 1151±1158. Zeegers, A. G. M., Kiesswetter, H., Kramer, A. E. J. L., & Jonas, U. (1987). Conservative therapy of frequency, urgency and urge incontinence: A double-blind clinical trial of flavoxate hydrochloride, oxybutinin chloride, emepronium bromide and placebo. World Journal of Urology, 5(1), 57±61.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

7.20 Community Mental Health Services in the United States and the United Kingdom: A Comparative Systems Approach BOB G. KNIGHT and BRIAN KASKIE University of Southern California, Los Angeles, CA, USA BOB WOODS University of Wales, Bangor, UK and EMILY PHIBBS University College London, UK 7.20.1 INTRODUCTION

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7.20.2 MULTIPLE SYSTEMS OF MULTILEVEL CARE

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7.20.3 THE STATUS QUO ANTE: LONG-TERM INSTITUTIONAL PSYCHIATRIC CARE

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7.20.3.1 Deinstitutionalization of Mentally Ill 7.20.3.2 Do The Old Institutions Still Exist? 7.20.3.3 Who Was Discharged from Psychiatric Institutions? 7.20.4 ACUTE PSYCHIATRIC INPATIENT SERVICES 7.20.4.1 Who is Served in Geropsychiatric Inpatient Units?

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7.20.5 MENTALLY ILL OLDER ADULTS IN NURSING HOME CARE

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7.20.6 OLDER ADULTS IN COMMUNITY MENTAL HEALTH SERVICES

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7.20.6.1 Community-based Mental Health Outpatient Care in the UK 7.20.6.1.1 Multidisciplinary teams 7.20.6.1.2 Memory clinics 7.20.6.1.3 Family therapy clinics 7.20.6.2 Community Mental Health Outpatient Services in the US 7.20.6.2.1 What types of clients are served? 7.20.6.2.2 Were CMHCs effective in outreach to elderly? 7.20.6.2.3 What comes next? 7.20.6.3 Summary: Community-based Outpatient Services 7.20.7 PARTIAL HOSPITAL SERVICES

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7.20.7.1 British Models

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7.20.7.2 American Models 7.20.7.3 Summary 7.20.8 RESPITE CARE

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7.20.9 CAREGIVER SUPPORT

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7.20.10 MENTAL HEALTH SERVICES IN THE HEALTH CARE SYSTEM

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7.20.11 DISCUSSION

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7.20.11.1 Cross-national Systems Comparisons 7.20.11.2 Dementia Services 7.20.11.3 Mental Health and Primary Care 7.20.11.4 Roles for Clinical Psychology in Community Care 7.20.11.4.1 Development of clinical geropsychology

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7.20.12 SUMMARY

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7.20.13 REFERENCES

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7.20.1 INTRODUCTION Community-based mental health services assist older adults with serious psychological disorders who have been moved out of institutional care facilities, as well as seeking to prevent older adults with such disorders from entering institutional care. In addition, communitybased services assist older adults with acute psychological distress who are not at risk of placement in institutions. In this chapter, we describe community-based mental health services in the United Kingdom and the United States, we highlight similarities and differences, and we explore the historical and political± economic contexts that shaped these service systems. 7.20.2 MULTIPLE SYSTEMS OF MULTILEVEL CARE The notion that community-based services for older adults with mental illness form one coordinated system is not a sufficient description. Knight (1991; Knight & Kaskie, 1995) argued that older adults with mental health problems are embedded in a variety of distinct care systems at both institutional and community-based levels: mental health systems, medical care services, long-term care for the elderly, and aging network services. Our understanding of community-based mental health services necessitates a systems level analysis where each system is considered independently and in relation to each other. This systems analysis departs from the more typical ªcoordination of servicesº and ªgaps in the systemº arguments in four distinct ways. First, we contend that systems of care operate on different principles and create a legitimately confusing service world for both the older client and the professional service provider. Gaps in service provision exist because different systems

were created for different purposes (mental health treatment, medical care, or social support). These systems have developed in response to different historical pressures rather than because someone overlooked elements while rationally laying out a system for older adults. Second, failures to coordinate are more often dictated by economic pressures than by muddled planning or by providers' personal failings. Economic resources for mental health services are scarce and have become even more meager since the Reagan±Thatcher era of tax cuts and cost reductions to public services. Older people, especially those who need mental health services, continue to suffer from the ªlastin, first-outº principle. In the UK, financial pressures and the increasing costs of acute medicine have drawn health services funding away from the chronic problems typical of those faced by older adults. In the US, support for older adults' mental health services by the Carter administration was rescinded by Reagan era cutbacks. Older adult services receive a minimal amount of funding, and continue to be subjected to further cutbacks. With such severely limited resources, the economic pressure is for systems to compete rather than to cooperate. Third, service use is further complicated because older adults experience coexisting physical health and/or social difficulties, making it all too easy for each system to displace responsibility to another ªmore appropriateº system of care. A system may limit service delivery to existing clients and may not accept clients who ªbelongº to some other system. Further, limited financial support may cause a system to not provide adequate care even to those older adults who ªbelongº to the system. As noted by Gatz and Smyer (1992, p. 744), ªeveryone and no one is responsible for the clients.º Indeed, the task of assuring appropriate community-based care for older adults

The Status Quo Ante: Long-term Institutional Psychiatric Care with mental health problems becomes one of securing appropriate services from multiple competing systems, each of which has distinctive operating principles and incentives to provide services. Fourth, the delivery of community-based services is further complicated by the fact that the different systems do not share the same definition of ªcommunity.º For example, Knight and Lower-Walker (1985) noted that the mental health system moved older adults into nursing homes, which it defined as a transition from state hospital care to ªthe community.º The aging network in the US has, in marked contrast, tended to define nursing homes as the prototypical institution from which older adults must be moved ªto the community.º Our objective is to place the provision of mental health services for older adults in the context of the multilevel mental health services system as well as within other systems of care: long-term care, medical health care, and social services. In what follows, we begin with the long-term hospitals for older adults with mental disorders which are the historical antecedents of community care. The remainder of the chapter will consider community-based interventions. 7.20.3 THE STATUS QUO ANTE: LONGTERM INSTITUTIONAL PSYCHIATRIC CARE In the UK, county asylums emerged from the seventeenth and eighteenth century workhouses and institutions of confinement which were common throughout industrial±urban Europe (Foucault, 1965). The nineteenth century saw the development of psychiatry and the redefinition of these institutions as places for treatment of the insane (Foucault, 1965). Many county asylums became large institutions with several thousand inmates. Arie and Jolley (1982) commented that in the mid-1970s half of all asylums were occupied by people over 65, reflecting that: Mental hospitals which were built to provide asylum for the mentally ill before more active treatments were available, are nowadays increasingly occupied by old people whose numbers would grow even further were it not for enforced government rationing and not uncommon reluctance on the part of psychiatrists to admit them. (Arie & Jolley, 1982, p. 225)

Institutional psychiatric care developed in the US in the late nineteenth century as a humane alternative to imprisonment, to mistreatment in family homes, and to vagabond status for the

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mentally ill (Rosen, Pancake, & Rickards, 1995). The US had a shorter, less urban± industrial history, and so institutional care emerged as an alternative to no care rather than a redefining of existing institutions. Older adults were often over-represented in US inpatient psychiatric institutions in comparison to their representation in the general population. Between 1910 and 1950, for example, the state and county psychiatric hospital network expanded substantially in the US and admissions of older adults doubled (Grob, 1987; Rosen et al., 1995). Adults over the age of 65 represented 25% of the total patient population, and state and county psychiatric hospitals were the principal points of care for a population with an assortment of diagnostic, economic, and social attributes (American Psychiatric Association, 1993). 7.20.3.1 Deinstitutionalization of Mentally Ill In the UK, the move to close large psychiatric institutions and replace them with local, community-based services began with the development of acute psychiatric units which were attached to local general hospitals during the 1960s and 1970s. The continued closure of mental hospitals was underpinned by rhetoric regarding the benefits of community-based care and driven by several Public Inquiry Reports of the scandalously poor conditions existing in such institutions. There were clear financial incentives also. The cost of maintaining and refurbishing the hospitals was growing and they became increasingly inefficient to operate with the falling number of patients. Also, there was an opportunity during the 1980s to transfer financial responsibility for patients from health budgets to the social security budget, through the transinstutionalization of patients from asylums to residential and nursing homes. The movement of younger patients into the community led to older people forming an increasing proportion of the mental hospital population. Yet, the development of ageappropriate services varied greatly from area to area, often depending on the presence of a charismatic psychiatrist. By 1986, about 70% of the UK population had access to a specialist psychiatrist in old age mental health care (Ineichen, 1989) and developments have subsequently continued. This growth has helped to focus attention on the inadequacy of mental hospitals for older people with dementia or other mental health problems. Beginning in 1955, older Americans were included in the mass ªdeinstitutionalizationº of psychiatric patients from state hospitals to the community. Publicly supported psychiatric hospitals began an extended process of transfer-

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ring older patients to the community (i.e., deinstitutionalization) or to other facilities such as nursing homes (i.e., transinstitutionalization). Moreover, state and county psychiatric hospitals applied more stringent admission criteria that reduced older adult admissions altogether (Kahn, 1975). This movement is generally attributed to the discovery of more effective psychopharmacological interventions and to a desire to provide more humane care in the least restrictive setting (Rosen et al., 1995), although cost control undoubtedly played a part. Hospitals were full and state legislatures were faced with the choice of building more or doing something else (Rounds, 1984). Moak and Fisher (1991) reported that 96% of the state hospitals had a floor, unit, or wing designated for geriatric patients. Yet, just 60% of the state hospitals retained a professional staff member who was trained in geriatric psychiatry and less than 20% of the hospitals provided any form of psychosocial treatment. These findings support the American Psychiatric Association's (1993) position that state and county hospitals rely on psychotropic medications and rarely use psychosocial interventions±±even though welldesigned, multidisciplinary treatment principles have been formulated. 7.20.3.2 Do The Old Institutions Still Exist? The care of older adults who reside within institutional settings has changed. The image that county asylums and state hospitals provide only chronic, custodial care is contradicted by recent studies. In the areas of the UK where final closure has yet to occur, older patients are likely to be admitted to specialist inpatient assessment and rehabilitation units with a very few continuing care beds. Most of the long-term care admissions occur in areas where the independent sector has been slow to develop nursing home alternatives (Tomenson, Benbow, & Jolley, 1994; Wattis & Fairbairn, 1996). In the US, Clark and Travis (1994) reported that just 20% of their older adult sample remained in the hospital for more than one year, while most of the rest were discharged. At least 15% of these older patients returned to the community while the remainder were released to another community-based facility such as a foster home, board and care facility, or nursing home (10% died in the hospital). 7.20.3.3 Who Was Discharged from Psychiatric Institutions? In the UK, the older people affected by the closure of county asylums fit into two principal

groups: (i) Chronic patients, usually with a long history of psychosis and having been hospitalized for many years. Arie and Jolley (1982) estimated they formed approximately 20% of the mental hospital population. They have often been discharged to hostels, residential and nursing homes (e.g., Dean, Briggs, & Lindesay, 1993). Anderson and Trieman (1995) suggested that over half this group may additionally have a moderate to severe degree of cognitive impairment. (ii) People with severe dementiaÐ usually admitted because of behavioral problems and mainly discharged to nursing homes (e.g., Lyons, Cohen, Henderson, & Walker, 1995). In some cases, they are discharged to homes that are specially designed for people with dementia, for example, domus homes (Dean et al. 1993; Lindesay, Briggs, Lawes, MacDonald, & Herzberg, 1991; Skea & Lindesay 1996). These are small, ªhomelyº living units, with specially trained staff and a philosophy encouraging attention to psychosocial aspects of care, to balance the traditional emphasis on physical care. Based on the 1994 State and County Mental Hospital Inpatient Survey, Semke, Fisher, Goldman, and Hirad (1996) suggested that the US state hospital population could be sorted into three prominent groups: older adults with schizophrenia comprise 40.2% of the population, older adults with dementia total 30.0%, and those with depression and other late-onset disorders account for 13.1% of elderly patients. Another 10% were diagnosed with alcoholism, mental retardation, and other psychoses. In summary, the image of county asylums and state hospitals as custodial warehouses where older patients are admitted and abandoned appears to be out of date. Rather, most hospitals provide limited inpatient services to older adults who are placed back to the community or another facility within a year of admission. In some places, the state or county hospital may be the only point of inpatient service. In considering policies surrounding community care, it is important to recognize that the county asylum and state hospital systems have changed dramatically. These hospitals have emerged as a form of communitybased care, especially for older adults affected by psychoses, dementia, and severe affective disorders.

7.20.4 ACUTE PSYCHIATRIC INPATIENT SERVICES In the UK, many districts have an inpatient old age psychiatry assessment unit on a general hospital site, with varying degrees of collabora-

Mentally Ill Older Adults in Nursing Home Care tion with geriatric medicine units (see Arie & Jolley, 1982; Ineichen, 1989). Typically, these are the central component of a communitybased service for older people. Some of these inpatient units provide separately for those presumed to have dementia and those with an affective disorder. The advantages of having the inpatient unit on a general hospital site include increased access to the general hospital, access to specialists for coexisting physical health problems which might complicate the person's presenting state and course, and the opportunity to develop liaison services between mental health and general medical wards. Over the last 20 years in the US, adult psychiatric inpatients have moved from state and county facilities, and now predominantly use general medical and private psychiatric inpatient hospitals (Kiesler, 1991). Narrow, Regier, Rae, Manderscheid, and Locke (1993) reported that 43.3% of all adult inpatients were admitted to either a general hospital psychiatric unit or scatter bed (ªscatter bedº refers to individuals who are admitted to a hospital that does not have a special psychiatric unit or department), while 10.8% were admitted to a private psychiatric hospital. Atay, Whitkin, and Manderscheid (1995) examined the Inventory of Mental Health Organizations survey and, after excluding those older adults who resided in nursing homes, found that 21.6% of all elderly inpatients were treated in general hospitals, and 10.6% were treated in psychiatric hospitals. The remainder were treated in state or county hospitals, Veteran's Administration Hospitals, or by inpatient services affiliated with multiservice community mental health centers. 7.20.4.1 Who is Served in Geropsychiatric Inpatient Units? Are these the psychotic and demented elderly who were the principal patient populations of state hospitals? Reports from individual hospital programs suggest that this may not be the case. In the UK, Domken, Bothwell, and McKeith (1995) analyzed discharge data from a well-established old age psychiatry unit. Comparison of the years 1985, 1988, and 1991 illustrated the growth in discharges to independent sector homes, together with increased admission rates and shorter lengths of stay. The proportion of patients having a functional disorder without organic impairment fell from 50% in 1985 to 25% in 1991, reflecting increasing reliance on day-hospital and community support for the functional disorders group. In the US, Conwell, Nelson, Kim, and Mazure (1989) found that of 168 consecutively

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admitted patients to a geriatric inpatient unit in New Haven, 75% were diagnosed with an affective disorder and 25% with dementia. Knight and Carter (1990) reported that most geriatric admissions to a psychiatric inpatient unit in southern California were diagnosed with psychoses (47%) or with affective disorders (36%), with about 14% diagnosed with an ªorganic brain syndrome.º In summary, the role of acute psychiatric inpatient care has been overlooked when discussing community-based services, reflecting a tendency to equate inpatient care with custodial institutional care. However, impatient treatment of mentally disordered elderly appears successful using both psychopharmacologic (Schneider, 1995) and psychosocial (Gatz, Popkin, Pino, & VandenBos, 1985) interventions. Moreover, Knight (1983, 1986) reported that the utilization rates of inpatient and outpatient care by older adults in the counties of California were statistically independent of one another, suggesting that the systems serve different community-based populations. Shortterm inpatient care close to home appears in fact, to be an important and distinct component of community-based care for older adults.

7.20.5 MENTALLY ILL OLDER ADULTS IN NURSING HOME CARE In the UK, around 5% of older adults live in permanent institutional care. The majority (approximately 72%) of these older adults in 24 hour care live in residential or nursing homes which are not provided by the National Health Service (NHS), housing authority, or by local government. Many of these people are funded, at least in part, by a combination of Social Services and Social Security payments. The high prevalence of psychiatric morbidity in residential homes in the UK is well established. For example, Neville et al. (1995) assessed older people in four local authority residential homes. The great majority (82%) had some degree of dementia. Over half (53%) of the residents were assessed as having severe dementia. Of those (45%) able to complete a self-report depression scale, 17% scored in the depressed range. Of the whole sample, only 17% showed no evidence of dementia or depression. The rate of depression reported here is much lower than in previous studies (see Ames, 1991), where over a third of residents without severe dementia have been depressed. The lower prevalence of depressed older adults in residential care may be due to improved assessment as well as more creative community treatment and support packages

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which enable older people with depression to remain in their own homes. An alternative hypothesis would be that the closure of hospital beds for severe dementia places pressure on local authority homes to accept a greater number of people with severe dementia, while independent sector nursing and residential homesÐwho have more choice over which residents to acceptÐabsorb the less physically dependent and behaviorally disturbed group of depressed older adults. This illustrates the need to examine trends across the multiple systems (health, mental health, social) of institutional care. Examining one component in isolation gives an incomplete, and perhaps misleading, picture. In the UK, the National Health Service and Community Care Act (1990) was motivated by the need to control the flow of resources into residential and nursing homes; previously, funding had been available without assessment of need. Although wrapped in rhetoric about providing better community support and services, assessments of need form the basis for targeting the provision of institutional care (see Gilleard, 1996a). ªNeedº for continuing hospital care is more likely to depend on availability than on any rational assessment; some districts have very few hospital beds, others retain a significant number (Tomenson et al. 1994). Between 1963 and 1990, nursing homes expanded tremendously in the US from 445 000 to 1 772 000 individual beds as Medicare and Medicaid were initiated and included financial support for long-term care services (Darney, 1994; Schick & Schick, 1994). Moreover, the nursing home population grew as patients were supplied by the transinstitutionalization of older adults from state psychiatric hospitals (Kahn, 1975), a move which represented a cost-cutting strategy for state legislatures who moved the elderly mentally ill from totally state-funded psychiatric hospitals to partly federally-funded nursing homes (Estes, 1995). In 1963, 48% of institutionalized mentally ill elderly were in state psychiatric hospitals with the remainder in nursing homes; in 1969, 75% were in nursing homes (Dorwart & Epstein, 1993). The nursing home setting would appear to be where many of the former psychiatric hospital population would now receive care: 50% of nursing home residents are demented, 30% have psychoses (Shadish, 1989). More recently, the US Federal Government responded to the relocation of older mentally ill with the Nursing Home Act of 1987. This act recognized that older adults with psychiatric conditions were over-represented in nursing

homes and stipulated that nursing homes must screen patients for psychiatric illness. If patients were diagnosed with a mental illness, then the nursing home was required to (i) provide appropriate psychiatric care, or (ii) deny admission to them and/or transfer them to a more appropriate facility (Smyer, 1989). Smyer, Shea, and Streit (1994) reported that at the time of the passage of this law, 65% of older adults in nursing homes who had mental health problems did not receive treatment for these problems. They also reported that for-profit homes tended to rely on bachelor's level counselors and government homes used psychiatrists, whereas private nonprofit homes used psychologists and social workers as well as psychiatrists. Early estimates suggested that between 2.4% and 18% of residents would be excluded from nursing home care by this act (Freiman, Arons, Goldman & Burns, 1990; Eichmann, Griffin, Lyons, Larson, & Finkel, 1992). However, later reports suggest sharp increases in mental health service provision in nursing homes after the passage of this law (Knight & Kaskie, 1995; Office of Inspector General, 1996), rather than discharges of patients with mental health problems. However, there are concerns about service standards and fraud: approximately 24% of Medicare billings in 1993 for mental health services to nursing home residents were estimated to be medically unnecessary (Office of Inspector General, 1996). Two-fifths of the insurance carriers for the Medicare program considered part of the problem to be ªexcessive entrepreneurialismº on the part of mental health professionals (Office of Inspector General, 1996, p. 13). On the whole, the issue of providing adequate treatment to the transinstitutionalized older mentally ill resident of nursing homes in the US is still unresolved. For these individuals, ªreturn to the communityº has meant a shift from the mental health system to the long-term care system, reduced access to mental health treatment, a shift of care from the states to private sector institutions, and a shift of costs from states to a mix of federal-state (Medicaid) and private (patient and family) financing. Lomranz and Bar-Tur (see Chapter 21, this volume) provide more comprehensive coverage of the nursing home population and service models for mental health treatment. Our point is that many, probably most, of those moved to ªthe communityº were transferred to nursing homes from state hospitals, and that long-term psychiatric hospital treatment and care has been replaced by such homes in both the US and UK. In the remainder of this chapter, we explore community-based outpatient mental health services for older adults.

Older Adults in Community Mental Health Services 7.20.6 OLDER ADULTS IN COMMUNITY MENTAL HEALTH SERVICES In this section, we cover the provision of mental health services to older adults outside of 24-hour care institutional environments. The range of services and settings described includes traditional and nontraditional outpatient services, partial hospitalization and related day care services, respite care, and support for caregivers. 7.20.6.1 Community-based Mental Health Outpatient Care in the UK All community-based services in the UK operate in the context of Department of Social Services community care assessment and care management, intended to ensure that needs are properly assessed and that service provisions are targeted appropriately. Challis (1992) reviewed good models of providing community care through care management schemes. Some success is reported with mental health problems as well as with physical frailty. They have tended to include older people with dementia, rather than to focus specifically on them. Although apparently intended to be the basis of UK community care provision, important elements of the demonstration programs have often not been present in mainstream practice. The key elements included a high degree of flexibility, an available budget per person to ªbuy inº services, availability of paid volunteers, and a skilled assessment of need. There is widespread disappointment with the very basic packages of care being offered, and there is concern to ensure that specialist mental health services are involved more fully in assessment and care planning (Department of Health, 1996). 7.20.6.1.1 Multidisciplinary teams The key element of such specialist community services in most areas of the UK would be a multidisciplinary team (MDT) usually seeing the older person in his/her own home. Most teams aim to respond quicklyÐwithin a few daysÐto referrals, more rapidly for urgent cases. The range of disciplines involved varies greatly; at a minimum, most members may be community psychiatric nurses, perhaps with an old age psychiatrist having a part-time input to the team. Elsewhere, occupational therapists, physiotherapists, social workers, speech therapists, clinical psychologists, and workers from voluntary agencies for older people may be team members. Typically the teams have been established by redirecting resources from mental health hospital provision; most teams liaise closely with inpatient old age psychiatry units

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and day hospitals. Often the team will share a hospital base with these services, although increasingly efforts are being made to locate such teams more accessibly, for example, in primary health care centers. Most teams have a defined population to serve, and will usually see clients referred from residential and nursing homes within this area, as well as those living at home (Brown, Challis, & von Abendorff, 1996). Many teams will accept referrals from any agency, or from families or self-referrals; other teams maintain the traditional, less accessible, stance of only accepting referrals from the person's primary care physician. Some teams insist that all referrals are seen by a medical member of the team; others have a policy that a team member from any discipline may carry out the initial assessment meeting, where medical input would be available. Coles, von Abendorff, and Herzberg (1991) evaluated the initial impact of a new community mental health team in an Inner London borough. This service replaced a traditional hospital-based system in which a consultant psychiatrist made domiciliary visits. The new community team was multidisciplinary, and used a keyworker scheme, where one member of the team would be allocated primary responsibility for the coordination and delivery of the service provided to each case. In a period of six months the team assessed over 90 more referrals than the consultant had seen in the equivalent period. The primary diagnosis for both the MDT and the consultant was dementia, which made up approximately 40% of all referrals. Depressive disorder accounted for 30.3% of diagnoses by the MDT and 18.3% of diagnoses by the consultant. The team was able to provide increased levels of input including treatment for depression, coordinating a range of services, and counseling and support for caregivers. Junaid and Bruce (1994) investigated the effectiveness of community psychiatric nurse services for the elderly in a particular district. They found wide variation in the numbers employed per thousand people over 65 (from one per 2255 to one per 9200; The Royal College of Psychiatrists recommends one nurse per 5000 of the population over 65). They found large differences in the skill mix of the community teams. In some teams nurses would specialize in patients with specific diagnoses, for example, cognitive impairment, neurosis, or psychosis. Other teams would share case loads equally. In conclusion, Junaid and Bruce stated ªCurrent provision appears to be based primarily on historical trends of resource allocation, and also on a varying commitment to community development which is evident in the philosophy

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or approach of the teamsº (p. 718). It would seem that while the development of MDTs may have led to an improvement in services at a local level, the variation among teams' working practices and funding allocations has led to wide regional and inter-regional differences. In the UK, some mental health teams (see Dening, 1992) specialize exclusively in working with people with dementia, whereas others cover all mental health problems of older people. Brown et al. (1996) provide details of referrals, caseloads, contact history, and outcomes of two well-established and pioneering teams which work with both organic and functional disorders. They took a random sample of 120 open cases on caseloads of two MDTs for elderly people, both with an open access policy, and followed up these cases over an 18-month follow-up. The teams' caseloads contained a greater proportion of patients with affective disorders, and less with dementia, in comparison with referrals to the team. The response to dementia appeared to be a briefer episode of contact, emphasizing assessment and diagnosis more than continuing support. A higher proportion of those with affective disorders remained at home at follow-up. This tendency for people with dementia and their caregivers to be rapidly discharged from the active caseload has led these teams to explore the use of specific long-term workers attached to the team to act as case managers for people with dementia and their families. Elsewhere, an innovative response has been the development of a specialist mental health nursing service to work specifically with family caregivers (see Woods, 1995), or teams working only with people with dementia, offering assessment, ongoing support, interventions to relieve caregiver strain, and facilitation of appropriate services. Outcome studies of the work of such teams with people with dementia are yet to be completed. O'Connor, Pollitt, Brook, Reiss, and Roth (1991) have reported a controlled trial of the effect of an MDT on admission rates of people with dementia over the age of 75 over a two-year period. The team offered a wide range of help to people with dementia and their families identified in an ascertainment surveyÐ including advice on and help in arranging services and benefits and respite admissions. No difference in admission rates, compared with control patients, was noted in those living with a caregiver. Those living alone were much more likely to enter residential care than controls. However, this study does not necessarily reflect outcomes in usual practice where the person or their family seeks help, rather than being identified as someone in need, as was the case here. More positive results are reported by

Hinchliffe, Hyman, Blizard, and Livingston (1995) in a study where caregivers were offered an intervention devised by an MDT, which included components of behavioral, practical, and pharmacological input depending on the assessed needs of the situation. Caregiver mental health and the patient's behavioral difficulties improved compared with a waitinglist control group. Although around 10% of the teams' caseload in Brown et al. (1996) had a diagnosis of schizophrenia, it is not clear what proportion of these had developed a psychotic illness such as paraphrenia in late life, as opposed to having a long-standing mental health problem. Generally, patients who have been receiving mental health services for many years are not transferred to old age services when 65, unless these services are more appropriate (e.g., because of the development of a dementia or physical health complications). Little has been documented regarding the effects of this approach. In summary, community teams have developed widely, with very little in the way of evaluation, or even detailed descriptions of practice, since the early publications (Lindesay, 1991). Their service coordination role has, to an extent, been taken on formally by Social Services through the community care assessment and care planning process, and there are significant differences between areas in the extent to which the skills of the MDTs are utilized in carrying out specialist assessments and planning programs of care for older people with mental health problems. Some teams have very close links with social worker team members, and carry out many community care assessments; others find themselves much less involved, at best acting as an advocate for the patient's service needs. Although diversity of team functioning can be seen as flexibility to respond to local circumstances, the lack of consistency makes it difficult to know whether such teams do offer an effective way of organizing the response to mental health needs of older people in the community. Most teams attract high levels of referrals, and so appear to be meeting a demand, but this is of course an inadequate measure of efficacy. Two further developmentsÐMemory Clinics and Family Therapy ClinicsÐin the UK are worthy of mention. Although their implementation is not yet as widespread as community teams, they promise to significantly shape the direction of future services. 7.20.6.1.2 Memory clinics Early diagnosis of memory disorders is regarded as fundamentally important when

Older Adults in Community Mental Health Services treating and counseling individuals with dementia. The memory clinics have been developed to provide community-based services to older adults with dementia. All memory clinics provide an outpatient diagnostic assessment, and, in many centers, advice and counseling is offered to the person and their family, along with any appropriate treatment. The first British memory clinic was established in 1983 at St. Pancras Hospital, London. A recent review of memory clinics in the British Isles (Wright & Lindesay, 1995) identified 20 clinics running in the UK and Ireland. Memory clinics provide diagnostic assessments for dementia and other memory disorders. Typically, patients receive a cognitive assessment involving standardized tests of cognitive functioning (including the Mini Mental State Examination, MMSE; Folstein, Folstein, & McHugh, 1975) and mood. A wide variety of physical investigations are used including full physical examination, computerized tomography scanning, magnetic resonance imaging, and blood tests. On average, around three-quarters of referrals to the clinics were diagnosed as having a dementing condition. Clinics vary in the cognitive tests and physical investigations used. The time taken to carry out full assessments was reported to vary from one to six hours. It is not clear whether the differences in practice have any clinical impact. The number and type of staff running memory clinics vary. The professionals commonly involved are psychiatrists, geriatricians, neurologists, psychologists, and nurses, as well as speech therapists, social workers, and occupational therapists. Staffing levels vary as does the amount of any specific type of professional input to the service. Many of the memory clinics in the UK are actively involved in recruiting participants for research into dementia and specifically Alzheimer's disease. The research is both pharmaceutical and nondrug orientated. Memory clinics provide an important service within the communities they serve. They are a useful point of referral for general practitioners, and may provide a starting point for many individuals to find help and information about memory impairment, as well as access to other community services. In a few areas, the followup from the clinic is extensive and caregivers receive considerable support over an extended time period (Bayer, Richards, & Phillips, 1990; Gilliard & Wilcock, 1993). 7.20.6.1.3 Family therapy clinics Family therapy for older adults has only a brief history of implementation in the UK,

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although old age mental health service providers have long recognized the role of the family as being a significant factor in the psychological and physical well-being of older adults (Colwell & Post, 1959). UK research suggested that family-based work with older adults had useful clinical implications (Ratna & Davies, 1984). However, it is only in the last few years that family therapy for older families has begun to be implemented in practice. Traditionally, families with young children or adolescent members have been the prime focus for family therapy practice. In 1992, Gilleard, Lieberman, and Peeler set up a team for older adults in an established family therapy center in Inner London. The service was underutilized and referrals soon began to ªdry up.º Research revealed that professionals working with elderly people were unaware of the existence of the team, or had limited knowledge of family therapy with older people in general. Some professionals expressed doubts as to the usefulness of such a service, believing that there was little potential for change in the families of older people. Although misconceptions about older people did have some bearing on the lack of referrals to the new service, practical problems also played a large part. Professionals (especially community nurses and social workers) did not know that they were able to make referrals. The overwhelming majority of professionals working with elderly people expressed positive attitudes towards family therapy. They suggested ways of making the service more accessible to their particular client groups, by limiting the amount of traveling and by holding all or some of the sessions in the client's home. Altering times of sessions to accommodate working hours was also suggested. By disseminating information regarding the service and by implementing changes suggested by health professionals, family therapy with older adults may become an important resource available to the community. Research has highlighted the efficacy of family therapy to different elderly client groups (Gilleard, 1996b). Benbow, Marriott, Morley, and Walsh (1993) assessed the usefulness of family therapy with older adults suffering from dementia. The basic therapeutic techniques remained the same as for those older adults with other mental health problems, however, a few differences were found. Family therapy based treatment with dementia patients was often seen in terms of psychological management of the disorder and an increased focus on caregiver stress. Families were crisis-oriented and attended for fewer sessions. These difficulties present new challenges in providing family

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therapy for dementia sufferers. Continuing development indicates that family therapy with older adults will prove an important addition to older adult mental health services in the UK. Curiously, family therapy for the elderly has grown slowly in the US. While there are services for caregivers (see Chapter 22, this volume) and well-known advocates for family therapy with the elderly (e.g., Qualls, 1996), there is no effort to establish family clinics as such. In summary, for the foreseeable future, community MDTs seem likely to form the basis of specialist community mental health services for older people in the UK. Developments which reflect the importance of careful assessment and working with families, such as memory clinics and family therapy clinics, are likely to augment the basic service in some areas, and to influence practice within the teams more broadly. 7.20.6.2 Community Mental Health Outpatient Services in the US In the US, the Community Mental Health Centers (CMHC) Act of 1963 financed the development of comprehensive community mental health centers. These centers were intended to provide services to the deinstitutionalized mentally ill and to provide services to persons who would have been institutionalized in the past. CMHC services target state hospital patients who do not require intensive supervision and CMHCs also serve community residents who need intermittent care (US Congress, Senate Committee on Labor and Welfare, 1973). CMHCs provide comprehensive mental health services including individual assessment, diagnosis, and treatment in acute inpatient, day treatment, or outpatient settings. Unlike the UK approach, the US CMHCs were newly created agencies rather than programs reaching out from existing hospital services. As noted in Section 7.20.2, the focus on community-based services for the elderly did not begin in the mental health system until shortly before the national initiative was terminated and responsibility was returned to the states. Perhaps for this reason, the efforts at national planning of community mental health services for the elderly that are seen in the UK are lacking in the US. However, there are model programs that can provide guidance in conceptualizing what community mental health services could offer older adults. Knight, Rickards, Rabins, Buckwalter, and Smith (1995) reviewed a variety of mental health programs for older adults with a range of mental health problems. The programs included community mental health services in Spokane,

Washington, Cedar Rapids, Iowa, and Ventura County, California, as well as a multiservice program at Long Island Jewish Hospital in New York and a psychiatric consultation service to a federal housing program for the elderly in Baltimore. The services spanned urban and rural areas and used a variety of approaches to the coordination of care. These programs have shown that it is possible to provide high-quality, community-based mental health services to the mentally ill elderly. The programs also share some common features: (i) All emphasize accurate diagnosis of older adults. (ii) All are interdisciplinary and treatment focused. (iii) All use active case-finding methods and community education approaches to bring clients in. They also collaborate actively with other agencies that serve older adults and in three cases with postal carriers, meter readers, and other ªcommunity gatekeepersº (Raschko, 1990). (iv) All of them deliver mental health services to older adults at home. Mobile geriatric outreach teams, which use home delivered services and interdisciplinary teams (see Chapter 24, this volume) have proven effective in increasing service use by older adults in both urban (Knight, 1983) and rural areas (Buckwalter, Smith, Zevenbergen, & Russell, 1991). MosherAshley (1994) also has highlighted the importance of home delivered services in reaching this population. 7.20.6.2.1 What types of clients are served? In a survey of 349 older adult CMHC clients in Miami, Pruchno et al. (1983) reported that 54% were diagnosed with a unipolar or bipolar mood disorder, 21% had dementia, and 8.9% had schizophrenia or psychoses. Speer, Williams, West, and Dupree (1991) determined that 29% of their Tampa sample was diagnosed with dysthymia, 20% had mood disorder, and 10% had maritial problems. If these local samples are representative, it would appear that CMHCs serve high proportions of depressed older adults, but may be less successful in reaching the demented and psychotic populations that were a large part of the state hospital population. 7.20.6.2.2 Were CMHCs effective in outreach to elderly? While the CMHCs did not develop sufficient services for older adults with mental illness (Lebowitz, 1988), they did not completely overlook older adults. In fact, the use of CMHC services by older adults grew steadily through the 1970s and 1980s. The Government Accounting Office (1982) reported that 4% of all CMHC

Partial Hospital Services clients were over the age of 65 in 1978, whereas by 1983 the elderly comprised 6% of the users of community mental health (Fleming, Rickards, Santos, & West 1986), with lower representation in other clinics and fewer still in private practices. In the 1990s, more of the elderly have begun to use mental health services. In 1990, the Inventory of Mental Health Organizations showed that 9.72% of all outpatient mental health clinic clients were older adults; 11.87% of clients in publicly supported clinics were older adults (Stiles, 1994). Lebowitz, Light, and Bailey (1987) gathered information from 45% of the 624 CMHCs and found that 52% of those responding to the survey provided both professional mental health services to older adults and employed a geriatric staff specialist. However, 28% of their sample had neither age-targeted services nor a staff specialist. They concluded that older adults were offered more services by those CMHCs with trained staff or specific programs. In these centers, the older adult population represented 15.8% of the entire population; among the CMHCs with no staff or services, the older adult census averaged 8%. Also, Knight (1986) reported that for county mental health programs in California, service use by older adults was predicted by the number of specialist staff and was uncorrelated with percentage of elderly in the county population. 7.20.6.2.3 What comes next? In the mid-1980s, Fox, Swan, and Estes (1986) reported that more than 60% of CMHCs were maintaining or increasing their services for older adult populations. More recently, they reported in a follow-up study that older adults services are more likely to be dropped than added to community-based mental health programs (Estes, Linkins, & Kane, 1994). Since the control of mental health programs was shifted back to the states, they have increasingly left individual CMHCs with a reduced budget, and without any stipulation concerning how the money should be spent (Christianson & Gray, 1994). In the mid-1990s, California continued the displacement of responsibility from federal to local governments by shifting control of mental health programs from states to counties, where these services compete with the medical care system for the indigent as well as with police and fire services for funding. It seems unlikely that comprehensive CMHCs will be a major part of mental health services for older adults in the future. As mental health services in the US move to the private sector and to managed care organizations, active casefinding and other community mental

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health outreach strategies are likely to be inverted with probable negative impact on the accessibility of mental health services to older adults with depression, anxiety, substance abuse, and especially with long-term mental disorders like schizophrenia. 7.20.6.3 Summary: Community-based Outpatient Services At this level, outpatient mental health services within the UK and US diverge most markedly. The UK's history of universal coverage has led to relatively systematic programming for the elderly, including MDTs, and more recently in some areas memory clinics and family therapy clinics. In the US, the federal role in mental health services has been more research-oriented than services-oriented with the individual states playing the major role in mental health services provision (Rosen et al., 1995). The history of federal±state relationships regarding mental health in the US has been characterized by shifting responsibility back and forth between the two with neither level of government taking clear responsibility at present. As noted by Liebig (1993) with regard to health and social policies for the aged, the federal system tends to lead to wide variation in policy among states, and in some cases the absence of policy. In the mental health sector, this is perhaps most clearly the case with dementia care, which some states would include in mental health services, while others would define it as in a different system, as its own system, or as not a state responsibility (Knight & Macofsky-Urban, 1990). The US has a few model programs for community-based outpatient services for the elderly, but lacks a system or a coherent national policy.

7.20.7 PARTIAL HOSPITAL SERVICES 7.20.7.1 British Models In the 1970s and 1980s, day hospitals developed as the central component of many local older adults mental health services. By 1990, 20 000 older people were attending such day hospitals regularly, with over 1.7 million day places available per year (Fasey, 1994). Day hospitals have served a variety of functions: preventing admission to inpatient facilities, providing relief to caregivers of people with dementia, assessment, monitoring, and treatment of people with depression, facilitating discharge from an inpatient unit back to the community, and for observing the person's behavior and mental state for a longer period than is possible in the person's own home.

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There is considerable debate concerning how effective the day hospital is in fulfilling these functions, and whether it represents the most effective use of resources (Fasey, 1994; Howard, 1994; Murphy, 1994). There is relatively little in the way of evidence to inform the debate. Day hospitals have not been effective in delaying admission to long-term care (Diesfeldt, 1992; Woods & Phanjoo, 1991), but do reduce strain for many (but not all) caregivers (Gilleard, 1987). However, some caregivers find the strain of getting the person ready for day care an additional burden, or find that most of their difficulties are at night and so they are not helped by day care. A few ªnight hospitalº programs have been developed in response to this need. The role of day hospitals in the treatment of depression has not been evaluated in the UK context. The UK also makes the distinction between ªday hospitalsº and ªday centers,º the former are health facilities, with a team including doctors, nurses, and therapists, and the latter are primarily ªsocial careº resources but may have input from visiting health professionals. In reality, the distinction is not always clear, and those opposed to day hospitals argue that resources spent upon them are better used to provide more health input to day centers, many of which work well in providing relief for caregivers or as a social base for older people with depression needing to expand their social network. Although Tester (1989) argued that day hospitals generally provide respite care for those older people whose behavioral problems or level of dementia proves ªtoo severeº to be managed in a day center setting, Warrington and Eagles (1996) reported from a specific sample that the overall level of behavioral disturbance was no greater in cognitively impaired day hospital attenders than in those attending day centers.

psychiatric services seem to be expanding rapidly, especially in the private sector. For example, Stiles (1994) reported that partial hospital services increased by 50% between 1986 and 1990. Culhane and Culhane (1993) added that older adults represent between 4.8% and 7.9% of all partial hospital patients. The American Psychiatric Association (1993) noted that partial hospitals serve 18% of those older adults who actually use professional mental health services. Since the history of partial hospitalization is directly related to substitution for hospitalbased care, it is perhaps not surprising that the population served is more similar to the state hospital population. Eskew, Sexton, Tars, and Wilcox (1983) indicated that 34% of partial hospital patients were diagnosed with dementia, 32% had an affective disorder, and 24% were schizophrenic. The patient population appears to vary by program though; Plotkin and Wells (1993) reported that 60% of their partial hospital sample were depressed, 13% had a cognitive impairment, and 9% had an adjustment disorder. The majority of these patients received treatment subsequent to an inpatient hospital stay. In a program designed and implemented at the Florida Institute for Mental Health, Roger Patterson and associates designed a behaviorally-oriented social skills training approach to day treatment which assisted chronically mentally ill older adults to return to the community from state mental hospitals. As described and evaluated in Patterson et al. (1982), the program used applied behavioral analysis, behavioral intervention, and psychotropic medication to overcome effects of chronic psychosis and chronic institutionalization. Program attenders and graduates were more successful in community placements with lower recidivism rates.

7.20.7.2 American Models

The day program model has been used quite successfully for older adults in both the UK and the US and appears to be well suited to the needs of the older adults who formerly used long-term institutional care. However, this modality of treatment has neither been extensively reported in the clinical literature nor evaluated. We would hope that it would receive more attention in future research, clinical reports, and public policy consideration.

Partial hospital programs have expanded significantly in the US in the last 10 years and have also become a more common form of mental health service for older adults. These partial hospital programs are organized under many different models that offer a range of social and medical services (Whitelaw & Perez, 1987). Culhane and Culhane (1993) reported that 63% of day treatment programs in the US are located in CMHCs, 17% are affiliated with general hospitals, and 12% are found in private psychiatric hospitals. As fiscal incentives promote alternatives to inpatient care, partial

7.20.7.3 Summary

7.20.8 RESPITE CARE As developed in the UK, respite care generally means a short stay in hospital or in

Caregiver Support another 24-hour care setting. In the US, respite has been used to refer to community-based social services such as social day care and inhome care workers. In the UK, respite can be considered as another partial hospitalization program. As noted above, this may be one of the functions of a day care program. Often a rationale will be made as to why a particular patient ªrequiresº respite in a hospital rather than a residential or nursing home, in terms of severity of disturbance, or of need for nursing care. The availability of resources is of course an over-riding factor in these considerations, but the need to support caregivers in this way is widely recognized. Residential respite care involves the patient staying in a residential/nursing home/hospital setting for a given period of time, thus allowing their caregiver to have a sustained period of time off from caring. Some beds are designated as ªrota beds,º in that a number of patients share the resource, taking turns to come into the facility. For example, four patients might each have two weeks in hospital and six weeks at home on a rotational basis, filling one bed continuously. Some relief schemes do not run on a rota system, but allow admission over a period when the caregiver may wish to go on holiday. Relief care may also include crisis admissions, say when a caregiver is taken ill. Nolan and Grant (1992) carried out an extensive evaluation of such a hospital rota bed scheme, concluding that respite care fulfills a deeply felt need in caregivers, but also raises issues about caregivers' attitude towards institutional care. Caregivers possess unique knowledge of their relative, and often feel that the needs of the care recipient could not possibly be met by those working in an institution who have only limited knowledge of the care recipient (Worcester & Quayhagen, 1983). It is interesting to note that although this type of respite care is generally reported as being beneficial to caregivers, they also report feeling sad and lonely when their relative is away (Pearson, 1988). Guilt and worry may also be pervasive emotions felt by a caregiver who places a relative in residential respite care (Nolan & Grant, 1992). Evaluations of respite care have shown that it has considerable benefit for caregivers. Levin, Moriarty, and Gorbach (1994) found respite was valued highly by caregivers. When respite services were introduced, they formed an ongoing source of support. Levin et al. emphasize the need for services to be targeted to the individual, noting that one ªcare packageº may not suit all caregivers' needs. Flexibility of service is important, especially where disease progression is an element.

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Some caregivers report that the person with dementia returns from respite more confused than when he/she was admitted. This may be understood in terms of the effects of a change in environment and routine on the person with dementia, and the difficulty of staff in ascertaining quickly the person's needs. Preadmission visits to a familiar place might reduce such effects, but an alternative strategy is to provide the respite care in the person's own home to minimize the disruption for them. This service is referred to as domiciliary respite where an outside agency will dispatch trained caregivers (i.e., a ªsitterº or care attendant) to the home to take over the role of the caregiver for a given amount of timeÐa few hours or several days. Some care workers may even spend the night at the person's home, as this is often the most difficult time. There are some indications that caregivers find these services beneficial (Turvey & Toner, 1991). In the US, day care and in-home respite services are not typically viewed as a part of mental health service systems but rather as a part of community-based long-term care or of home health services. Curiously, these services seem more effective at meeting mental health goals (i.e., improving the caregivers' life satisfaction or reducing emotional distress) than meeting community-based services goals of reducing care costs or preventing institutional care (Weissert, Cready, & Pawelak, 1988; Knight, Lutzky, & Macofsky-Urban, 1993). However, it has long been noted that respite may not be provided in sufficient quantity to meet these other objectives, and recent research tends to support the notion that longer respite may lead to reduced institutional care (Koslowski & Montgomery, 1995)

7.20.9 CAREGIVER SUPPORT In the UK, caregiver support groups have been a popular development from the early 1980s. They take many different forms: some are organized as ªtraining coursesº; some are akin to therapy groups, being closed and having a facilitator; many are open-ended, self-help groups. Some are organized by voluntary agencies (especially the Alzheimer's Disease Society); others are based in day centers, day hospitals, residential homes, and primary health care centers. Few evaluations have been reported of their impact, although they are positively regarded by the caregivers attending. Morris, Woods, Davies, Berry, and Morris (1992) showed no differential impact of a coping skills-based group compared with a conventional course with invited speakers on strain and

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depression, although knowledge and use of coping skills did increase in both groups. Services for caregivers in mental health settings have been a prominent feature of programs for older adults in the US since 1980. In a meta-analytic summary of program evaluation literature in the US, Knight et al. (1993) found that individual psychosocial interventions with caregivers appeared to be more effective than group interventions. Fully randomized evaluations of caregiver interventions have provided mixed results regarding the effectiveness of either individual or group interventions, a finding that is more curious given the effectiveness of psychological interventions with other groups of older adults (Scogin & McElreath, 1994).

7.20.10 MENTAL HEALTH SERVICES IN THE HEALTH CARE SYSTEM In the UK, most mental health problems (including those of older people) are managed in primary care, without recourse to specialist mental health services. It is important to note that mental health problems are common in patients admitted to geriatric units (i.e., those designated for physical health care). Burn, Davies, McKenzie, Brothwell, and Wattis (1993) reported that 43% of such admissions who could be assessed had a diagnosable psychiatric condition (30% were depressed or anxious); many others could not be assessed because of a severe cognitive impairment. Conversely, significant physical health problems are also common in those admitted to old age psychiatry units (34% in one prospective study; Perry, Milner, & Krishnan, 1995). In the UK, the problems center on the inaction of primary care physicians rather than the lack of recognition of mental disorders in older adults by physicians, which is more common among physicians in the US (Rapp, Parisi, Walsh, & Wallace, 1988). Jenkins and Macdonald (1994) indicated that general practitioners do recognize depression in their older patients, but rather rarely respond. A randomized controlled trial of depressed patients referred from primary care to a multidisciplinary team did not show any significant benefitsÐ but the sample was small; the authors concluded that male patients might benefit from being referred more frequently, as their outcomes were slightly better. Blanchard, Waterreus, and Mann (1995) achieved slightly more positive results. They identified older adults with depression from a community screening survey. The older patients were randomly allocated to intervention from a

primary care nurse or to ªusual careº from the general practitioner. Interventions were individually designed by a MDT, and included increasing the person's social network, antidepressant medication, counseling, and the involvement of relatives. Depression scores improved in this intervention group. General practitioners in the UK refer people with dementia to specialist services at times of crisis, or when the dementia is well advancedÐ hence the need for open-access services described above. Wolff, Woods, and Reid (1995) have shown that GPs mainly saw dementia as a social rather than a health problem, and felt that early referral was unhelpful. They felt that they had little to offer patients with dementia, and this sense of helplessness may contribute to the failure to refer. Primary care teams are now encouraged to carry out an annual screening of individuals over the age of 75. This normally includes a rudimentary assessment of mental state. Consequently, the awareness of patients with dementia in the primary care context could grow. In the US, there has been an increasing recognition that the health care system in general, and physicians' offices in particular, are a de facto part of the system of mental health care in the community. Analyses of service utilization data by George, Blazer, WinfieldLaird, Leaf, and Fischbach (1988) call attention to the fact that adults of all ages with a mental health problem are more likely to go to a health care provider than to a mental health professional. This tendency to seek mental health care from primary care physicians rather than from mental health professionals also appears to increase with age after the age of 55. What happens during these visits is less clear. Physicians have been shown to be poor at detecting depression in medical impatients (Rapp et al., 1988) and outpatient service provision does not appear to be any better. Katz (1996) reported that primary care doctors often misdiagnose or overlook depression among older adultsÐone survey revealed that 26.4% of primary care physicians never evaluate the emotional status of individuals over the age of 75 (Mann, 1995). Further, primary care physicians tend to treat mental health problems only with psychotropic medications (Burns & Taube, 1990). These physicians are not likely to conduct clinical histories, involve family members with treatment, or to use psychosocial interventions. Haley, Salzberg, and Barrett (1993) reported that geriatric specialists in medicine tend to be more open to psychological interventions and to working with psychologists as part of the care team than primary care physicians without

Discussion geriatric training. Haley (1996) has also argued for the importance of staffing medical clinics with psychologists as part of the outreach effort to assure that older adults in need receive adequate services. In short, it appears that on both sides of the Atlantic, mental health services for older adults are moving into the medical care system. While the move is conceptually unassailable and has the potential to improve access to mental health services and the coordination of mental health and medical services, short-term results suggest that the result may be decreased access to mental health services due to ineffective screening and intervention by primary care physicians. The multiple systems perspective would suggest that the medical system will, of course, recognize and treat medical disorders rather than mental health disorders and so the elimination of the separate mental health system may be undesirable. 7.20.11 DISCUSSION 7.20.11.1 Cross-national Systems Comparisons The contrasting histories of mental health service systems in the UK and US are reflected in much of our previous discussion. While both systems have seen the demise of the large institutions, in the UK a long-term tradition of universal health care coverage and parity of coverage between mental health and health services created an environment in which old age psychiatry has developed as a new and influential speciality in psychiatry. New-style, community mental health services have been established with the resources released by hospital closure. However, as Murphy (1994) points out, not all the services that the asylums offered have been replaced. Extensive social support, health care, and social care resources have not been developed extensively. In the UK, institutional care still absorbs most of the available resources, despite preferences of families and older people and the stated aims of services. In the US, community-based programs for older adults have never been well-funded and continue to face major threats to funding. Historically, federal policy in the US has placed restrictions on mental health services as supported by Medicare and Medicaid health insurance programs. These restrictions are beginning to be eliminated in the 1990s, but it is too early to assess the impact of increasing Medicare reimbursements to more providers or of recent moves toward parity in mental health insurance reimbursement. In summary, both nations have been more successful in closing

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down the institutions than in creating substitute systems in the community. Research in both nations has focused on dementia and depression (rather than anxiety, alcohol abuse, or older schizophrenics) and on outpatient services rather than on inpatient or partial hospital services. These tendencies need correction to provide an empirical basis for comprehensive services in clinical geropsychology. 7.20.11.2 Dementia Services The nature of services for older adults with dementia also differs. In the UK there is considerable focus on services to demented people themselves within the mental health sector with active concern for improving the well-being of the person with dementia. Kitwood (1996) provides a timely reminder of the ªpersonhoodº of the patient with dementiaÐ psychological approaches to dementia must entail ensuring that the full human needs and potential of older people with severe cognitive impairments are recognized and nurtured. He contrasts his approach with the ªneurological determinismº of the traditional model of working with the demented. The US, perhaps caught up in the ªneurological determinismº viewpoint, has tended to conceptualize services for dementing elderly as services for the family caregiver and often places dementia services outside of the mental health sector: in social services, aging services, and so forth. 7.20.11.3 Mental Health and Primary Care In the UK, mental health services for older people are likely to be provided in primary healthcare settings (see Mann, 1995) where most older people with mental health problems are actually found. A new relationship with the independent sector providing consultation outside the traditional NHS and Social Services settings needs to be established. This is a remarkably difficult change for clinicians brought up to feel that the NHS should provide care ªfrom the cradle to the grave,º at no cost at the point of service delivery. In the US, the same change is likely to occur, driven in large part by the increasing organization of both health and mental health care into various types of managed care networks of providers. In the US, where the private sector is the traditional provider of health care and of much outpatient mental health care, resistance to these arrangements has more to do with the traditional independence of mental health providers and the differing organizational

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cultures of medical and mental health care. The latter reason has been offered as an explanation for the tendency to rely on separate managed care provider organizations for mental health services (Wholey, Christianson, & Peterson, 1996). Indeed, as both nations move toward versions of managed care, primary care physicians will assume increased control over the provision of health and mental health services. For different reasons, this change may not bode well for access to required services since primary care physicians have not shown a great willingness to refer older adults for required mental health services (the UK) or even to recognize the need for such services (the US). In both cases, the problems may stem from the distinct world views of physical medicine and the mental health disciplines, a gap which must be bridged in order to effectively serve older adults. Creating the required levels of communication and collaboration will require orienting the two worlds to one another's languages, professional practices, and folkways (see Chapter 24, this volume; Qualls & Czirr, 1988). However, as noted in the beginning of this chapter, older adults have a variety of medical, social service, and mental health needs which have traditionally been served by multiple systems of care, each with its own expertise, organizational structure, and economically driven imperatives. Mental health policy for the last few decades has tended to assume that people in general and older adults in particular would be better served by a single, formally organized system. Yet, participant observation would suggest that formal attempts to coordinate services have a tendency to serve the needs of the organization rather than those of the client; that is, groups of providers come together to discuss how to prevent clients from overusing services or to impose organizationally defined models of ªappropriateº service use on the client. Myrtle and Wilber (1994) argued that a modern organizational theory, ªloosely coupled systems,º may better describe the functioning of services for the aged and also be a better model for assuring that the client gets the best services. Interlocking multiple systems can assure that specialized services are available for the client's multiple needs; restricted access systems (e.g., ªsingle point of entryº and so forth) are likely to create barriers to some needs being met. A salient example is the attempts in both the UK and the US to funnel older adults with mental health problems through primary care medicine, a gatekeeper strategy that seems likely (perhaps unintentionally) to deny care rather than assure it. An empirical test of an organized system of mental health care for children in the

US (the Fort Bragg Demonstration) showed that the organized system provided better continuity of care but that clinical outcomes were no better and the cost was higher than in the business as usual fee-for-service system (Bickman, 1996). Older adults often need a wide range of services from several different service systems and their needs may be met more effectively by an informed consumer who negotiates with the loosely coupled systems and interacts with those professionals who collaborate with other systems (ªinterpersonal coordination,º Myrtle & Wilber, 1994). Their needs are less likely to be met within artificially constrained ªmegasystemsº whose organizations make the individual systems less adaptable to specific, changing problems. Myrtle and Wilber (1994) argued that, over time, the informed consumer and gerospecialists would be expected to evolve their own norms for coordination of care and perhaps create a new aging-centered network of services in which current boundaries (e.g., between health and mental health or between mental health and social services) would have withered away.

7.20.11.4 Roles for Clinical Psychology in Community Care There are many areas in community care where a key role could be assumed by a clinical psychologist. (i) In assessment, it is clear that individualized approaches are required to provide care in the communityÐin memory clinic contexts and elsewhere, neuropsychological assessment and professional consultation with other professionals is valued. The identification of neuropsychological problems underlying behavioral difficulties is important as is greater attention to differential assessment of emotional distress (anxiety versus depression) and personality disorders in older clients. (ii) Depression and anxiety are responsive to psychological treatment approaches (see Scogin & McElreath, 1994; Woods & Roth, 1996), and their adequate treatment would reduce a great deal of suffering. This treatment could be provided across a number of community-based systems. (iii) In support for family caregivers, there is evidence that psychological factors mediate strain and depression in family caregivers, and the development of more effective programs with psychological underpinning is desired (see Knight et al., 1993; Woods & Roth, 1996). (iv) In prevention and systems-level analysis and intervention, there is a strategic role in evaluating and developing more effective community services, and a need exists for a

References systemic approach to thinking, practice, and evaluation. For example, outcomes for caregivers and for their relatives with dementia cannot be viewed separately and in isolation. Also, the realities of elder abuse need to be considered alongside caregiver strain. The risk factors for institutionalization need to be understood more fully, along with better insight as to when entry to a nursing home is a good outcome for all concerned. 7.20.11.4.1 Development of clinical geropsychology Clinical psychology with older people has had contrasting histories in the two countries. In the UK, in the 1960s and 1970s contact of clinical psychologists with older people concerned assessment, usually to attempt to answer the depression vs. dementia question. Very few psychologists specialized in aging. This changed during the 1970s when a small group developed a special interest in the field and explored a much broader range of roles, including treatment approaches to depression and dementia. By 1980, a formal interest group was formed and membership has continued to grow dramatically. The training of all clinical psychologists in the UK now requires experience in working with older adults, which includes working with people with depression and dementia and with family caregivers. In the US, specialization in aging within clinical psychology developed later and more slowly. The first meeting on training psychologists to work with the elderly was held in 1981 (Santos & VandenBos, 1982). A follow-up conference in 1992 provided mixed impressions of the growth of the specialty during the 1980s (Knight, Santos, Teri, & Lawton, 1995); university-based training showed little expansion although internship training, especially in the Veterans Affairs hospital system, had expanded (Cooley, 1995). The national organization for clinical geropsychology in the US was formed in 1992 (Knight, Santos et al., 1995). Training for psychologists in aging is not widespread in the US and not a requirement for all psychologists as in the UK. The training models in the US emphasize university teaching and research, Veterans Affairs or university medical center employment, or independent practice as eventual employment opportunities in clinical psychology. Training and working within community-based mental health programs has been relatively ignored, except for the use of community practica in training geropsychologists (Qualls, Duffy, & Crose, 1995). Few psychologists with expertise in clinical geropsychology are found in community settings

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(Knight, Rickards et al., 1995; Qualls et al., 1995). Psychologists in the US are also facing increased competition from master's level providers not identified with psychology (e.g., clinical social work, marriage and family therapists). These other mental health professionals are employed as a less expensive provider of psychological services, especially under managed care approaches. Training programs need to rethink their goals to train psychologists for the jobs of the twentyfirst century. Clinical geropsychology tends to be progressive in its emphasis on the interface between medicine and mental health, between social services and mental health, and placing psychologists into nontraditional settings. The future of clinical geropsychology depends upon developments in public policy and in the management of health care services over the next several decades. Certainly, it would be helpful for clinical geropsychologists to study the successes and failures of colleagues in other countries. 7.20.12 SUMMARY In both nations, clinical geropsychology can offer a great deal to the delivery of services to older adults. Clinical geropsychology focuses on the clinical psychology of medical illnesses, on services to demented older adults, and involves psychologists in services and research across a wide variety of hospital, partial hospital, clinic, and community settings. Training and practice in community-based clinical geropsychology is inherently multidisciplinary in focus. Clinical geropsychologists, like geriatricians and other specialists in aging services, are likely to be well-positioned on the mental health side for the kind of collaboration required to make the loosely coupled systems of services work for older adults. 7.20.13 REFERENCES American Psychiatric Association (1993). State mental hospitals and the elderly: A task force report of the American Psychiatric Association. Washington, DC: Author. Ames, D. (1991). Epidemiological studies of depression among the elderly in residential and nursing homes. Special Issue: Affective disorders in old age. International Journal of Geriatric Psychiatry, 6. 347±354. Anderson, J., & Trieman, N. (1995). The TAPS Project. 21: Functional and organic comorbidity and the effect of cognitive and behavioural disability on the placement of elderly psychiatric inpatients: A whole hospital survey. International Journal of Geriatric Psychiatry, 10, 959±966. Arie, T., & Jolley, D. (1982). Making services work: Organization and style of psychogeriatric services. In R. Levy & F. Post (Eds.), The psychiatry of late life (pp. 222±251). Oxford, UK: Blackwell.

472

Community Mental Health Services in the United States and the United Kingdom

Atay, J., Whitkin, M., & Manderscheid, R. (1995). Data highlights on: Utilization of mental health organizations by elderly persons. Rockville, MD: Center for Mental Health Services. Bayer A. J., Richards V., & Phillips G. (1990). The Community Memory Project: A multidisciplinary approach to patients with forgetfulness and early dementia. Care of the Elderly, 2, 5±6. Benbow, S. M., Marriott, A., Morley, M., & Walsh, S. (1993). Family therapy and dementia: Review and clinical experience. International Journal of Geriatric Psychiatry, 8, 717±725. Bickman, L. (1996). A continuum of care: More is not always better. American Psychologist, 51, 689±701. Blanchard, M. R., Waterreus, A., & Mann, A. H. (1995). The effect of primary care nurse intervention upon older people screened as depressed: International Journal of Geriatric Psychiatry, 10, 289±298. Brown, P., Challis, D., & von Abendorff, R. (1996). The work of a community mental health team for the elderly: Referrals, caseloads, contact history, and outcomes. International Journal of Geriatric Psychiatry, 11, 29±39. Buckwalter, K. C., Smith, M., Zevenbergen, P., & Russell, D. (1991). Mental health services of the rural elderly outreach program. Gerontologist, 31, 408±412. Burn, W. K., Davies, K. N., McKenzie, F. R., Brothwell, J. A., & Wattis, J. P. (1993). The prevalence of psychiatric illness in acute geriatric admissions. International Journal of Geriatric Psychiatry, 8, 171±174. Burns, B., & Taube, C. (1990). Mental health services in general medical care and in nursing homes. In B. Fogel, A. Furino, & G. Gottlieb (Eds.), Mental health policy for older Americans: Protecting minds at risk (pp. 63±84). Washington, DC: American Psychiatric Press. Challis, D. (1992). Providing alternatives to long stay hospital care for frail elderly patients: Is it cost effective? International Journal of Geriatric Psychiatry, 7, 773±781. Christianson, J., & Gray, D. (1994). What CMHCs can learn from two states' efforts to capitate Medicaid benefits. Hospital and Community Psychiatry, 45, 777±781. Clark, W., & Travis, S. (1994) Elderly admissions to a state psychiatric hospital: Cohort characteristics, after care needs, and discharge destinations. Journal of Gerontological Social Work, 21, 101±115. Coles, R. J., von Abendorff, R., & Herzberg, J. L. (1991). The impact of a new community mental health team on an inner city psychogeriatric service. International Journal of Geriatric Psychiatry, 6, 31±39. Colwell, C., & Post, F. (1959). Community needs of elderly psychiatric patients. British Medical Journal, 270, 214±217. Conwell, Y., Nelson, J. C., Kim, K., & Mazure, C. M. (1989). Elderly patients admitted to the psychiatric unit of a general hospital. Journal of the American Geriatrics Society, 37, 35±41. Cooley, S. (1995). Geropsychology services and training in the US Department of Veterans Affairs. In B. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults: Implications for training and practice in geropsychology (pp. 11±20). Washington, DC: American Psychological Association. Culhane, D., & Culhane, J. (1993). The elderly's underutilization of partial hospitalization for mental disorders and the history of Medicare reimbursement policies. Journal of Geriatric Psychiatry, 26, 95±112. Darney, A. J. (Ed.) (1994). Statistical record for older Americans. Detroit: Gale Research. Dean, R., Briggs, K., & Lindesay, J. (1993). The domus philosophy: A prospective evaluation of two residential units for the elderly mentally ill. International Journal of Geriatric Psychiatry, 8, 807±817. Dening, T. (1992). Community psychiatry of old age: A

UK perspective. International Journal of Geriatric Psychiatry, 7, 757±766. Department of Health (1996). Assessing older people with dementia living in the community: Practice issues for social and health issues. London: Social Services Inspectorate/Department of Health. Diesfeldt, H. F. (1992). Psychogeriatric day care outcome: A five-year follow-up. International Journal of Geriatric Psychiatry, 7, 673±679. Domken, M., Bothwell, R., & McKeith, I. (1995). Discharge patterns from a psychogeriatric inpatient unit. International Journal of Geriatric Psychiatry, 10, 41±46. Dorwart, R. A., & Epstein, L. (1993). The privatization of mental health care: A fragile balance, Westport, CT: Auburn House. Eichmann, M. A., Griffin, B. P., Lyons, J. S., Larson, D. B., & Finkel, S. (1992). An estimation of the impact of OBRA 1987 on nursing home care in the United States. Hospital and Community Psychiatry, 43, 781±789. Eskew, R., Sexton, R., Tars, S., & Wilcox. F. (1983). Day treatment program evaluation. In M. Smyer & M. Gatz (Eds.), Mental health and aging: Programs and Evaluations (pp. 63±84). Beverly Hills, CA: Sage Publications. Estes, C. L. (1995). Mental health services for the elderly: Key policy elements. In M. Gatz (Ed.), Emerging issues in mental health and aging (pp. 303±328). Washington, DC: American Psychological Association. Estes, C. L., Linkins, K. W., & Kane, K. (1994, November). Mental health services and the elderly: Organizations in transition. Paper presented at the meeting of the Gerontological Society of America, Atlanta. Fasey, C. (1994). The day hospital in old age psychiatry: The case against. International Journal of Geriatric Psychiatry, 9, 519±523. Fleming A. S., Rickards, L. D., Santos, J. F., & West, P. R. (1986). Mental health services for the elderly (Vol. 3). Washington, DC: Retirement Research Foundation. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189±198. Foucault, M. (1965). Madness and civilization: A history of insanity in the Age of Reason. R. Howard (Trans.). New York: Random House (Original work published 1961). Fox, P., Swan, J., & Estes, C. L., (1986). Trends in CMHC services to elderly populations. Hospital and Community Psychiatry, 67, 58±102. Freiman, M. P., Arons, B. S., Goldman, H., & Burns, B. J. (1990). Nursing home reform and the mentally ill. Health Affairs, 9, 47±60. Gatz, M., Popkin, S. J., Pino, C. D., & VandenBos, G. S. (1985). Psychological interventions with older adults. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging. (2nd ed., pp. 455±488). New York: Van Nostrand. Gatz M., & Smyer, M. A. (1992). The mental health system and older adults in the 1990's. American Psychologist, 47, 741±751. General Accounting Office (1982). The elderly remain in need of mental health services. Pub. No. GAO/HRD 82±112. Washington, DC: Government Printing Office. George, L., Blazer, D., Winfield-Laird, I., Leaf, P., & Fischbach, R. (1988). Psychiatric disorders and mental health service use in later life: Evidence from the epidemiological catchment area programs. In J. Brody & G. Maddox (Eds.), Epidemiology and aging: An international perspective (pp. 189±219). New York: Springer. Gilleard, C. (1987). Influence of emotional distress among supporters on the outcome of psychogeriatric day care. British Journal of Psychiatry, 150, 219±223. Gilleard, C. (1996a). Community care: psychological

References perspectives. In R. T. Woods (Ed.), Handbook of the Clinical Psychology of Ageing (pp. 319±332). Chichester, UK: Wiley. Gilleard, C. (1996b). Family therapy with older clients. In R. T. Woods (Ed.), Handbook of the Clinical Psychology of Ageing (pp. 561±573). Chichester, UK: Wiley. Gilleard, C., Lieberman, S., & Peeler, R. (1992). Family therapy for older adults: A survey of professionals' attitudes. Journal of Family Therapy, 14, 413±422. Gilliard, J., & Wilcock, G. (1993). Counseling for the carers. Elderly Care, 5, 24±26. Grob, G. (1987). Mental health policy in post World War II America. New Directions for Mental Health Services, 36, 15±32. Haley, W. E. (1996). The medical context of psychotherapy with the elderly. In S. H. Zarit & B. G. Knight (Eds.), A guide to psychotherapy and aging: Effective interventions in a life stage context (pp. 221±240). Washington, DC: American Psychological Association. Haley, W. E., Salzberg, L. E., & Barrett, J. J. (1993). Psychologists in geriatric medicine: Results of a national survey. Professional Psychology: Research and Practice, 24, 491±495. Hinchliffe, A. C., Hyman, I. L, Blizard, B., & Livingston, G. (1995). Behavioural complications of dementia: Can they be treated? International Journal of Geriatric Psychiatry, 10, 839±848. HMSO (1990). NHS and Community Care Act 1990. London: HMSO. Howard, R. (1994). Day hospitals: The case in favour. International Journal of Geriatric Psychiatry, 9, 525±529. Ineichen, B. (1989). Senile dementia: Policy and services. London: Chapman & Hall. Jenkins, D., & Macdonald, A. (1994). Should general practitioners refer more of their elderly depressed patients to psychiatric services? International Journal of Geriatric Psychiatry, 9, 461±466. Junaid, O., & Bruce, J.M. (1994). Providing a community psychogeriatric service: Models of community psychiatric nursing provision in a single health district. International Journal of Geriatric Psychiatry, 9, 715±720. Kahn, R. (1975). The mental health system and the future aged. The Gerontologist, 15, 24±31. Katz, I. (1996). On the inseparability of mental and physical health in aged persons: Lessons from depression and comorbidity. American Journal of Geriatric Psychiatry, 4, 1±16. Kiesler, C. A. (1991). Changes in general hospital psychiatric care, 1980±1985. American Psychologist, 46, 416±421. Kitwood, T. (1996). A dialectical framework for dementia. In R. T. Woods (Ed.), Handbook of the Clinical Psychology of Ageing (pp. 267±282). Chichester, UK: Wiley. Knight, B. G. (1983). Assessing a mobile outreach team. In M. Smyer & M. Gatz (Eds.), Mental health and aging: Programs and evaluations (pp. 23±40). Beverly Hills, CA: Sage Publications. Knight, B. G. (1986). Management variables as predictors of service utilization by the elderly in mental health. International Journal of Aging and Human Development, 23, 141±148. Knight, B. (1991). Outreach to older adults: Matching programs to specific needs. In N. Cohen (Ed.), Psychiatric outreach to the mentally ill. A monograph in the New Directions for Mental Health Services series. San Francisco: Jossey-Bass. Knight, B., & Carter, P. M. (1990). Reduction of psychiatric inpatient stay for older adults by intensive case management. The Gerontologist, 30, 510±515. Knight, B. G., & Kaskie, B. (1995). Models for mental health service delivery to other adults. In M. Gatz (Ed.), Emerging issues in mental health and aging (pp. 231±255).

473

Washington, DC: American Psychological Association. Knight, B. G., & Lower-Walker, D. (1985). Toward a definition of alternatives to institutionalization for the frail elderly. The Gerontologist, 25, 358±363. Knight, B. G., Lutzky, S. M., & Macofsky-Urban, F. (1993). A meta-analytic review of interventions for caregiver distress: Recommendations for future research. The Gerontologist, 33, 240±249. Knight, B., & Macofsky-Urban, F., (1990). Toward a policy for Alzheimer's disease in California. In P. Liebig & W. Lammers (Eds), California policy choices for long term care (pp. 145±170). Los Angeles: Andrus Gerontology Center. Knight, B. G., Rickards, L., Rabins, P., Buckwalter, K., & Smith, M. (1995). Community-based services for mentally ill elderly. In B. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults: Implications for training and practice (pp. 21±30). Washington, DC: American Psychological Association. Knight, B. G., Santos, J., Teri, L., & Lawton, P. (1995). The development of training in clinical geropsychology. In B. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults: Implications for training and practice (pp. 1±8). Washington, DC: American Psychological Association. Kosloski, K., & Montgomery, R. (1995). The impact of respite use on nursing home placement. The Gerontologist, 25, 67±74. Lebowitz, B. D. (1988). Mental health policy and aging. Generations, 12, 53±56. Lebowitz, B. D., Light, E., & Bailey, F. (1987). Mental health center services for the elderly: The impact of coordination with area agencies on aging. Gerontologist, 27, 699±702. Levin, E., Moriarty, J., & Gorbach, P. (1994). Better for the break. London: HMSO. Liebig, P. S. (1993). The effects of federalism on policies for care of the aged in Canada and the United States. Journal of Aging and Social Policy, 5, 13±37. Lindesay, J., Briggs, K., Lawes, M., MacDonald, A., & Herzberg. (1991). The domus philosophy comparative evaluation of a new approach to residential care for the demented elderly. International Journal of Geriatric Psychiatry, 6, 727±736. Lindesay, J. (1991). Working out: Setting up and running community psychogeriatric teams. London: Research & Development in Psychiatry. Lyons, D., Cohen, M., Henderson, T., & Walker, N. (1995). Partnership nursing home care for dementia: The Glasgow experience: The first twelve weeks. International Journal of Geriatric Psychiatry, 10, 557±560. Mann, A. H. (1995). Future directions for the specialty of old age psychiatry: Some suggestions for debate. International Journal of Geriatric Psychiatry, 10, 87±92. Moak, G., & Fisher, W. (1991). Geriatric patients and services in state hospitals: Data from a national survey. Hospital and Community Psychiatry, 42, 273±276. Morris, R. G., Woods, R. T., Davies, K. S., Berry, J., & Morris, L. W. (1992). The use of a coping strategy focused support group for carers of dementia sufferers. Counseling Psychology Quarterly, 5, 337±348. Mosher-Ashley, P. (1994). Therapy termination and persistence patterns of elderly clients in a community mental health center. The Gerontologist, 34, 180±189. Murphy, E. (1994). A clinical role in service development: What should geriatric psychiatrists do? International Journal of Geriatric Psychiatry, 9, 947±955. Myrtle, R., & Wilber, K. (1994). Designing service delivery systems: Lessons from the development of community based systems of care for the elderly. Public Administration Review, 54, 245±252. Narrow, W. E., Regier, D. A., Rae, D. S., Manderscheid, R., & Locke, B. Z. (1993). Use of services by persons

474

Community Mental Health Services in the United States and the United Kingdom

with mental illness and addictive disorders: Findings from the National Institute of Mental Health epidemiologic catchment area programs. Archives of General Psychiatry, 50, 95±107. Neville, P. G., Boyle, A., Brooke, S., Baillon, S., Scothern, G., & Broome, C. (1995). Time for change: Psychiatric morbidity in residential homes for the elderly. International Journal of Geriatric Psychiatry, 10, 561±567. Nolan, M. R., & Grant, G. (1992). Regular respite: An evaluation of a hospital rota bed scheme for elderly people. London: Age Concern England. O'Connor, D. W., Pollitt, P. A., Brook, C. P. B., Reiss, B. B., & Roth, M. (1991). Does early intervention reduce the number of elderly people with dementia admitted to institutions for long-term care? British Medical Journal, 302, 871±875. Office of Inspector General, Department of Health and Human Services. (1996). Mental health services in nursing homes (OEI±02±91±00860). New York: Author. Patterson, R. L., Dupree, L. W., Eberly, D. A., Jackson, G. M., O'Sullivan, M. J., Penner, L. A., & Kelly, C. D. (1982). Overcoming deficits of aging: A behavioral approach. New York: Plenum. Pearson, N. D. (1988). An assessment of relief hospital admissions for elderly patients with dementia. Health Trends, 20, 120±121. Perry, D. W., Milner, E., & Krishnan, V. H. R. (1995). Physical morbidity in a group of patients referred to a psychogeriatric unit: A six month prospective study. International Journal of Geriatric Psychiatry, 10, 151±154. Plotkin, D., & Wells, K. (1993). Partial hospitalization for psychiatrically ill elder patients. American Journal of Psychiatry, 150, 266±271. Pruchno, R., Boswell, P., Wolff, D., & Faletti, M. (1983). A community mental health program: Evaluating outcomes. In M. Smyer & M. Gatz (Eds.), Mental health and aging: Programs and evaluations (pp. 41±62). Beverly Hills, CA: Sage Publications. Qualls, S. H. (1996). Family therapy with aging families. In S. H. Zarit & B. G. Knight (Eds.), A guide to psychotherapy and aging: Effective interventions in a life stage context (pp. 121±138). Washington, DC: American Psychological Association. Qualls, S. H., & Czirr, R. (1988). Geriatric health teams: Classifying models of professional and team functioning. Gerontologist, 28, 372±376. Qualls, S., Duffy, M., & Crose, R. (1995). Clinical supervision and practicum placements in graduate training. In B. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults: Implications for training and practice in geropsychology (pp. 119±128). Washington, DC: American Psychological Association. Rapp, S. R., Parisi, S. P., Walsh, D. A., & Wallace, C. E. (1988). Detecting depression in medical inpatients. Journal of Consulting and Clinical Psychology, 56, 509±513. Raschko, R. (1990). The gatekeeper model for the isolated, at-risk elderly. In N. Cohen (Ed.), Psychiatry takes to the streets: Outreach and crisis intervention for the mentally ill. New York: Guilford. Ratna, L., & Davis, J. (1984). Family therapy with the elderly mentally ill: Some strategies and techniques. British Journal of Psychiatry, 145, 311±315. Rosen, A. L., Pancake, J. A., & Rickards, L. (1995). Mental health policy and older Americans: Historical and current perspectives. In M. Gatz (Ed.), Emerging issues in mental health and aging (pp. 1±18). Washington, DC: American Psychological Association. Rounds, J. (1984). Information and ambiguity in organizational change. In L. Sproull & P. Larkey, (Eds.),

Advances in information processing in organizations. Greenwich, CT: JAI Press. Santos, J. F., & VandenBos, G. R. (1982). Psychology and the older adult: Challenges for training in the 1980s. Washington, DC: American Psychological Association. Scogin, F., & McElreath, L. (1994). Efficacy of psychosocial treatments for geriatric depression: A quantitative review. Journal of Consulting and Clinical Psychology, 62, 69±74. Schick, F. L., & Schick, R. (Eds.) (1994). Statistical handbook on aging Americans. Phoenix, AZ: Oryx Press. Schneider, L. S. (1995). Efficacy of clinical treatment for mental disorders among older persons. In M. Gatz (Ed.), Emerging issues in mental health and aging (pp. 19±71). Washington, DC: American Psychological Association. Semke, J., Fisher, W., Goldman, H., & Hirad, A. (1996). The evolving role of the state hospital in care and treatment of older adults: Cross state trends, 1984±1993. Psychiatric Services, 47, 1082±1087. Shadish, W. R. (1989). Private sector care for chronically mentally ill individuals: The more things change, the more they stay the same. American Psychologist, 44, 1142±1147. Skea, D., & Lindesay, J. (1996). An evaluation of two models of long-term residential care for elderly people with dementia. International Journal of Geriatric Psychiatry, 11, 233±241. Smyer, M. (1989). Nursing homes as a setting for psychological practice: Public policy perspectives. American Psychologist, 44, 1307±1314. Smyer, M. A., Shea, D. G., & Streit, A. (1994). The provision and use of mental health services in nursing homes: Results from the National Medical Expenditure Survey. American Journal of Public Health, 84, 284±287. Speer, D., Williams, J., West, H., & Dupree, L. (1991). Older adult users of outpatient mental health services. Community Mental Health Journal, 27, 69±76. Stiles, P. G. (1994, November). Utilization of ambulatory mental health services by the elderly: A preliminary report on the effects of recent Medicare reimbursement changes. Paper presented at the meeting of the Gerontological Society of America, Atlanta. Tester, S. (1989). Caring by Day: A Study of Day Care Services for Older People. Policy Studies in Ageing. London: Centre for Policy on Ageing. Tomenson, B., Benbow S. M., & Jolley, D. J. (1994). Traffic Lights: Extracting order from the chaos of longterm care. International Journal of Geriatric Psychiatry, 9, 985±987. Turvey, T., & Toner, H. (1991). The evaluation of a home based respite service for dementia sufferers and their carers. Generations, 16, 14±17. United States Congress: Senate Committee on Labor and Public Welfare (1973). Community Mental Health Center Act: History of the program and current problems and issues. Washington DC: Government Printing Office. Warrington, J., & Eagles, J. M. (1996). A comparison of cognitively impaired attenders and their coresident carers at day hospitals and day centres in Aberdeen. International Journal of Geriatric Psychiatry, 11, 251±256. Wattis, J. P., & Fairbairn, A. (1996). Towards a consensus on continuing care for older adults with psychiatric disorder. International Journal of Geriatric Psychiatry, 11, 163±168. Weissert, W. G., Cready, C. M., & Pawelak, J. (1988). The past and future of home and community based long term care. The Milbank Quaterly, 66, 309±388. Whitelaw, C., & Perez, E. (1987). Partial hospitalization programs: A current perspective. Administration in Mental Health, 15, 62±72. Wholey, D., Christianson, J., & Peterson, M. (1996). Organization of mental health care in HMOs. Administration and Policy in Mental Health, 23, 307±328.

References Wolff, L. E., Woods, J. P., & Reid, J. (1995). Do general practitioners and old age psychiatrists differ in their attitudes to dementia? International Journal of Geriatric Psychiatry, 10, 63±70. Woods, J. P., & Phanjoo, A. L. (1991). A follow-up study of psychogeriatric day hospital patients with dementia. International Journal of Geriatric Psychiatry, 6, 183±188. Woods, R. (1995). Dementia care: Progress and prospects. Journal of Mental Health, 4, 115±124. Woods, R. T., & Roth, A. (1996). Effectiveness of

475

psychological interventions with older people. In A. Roth & P. Fonagy (Eds.), What works for whom? A critical review of psychotherapy research (pp. 321±340). New York: Guilford. Worcester, M. I., & Quayhagen, M. P. (1983). Correlates of caregiving satisfaction: Prerequisites to elder home care. Research Nursing Health, 6, 61±67. Wright, N., & Lindesay, J. (1995). A survey of memory clinics in the British Isles. International Journal of Geriatric Psychiatry, 10, 379±385.

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7.21 Nursing Home Care and Interventions JACOB LOMRANZ and LIORA BAR-TUR The Herczeg Institute on Aging, Tel Aviv University, Israel 7.21.1 INTRODUCTION

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7.21.2 MENTAL HEALTH IN OLD AGE 7.21.2.1 Definition and Approach 7.21.2.2 Mental Health in Nursing Homes 7.21.3 NURSING HOMES: DIFFERENT SETTINGS OF LIVING AND CARE FOR DIFFERENT POPULATIONS 7.21.3.1 Mental Health and the Role of Nursing Home 7.21.3.2 The Effects of Institutionalization 7.21.4 MENTAL HEALTH IN LIGHT OF THE TRANSITION AND ADAPTATION TO A NURSING HOME: COGENT ISSUES 7.21.4.1 The Decision-making Process and its Impact 7.21.4.2 Preadmission Screening 7.21.4.3 Adaptational Tasks in Nursing Homes 7.21.4.3.1 Limited living space and seperation from personal effects 7.21.4.3.2 A novel geographic ecology 7.21.4.3.3 Structured and leisure time 7.21.4.3.4 Food and communal dining 7.21.4.3.5 Interpersonal and social adjustment 7.21.4.3.6 Reframing family relationships 7.21.5 MENTAL DISORDERS IN THE NURSING HOME 7.21.5.1 Prevalence of Selected Syndromes and Interventions 7.21.5.1.1 Dementia 7.21.5.1.2 Depression 7.21.5.1.3 Suicide 7.21.5.1.4 Psychotic symptoms and paraphrenia 7.21.5.1.5 Personality disorders 7.21.6 A CLINICAL GEROPSYCHOLOGICAL SERVICE IN NURSING HOMES: A PROPOSED MODEL 7.21.6.1 Setting and Clientele 7.21.6.2 Orientation and Philosophy 7.21.6.3 Methods 7.21.6.4 Applications 7.21.6.4.1 Preadmission screening 7.21.6.4.2 Follow-up services 7.21.6.4.3 Severe psychopathology 7.21.6.4.4 Family interventions 7.21.6.4.5 From education to psychotherapy 7.21.6.4.6 Working with nursing home staff 7.21.6.4.7 A university clinic 7.21.7 FUTURE PROSPECTS

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7.21.8 REFERENCES

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7.21.1 INTRODUCTION Should a separate approach be taken to mental health for the aged in nursing homes? Could we not comprehend treatment of the aged in nursing homes as we comprehend the aged in the community? The answer is no. Furthermore, elaboration of this issue has been neglected, especially in light of the growing elderly population residing in nursing homes. This causes damage and reduces the quality of life for the elderly. While there certainly are similarities in the mental health approach to nursing home and community residents, there also are clear differences and unique demands of psychological treatment in nursing homes, based on specific knowledge of conceptualizations and clinical methodology. The absence of such knowledge hinders the function of the geropsychologist. The question whether elderly should age in organized and institutional frameworks of one kind or another has concerned modern society for many decades. But while debates continue as to the best, or necessary environment for the elderly to age, the fact is that in the postwar era organizational and institutional frameworks for the elderly have grown steadily. This growth parallels increased longevity and what is termed the ªdemographic revolution,º that is, the colossal change in the population age structure, patterns of habitation, and the implications of these in all domains of life. Demographic projections suggest that the number of nursing home residents will triple in the 1990s (US Senate, 1987) since at least one person out of five will be institutionalized (Palmore, 1976). Keeping in mind that the needs of the elderly for mental health are extremely high, that psychiatric and medical institutionalization is unsatisfactory, and that the question of the appropriate residency in the later years is unsolved, there is a real danger that nursing homes will turn into centers inhabited by the most maladjusted elderly. At the outset the reader was asked to bear in mind that many elderly do not suffer but enjoy their residency in nursing homes and experience well-being, development, and growth. Unfortunately, however, the problem of mental health in nursing homes is colossal. In this chapter, after defining the approach to mental health in the elderly, the issues of mental health as they appear in homes for the aged are addressed. The threats to adjustment of elderly people before, after, and during their relocation to homes for the aged are then delineated. To this end, the different nursing homes are noted as well as their inhabitants and then the utility of the nursing home is discussed, as well as the effects of institutionalization. This leads to an exam-

ination of the transitional process, the implication and effects of relocation, as well as the problems to overcome and the tasks to be achieved, in order for satisfactory adjustment to the new environment and for the preservation of mental health. While the initial focus is on the psychosocial process of adjustment, the prevailing psychopathology in these homes is discussed and then a psychological community-oriented clinical model is proposed, before a discussion of its organization and implementation as it applies to methods of treatment, including consultation, psychotherapy, and education, to staff and residents in nursing homes. The chapter ends with a future perspective on clinical geropsychology in nursing homes. 7.21.2 MENTAL HEALTH IN OLD AGE 7.21.2.1 Definition and Approach The focus here is on the elderly person's ability to cope with personal aging processes in a specific, changing environment. Mental health is approached in the same way as those perceiving it beyond the absence of pathology. The modes of intervention and treatment are in line with such a broad perspective. The World Health Organization (1964) defines health as ªa state of complete physical, mental and social well-being and not merely the absence of disease or infirmityº (p. 1). While many scholars are concerned with psychopathological aspects of mental health, the ªpositive mental healthº approach (Jahoda, 1958) attempts to better understand the role of adaptive processes. Birren and Renner (1980) relate to four components in the concept of mental health: (i) the presence or absence of mental disease, (ii) the presence or absence of deficits or limitations in behavior, (iii) the satisfaction or contentment that is derived from one's life as it is being lived or has been lived, and (iv) some approximation of an ideal person. While the relevancy of (iii) and (iv) to the elderly could be understood in light of history, socialization processes, and life-review of the elderly, (i) raises problems since many elderly suffer from ªsocial pathology,º for example, loneliness (Pfeiffer, 1977) even in adjusted living, and (ii) is certainly complex since old age goes along with deficits and limitations in behavior. While mental health for the elderly may include many of the components applied to the young, such as adequate life satisfaction, self-acceptance, mastery of the self and environment, the ability to work, love, and play, the manner in which these criteria can be met changes in old age (Gatz, 1989).

Mental Health in Old Age While older adults experience the complete range of psychopathology seen in younger age groups (Knight, Santos, Teri, & Lawton, 1995), three points should be emphasized (Schaie & Willis, 1996). First, older people perform differently than younger on virtually all psychodiagnostic instruments, often resulting in inadequate assessment of their pathology. Second, in old age there is a high rate of physical or psychosocial loss which may constitute risk factors in mental illness. The third point concerns the major individual variability in old age. Some elderly may increase their psychological vulnerability through repeated inability to cope successfully with life stressors, while others may increase their sense of mastery as they improve resilience and become more resistant to mental illness. One should therefore be aware of the fact that applying various standards of mental health to the elderly in general, and to those residing in nursing homes in particular, is complex and requires clarification on the part of the clinical gerontologist. A development-growth and not a depletion model is adopted to the elderly, in line with Gutmann (1994) who states that the second half of life should be viewed ªneither catastrophically nor sentimentally; it is neither an exclusive tale of losses nor a golden age. Like any other sector in the life cycle, it has its own distinctive depletion, it has its own gains, and makes its own special contribution to individual development, social cohesion, and species continuityº (p. xviii). However, while adhering to this approach there is an awareness that due to, between others, lessened income, physical losses, poor health, enforced isolation, environmental relocation, retirement, interpersonal losses, widowhood, or the effects of drugs, many older persons cannot function according to the various standards of mental health. Elderly, especially in nursing homes, cannot always be autonomous and master their environments. They may lack the financial or personal and interpersonal resources to make decisions about their lives and, for certain individuals in specific situations, depression, hostility, apathy, or anxiety may be legitimate or even helpful (Gurland, 1973). Internal and environmental stress in the elderly may be more apt to produce mental disorder in the face of reduced physical and psychological reserves (Gatz, 1998). Therefore, when assessing the mental health of the elderly, it is more crucial to take into account the complete organism total life ecology, relocation being is a point in case. Exposition and explication of one's theory is crucial. Adherence to an adult developmental life-span approach is advocated (Baltes & Baltes, 1990), embedded in positive mental

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health as noted above and urge caution in defining and juxtaposing the different manifestation of ªmental healthº vs. ªmental illness.º

7.21.2.2 Mental Health In Nursing Homes The problems in later life are singularly appropriate for psychological treatment. They include organic and cognitive loss, coping with stress, identity roles, interpersonal and family behavior, neurosis, psychosis and, indeed, every category to be found in any version of the DSM (Bienefeld, 1990). Although the magnitude and severity of the mental health problems in the elderly and their need for care are obvious, the extent of the treatment provided is severely limited and most needs are not met. The aged receive disproportionately less mental health services. It is estimated that only about 3% of all clinical services provided by psychologists go to the older adult population (Gatz, Popkin, Pino, & VandenBos, 1985). Given the higher rates of mental illness in homes for the aged, mental health care is proportionately even less then in the general population. Longevity may have increased, but not the quality of living. Although many elderly persons enter longterm care institutions to improve their quality of life, unfortunately, the result is, at times, the opposite, with detrimental effects, often due to the inadequate quality of care ( Kane & Kane, 1982). While mental disorders and symptoms are estimated between 15 and 25% (Schaie & Willis, 1996) for the population over age 65 years, in medical and institutional settings, such as nursing homes, the figure is dramatically higher, generally estimated to be in the range 60±90% (Cohen, 1991; Gatz & Smyer, 1992). A major criteria for mental health is a person's ability to cope with their environment. For many who are unable to live independently in the community, this criteria has to be met in adjusting to a nursing home. The absence of a caregiver or the lack of social support networks distinguishes most nursing home residents from equally impaired elders dwelling in the community. Twenty-five percent of nursing home placements are precipitated by the illness or death of the caregiver (Colerick & George, 1986). In the early 1980s, a national nursing home survey (Eisdorfer & Cohen, 1982) found that 30% of nursing home residents had ªdiagnosableº psychiatric disorders and that 61% had one or more mental impairments. While more older adults have dropped out of, or never entered, the mental health system, other organizational settings, notably nursing homes, have become the service destination for the mentally impaired elderly (Johnson &

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Grant, 1985), especially since the Deinstitutionalization Act (Goplerud, 1979). Donahue (1978) estimated that 40% of the patients discharged from public mental hospitals eventually found their way into nursing homes. Despite the fact that a majority of nursing home residents are in need of mental health services (Newman, Griffin, Black, & Page, 1989), these settings are designed and staffed primarily for physical, rather than mental, health care (Smyer, 1989). In most nursing homes the staff is also untrained and too overburdened to deal with emotional problems, some of which are exacerbated or developed as a result of living in the home. Psychotherapeutic mental health programs and provisions are rare. Psychiatric visits or consultations are the exception to the rule (Johnson & Grant, 1985). It has been noted that ªthe tragic irony about nursing homes is that they represent a major setting for the mentally ill, with grossly inadequate mental health attentionº (Cohen, 1980, p. 983). There is a strong urgent need for interventions by mental health professionals such as psychiatrists, psychologists,or trained mental health social workers in order to handle the severe problems of mental health in homes for the aged.

increases, the quality of communication, satisfaction, and active involvement of residents may decline (Schaie & Willis, 1996). It should be emphasized that the different structures and kinds of nursing homes bear different implications for their residents' behavior in terms of social life, humanistic or dehumanizing atmosphere, adequate health care, independence, control, well-being, and mental health. Just as there are major difference between the various nursing homes, so do the residents differ in personality, coping abilities, mental health and cultural background. However, some generalities may be drawn. Generally, in contrast to the elderly dwelling in the community, most nursing home residents have the following in common: (i) their age is higher: 75% over 75 years of age and 35% of these are 85 or above (forecasts for the year 2003 suggest that 87% of nursing home residents would be over 75; National Center for Health Statistics, 1983); (ii) the majority are widowed; (iii) more have no surviving immediate family member living nearby; (iv) they are more functionally disabled; and (v) many more suffer from physical or mental problems as well as from chronic physical conditions involving pain, threat of hospitalization, and gradually increasing impairments.

7.21.3 NURSING HOMES: DIFFERENT SETTINGS OF LIVING AND CARE FOR DIFFERENT POPULATIONS

7.21.3.1 Mental Health and the Role of Nursing Home

Although the generic term ªnursing homesº has been adopted, the reader must realize the variability of these institutions. These habitats range from ªsheltered homesº to ªhomes for the agedº to ªconvalescent homes.º They differ in segregation (isolation from the outside world), policies, and control (the degree of autonomy permitted to patients). They range from ªopenº to ªclosedº institutions or floors, providing partial to total care, from secluded rural to urban community settings. They vary widely in quality, regulations, in the focus on instrumental and/or also social and affective needs, and offer various degrees of help in daily living. Some offer basic nursing and custodial care while others provide a variety of services to restore, or maintain, the residents' ability to function. Support in various homes may be related to the amenities and regulations of the facility and to the availability of more than minimal staff and care resources (Timko & Moos, 1990). Smaller facilities may, in certain instances, be more constructive since they resemble a home environment, better meet the resident's needs, and minimize the impact of institutionalization. As the size of the institution

The function and utility of the nursing home in society is influenced by social forces, policy, economics, family structure, commitment, and social values. However, the climate and physical environment in which people live and work is related to life expectancy, stress, and various medical, physical, and mental disorders (Wantz & Gay, 1981). Nursing homes, therefore, determine to a great extent the well-being and mental health of their residents (Lawton, 1985). For the elderly person with some deficit in self-care ability, the nursing home answers the major need for tending and care. It provides security, protection, and safety and assists in the activities of daily living. Usually nursing homes also attempt to satisfy the additional basic needs for shelter and human comfort. The family expects the nursing home to become a surrogate fulfilling the dual aspects inherent in the notion of care: providing concern, support and morale, as well as performing the direct work of tending. As illness, frailty, or loss in resources and support systems are often the background leading to nursing home admission (Hirschfeld & Fleishman, 1990), they highlight the fact that those admitted are vulnerable and in need of

Nursing Homes: Different Settings of Living and Care for Different Populations psychological support, in addition to tending. One task of the psychologist in nursing homes is to ensure that residents also receive mental support and care along with physical care. Various studies indicated psychological and social improvements following the move to public housing facilities or retirement community centers (Lawton & Cohen, 1974), especially in homes which were designed specifically for the elderly and the residents themselves choose the home. However, disagreement exists with respect to effects of rehousing on health, and many studies found negative effects of relocation (e.g., Lieberman & Tobin, 1983). Butler (1975) claimed that most elderly people view the move to a nursing home with fear and hostility and believe that the move to an institution is a prelude to death. Farrari (1963) compared two groups moving from home to an institution, one voluntarily and the other with no option, and found that 10 weeks later mortality among the latter was to be extremely high. Lawton (1980) suggests that the differences in findings may be due to the variability in the quality of housing, sampling, economic status of inhabitants, and personality variables as well as to research design differences. Determining, in varying degrees, are also the detrimental effects of institutionalization.

7.21.3.2 The Effects of Institutionalization Nursing homes are institutions and as such their inhabitants are subject to the effects of institutionalization. The very nature of an institution contradicts the nature of a ªhome,º which implies intimacy, autonomy, privacy, and control. As Tobin and Lieberman (1976) state ªit is difficult to avoid the implication that even the finest institutions cause the deleterious sequale commonly refered to as institutional effectsº (p. 5). Basic factors leading to institutional effects include: physical and human ecology, territory and space constructions and limitations, the structuring of time, sharing of space and interaction with neighbors, regimes, inspections, routines, the burden of authority, use and abuse of dependency, ritualizations, stigmation, the impact of crowding, lack of privacy, group pressure, and engulfment (Goffman, 1961). Negative effects upon inmates of institutions include: changes in self-perception, feelings of inferiority, dependency, alienation, stress, depression, somatic and mental illness. Such general factors have specific manifestations, impacts, and detrimental effects in nursing homes. The negative stereotyping of society incorporated by nursing home staff (Wright, 1988) may result in a negative

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atmosphere in the home and a lower selfconcept of its residents. Insecurity and insufficient privacy (Firestone, Lichman, & Evans, 1980) may cause a sense of intrusion and fluidity of personal boundaries. Limitations in providing care may result in loss of self-esteem, estrangement, isolation, and deindividuation (Tobin & Lieberman, 1976). Low quality of care (Johnson & Grant, 1985; Kane & Kane, 1982), lack of sufficient personal attention, and respect may all induce depressive moods. Constricting freedom and control may be detrimental. Rodin and Langer (1977) have demonstrated how reducing restriction of choice and control in a home for the aged resulted in increased alertness, activity, and general well-being, while increasing restrictions have the opposite effect. They conclude that ªsome of the negative consequences of aging may be retarded, reversed, or possibly prevented by returning to the aged the right to make decisions and a feeling of competenceº (pp. 897±902). Perlmuter and Monty (1979) suggest that the major problem for residents is the inability to exercise choice, control, and personal responsibility which then has a harmful effect on well-being and adaptation. Residents should be given greater control of their daily lives as well as participate in decisions affecting various aspects of the home's programs and policy (Moos & Lemke, 1985). Studies in social ecology of nursing homes show that reinforcing independence not only reduces dependence but also reduces the incidence of disease and death (Baltes, 1982). Assembled in a common environment, the newcomer to the nursing home cannot escape the dreaded identification with their surroundings which include being sick, yearning for care, and feeling closer to death. In order to adapt, they have to participate with others in the cannons of the institution, but in doing so they may lose uniqueness, and become discontent, bitter, and hostile. The institutional structure and atmosphere may restrict or promote interpersonal and social contact (Hansson & Carpenter, 1994). It may decrease family visits leading to loss of contact with family members and friends. As family members recede into the background, the position of the institution as the last and ªonlyº home for the elderly person is reinforced. The environment then signifies vulnerability, mutilation, and death, but at the same time protection and survival. Given all the above it should come as no surprise that individuals in nursing homes are significantly lower in psychological well-being than individuals with similar levels of physical and social function living in the community.

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The impact of institutional processes, including staff burnout, may be so great as to undo and render useless the effects of professional therapeutic interventions (Lomranz, 1991).To counteract this impact, nursing homes should be viewed as communities whose subsystems mutually interact with the broader surrounding community and its social policy dimensions. At the same time, investment in nursing home staff should be aimed at active preventive programs to counteract institutionalization. The chapter will now discuss the specific issues of the processes and mental health implications of moving to a nursing home and the factors involved in adjustment and adaptation.

7.21.4 MENTAL HEALTH IN LIGHT OF THE TRANSITION AND ADAPTATION TO A NURSING HOME: COGENT ISSUES The transition to a nursing home involves significant change, including separation, loss, and readjustment. For many it means ªclosingº a 60+ year chapter of their lives. The new location encompasses a novel territory, neighborhood, social group, entire community, and access to the outside, larger world. The location chosen, its atmosphere and culture may be crucial. For most people a house is a meaningful life-space: ªhome is where the heart is.º Home signifies stability, roots, a feeling of belonging, security, identity, intimacy, personal space, and generativity. Permanently relinquishing one's home can be a painful step. This surrender is especially hard for the elderly person who experiences many additional changes and may cling to the familiar for security and permanency. Thus, the need to adjust to a new framework involves the ability to separate emotionally from a previously meaningful stable world, that is, from habits and lifestyle held throughout many years, from defined identities, and from a familiar society and environment. Successful relocation, therefore, is a complex twofold process that requires reconciliation with loss as well as adaptation to a novel environment. The rationale to move to a nursing home, adjusting and maintaining well-being along time, all depend on a wide range of personal, interpersonal, and environmental resources. These include a complex range of factors, such as, individual characteristics and ego resources, past history, family structure, quality of relationships, economic status, social background, environment, and culture. Once in the nursing home, a variety of adaptational task are expected. Given the

variability in nursing homes and in coping patterns of the individuals, it is almost impossible to predict adjustment patterns. Nevertheless, some basic factors are highlighted which are deemed critical to the adjustment process.

7.21.4.1 The Decision-making Process and its Impact The decision to leave home and move to a nursing home is an emotionally-loaded process involving multiple aspects, phases, and actors (Groger, 1994). This major life decision often involves anxiety, stress, ambivalence, fears, doubts, hopes, and risk taking, feelings which may be unavoidable considering the life changes involved and the necessary uncertainty about the new habitat and the future. The family often plays a major role prior to admission and, thereafter, in the readjustment of the elderly. Overt and covert individual and family conflicts may often emerge. Family members frequently share the elderly person's ambivalence (BarTur, 1993; Halpert, 1991). Institutionalization of an elderly parent may also create family crisis. Moreover, data suggests that above 50% of those entering homes for the aged do so without having taken a meaningful part in the decisionmaking process (Reinardy, 1992). The decision-making process affects the person's adjustment to the nursing home. Elderly who exercised more control over the decision adjust better than those who have less control over the move. Often an elderly person may feel ªdumpedº by their family and consequently become alienated and depressed. Family structure has major impact. Having, for instance, one daughter or sibling reduces an older person's chances of admission by about one-fourth (Freedman, 1996). Sometimes family members act out conflicts in their relationships with the nursing home staff, further complicating the adjustment process. Children may seek professional help in the process of placing their parent in a nursing home. Guilt, anger, regret, and resentment are almost ubiquitous. Planning and implementing the decision with the family in a context of safety, nonthreatening, and open communication can minimize distortion and promote healing of the family (Bienenfeld, 1990). The psychological loaded milieu described here obviously indicates the possibilities for clinical geropsychologist to assist in conflict resolution and stress reduction for all those involved in this transition and relocation. At stake is not merely ªadjustmentº to the nursing home, but solving existential dilemmas to improve the quality of life.

Mental Health in Light of the Transition and Adaptation to a Nursing Home Over one-half of the persons admitted to a nursing home are discharged within three months. This figure includes those who die as well those transferred to hospitals or to the community. Most of the hospitalized, as well as those discharged to the community, eventually return to the nursing home (Lewis, Cretin, & Kane, 1985). Cooperation between hospitals, the community, and nursing homes is crucial, especially when dealing with the chronically sick elderly. 7.21.4.2 Preadmission Screening Elderly adults admitted to a nursing home usually present a combination of mental and physical health problems. Potential patterns of interaction between physical and mental health conditions among nursing home residents may be expressed in the four categories of (i) ªclassicalº psychosomatic disorders; (ii) somatizing responses (e.g., conversion syndrome); (iii) physical illness causing psychiatric symptoms; and (iv) psychological responses to illness. Family and social issues are often embedded in all these. The preadmission screening procedure is therefore very important for certifying the type of care, mentally and physically, the new resident requires (Symer & Garfein, 1988). It may add clarification to the decision-making process as to the kind of home to seek and may lay the basis for the kinds of interventions needed to assist the individual's adaptation in the nursing home. It is recommended (Newman et al.,1989) that psychologists become more involved in the substance and process of preadmission screening, assessment being one of the applied psychologist's strengths. Depending on the results of the prescreening, the clinical psychologist may further refer the candidate to a medical, family, or consulting psychologist as well as to social workers. 7.21.4.3 Adaptational Tasks in Nursing Homes The transition to a nursing home requires various adjustments. Some of the major tasks, in specific areas of daily living, that must be accomplished to promote an appropriate quality of life in the nursing home, are outlined in what follows. 7.21.4.3.1 Limited living space and seperation from personal effects Exchanging a macro- for a microenvironment implies radical reorientation of spacial experience. Personal and interpersonal space has to be modified. Transition to diminished space,

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sometimes sharing one room with someone else, requires residents to limit drastically their living space and separate from many objects they have accumulated throughout many years. In such objects, a person's history, identity, and lifestyle are encapsulated. Separation from such meaningful objects, in addition to other losses experienced in old age, may create a painful sense of discontinuity. Relocation sometimes involves rapid renunciation, resignation, and separation, whereas mourning over the losses may be prolonged. For example, about one year after admission, Mrs. B. realized at her birthday party that she didn't have a single flower vase. She burst into tears at the memory of all the beautiful things she had been forced to leave behind, expressing a sense of deprivation. Mr. Z., a widower without relatives, negotiated for two years with a nursing home for them to accept him with his 200 books; he passed away, bitterly, in midst of negotiations. Neither had any contact with a mental health professional. Stripped of personal belongings and yearning for them may cause depressive mood. Attachment to familiar objects lends a sense of security and may serve as an adjustment mechanism. While the importance of transitional objects in young children (Winnicott, 1953) is recognized, they should be considered significant throughout the life-span. Just as the child therapist may utilize transitional objects to reinforce growth and development, the geropsychologist may do the same, but usually on the basis of the absence of such objects. 7.21.4.3.2 A novel geographic ecology Adjustment to ecology includes the physical environment, the world of plants and animals, the human inhabitants, and the larger geographical surroundings. It also signifies the importance of environmental planning for older people (Moos & Lemke, 1985) and the behavioral and affective outcomes in the person-environment fit. Geographic experiences, defined as ªthe individual's involvement within the spaces and places of his lifeº (Rowles, 1979, p. 81), represent meaningful dynamics in the individual. Organization of a new living space is difficult. Residents must familiarize themselves with a whole new world. Mrs. B., a 90-year-old lady, said sadly ªI lived in the same four-room apartment for 60 years, and everything had its place. Here, in one room, I have hardly anything and I still can't find nothing.º The required adjustment not only concerns one's room, but also the facilities in the building and the surrounding area. Uncertainty as to what is usually posited firmly in our minds (e.g., rooms, buildings, streets, or bus schedules) may

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cause disorientation, especially for those who are confused, leading to anxieties and nightmares. Coping and adjusting to the ecological aspects consumes physical as well as mental energy but is crucial for enabling the residents to ªfeeling in placeº and enhances belongingness. 7.21.4.3.3 Structured and leisure time New residents face a transition from controlling and structuring their time, in the past, to a milieu in which almost all the time is structured for them and they also may be discontent about the way time is filled. Life in many nursing homes goes by a strict time schedule. There are specific hours for such things as eating, social activities, and receiving medication. Moreover, often these time-bound activities become the most significant events, the markers and content of existence and, as such, being after all very simple routines, may render the totality of life for the resident as boring and meaningless. Transition to a nursing home frees time and energy that in the past were devoted to activities of independent daily living. Potentially individuals may enjoy, as many do, and use their time for a variety of creative and educational activities. However, although being released from burden and given freedom for pleasure and personal enrichment, many residents may find it difficult to shift from fulfilling duties to enjoying leisure time. Such an inability to shift relates to the difficulty in giving up roles, values, identities, and lifestyles, all molded during one's life-span. Neulinger (1981) postulated that the ability to enjoy leisure time depends on a certain mental state that includes a feeling of freedom together with basic motivation to experience and enjoy. Physically or emotionally frail residents may find it hard to learn new outlets for satisfaction and as a result experience low morale. The passage of time may also be experienced as monotonous, slow, and dispersonalized, features associated with the depressed elderly. Further implications of temporality refer to the personal experience of time (Lomranz, Shmotkin, & Vardi, 1991) such as time perspective or the meaning of future time. Such aspects retain specific significance in the existence of nursing home residents and they present furtile ground for the work of the clinical geropsychologist. 7.21.4.3.4 Food and communal dining Gutmann (1994) found, cross-culturally, food and oral preoccupation to be a major avenue of joy and pleasure and of highest significance for elderly people. Many nursing

homes operate on the basis of communal dining and the issue of food becomes a major adaptational task for the resident. Coupled with changes in sense of taste, as well as the loss of familiar ªhome food,º losing the role, especially for women, of ªcook,º and communal dining, can all be extremely frustrating and may become a major source of friction between residents as well as with staff. For an elderly resident, oral intake sometimes constitutes the only source of gratification and a main channel of communicating, interacting, and coping with the caretakers at the home and the world at large. Food, its quality and associated eating rituals, the conflicts as well as memories around it, all indicate personal and interpersonal significance. The psychological features associated with food: satisfying, receiving, giving, and caring, the ability to manipulate food as a means to interpersonal contact, are all severely restricted in communal dining and bear psychodynamic implications regarding mental health of residents, that the geropsychologist should be aware of. 7.21.4.3.5 Interpersonal and social adjustment Adjustments in the interpersonal sphere and the social environment are perhaps the most crucial for the resident. The social circle, including residents as well as staff, is large, unknown, and unstable. Yet, new relationships have to be established. Many nursing homes are planned to have more than one resident per room. For some, the hardest tasks in adjusting to a nursing home are sharing personal space with a roommate, and forming a long-term intimate partnership. This requires a great deal of flexibility, compromise, and willingness to forego independence and freedom of choice regarding daily issues (e.g., when to turn out lights, cleaning and tidying, use of toilet, etc.) which take on increasing significance since they represent basic needs such as territory, belonging, or boundary intrusions, and become the ground for feelings of rejection, insult, or elicit aggressive behaviors. Stripped of their previous acquaintances and social markers, the resident may feel insignificant and worthless. Loss of identity, together with the need to integrate into a new society, can cause insecurity, anxiety, and a sense of alienation. Mrs. B. said sadly, ªfor 60 years I lived in the same neighborhood and everyone knew me. When I came here, I suddenly lost my identity. I became anonymous, nobody knew who I am, what I have done all my life. I have become inferior in the world. I am just one old lady out of 300 old people.º For many residents the absence of friends often renders the atmo-

Mental Health in Light of the Transition and Adaptation to a Nursing Home sphere in the home as distant and gloomy. Finding new friends and establishing personal relationships is a difficult task, especially in old age. Getting to know and be known requires motivation, risk-taking, confidence, learning, and adaptability, psychological qualities which the elderly resident may require professional help in utilizing for their well-being. The clinical geropsychologist may find here the appropriate ground upon which to help residents utilize their past experience, their social skills, and use ego strength to establish interpersonal and social relationships (Hansson & Carpenter, 1994). Since compatibility renders adjustment easier, the geropsychologist should be involved in decision-making about roommates. At times rearranging the environment may be useful. However, often they have to deal with already existing conflicts, in and between residents, and use them as analytic avenues towards adjustment and emotional security. 7.21.4.3.6 Reframing family relationships Entering a nursing home necessitates the reformulation of relationships between the residents and their family. This sensitive process is emotionally loaded and may be the ground for deep conflict, as well reciprocal respect and love. The role of the family in the elderly's adjustment and their quality of life in the home is paramount. Relationships may become engulfed in ambivalence and stress, and past family dynamics may become the cornerstone for present conflicts or sound relationships. Although many families experience a heavy burden providing daily care for the older person at home, such stress often continues after the person's institutionalization (Stephens, Crowther, Hobfoll, & Tennenbaum, 1990). There is an ongoing launching process (Lomranz, 1995) in which, in contrast to the stage of adolescence, it is the parent who is being launched. Nevertheless, it bears similar launching characteristics, for example, guilt, ambivalence, letting go, holding on, transfer of responsibility, and mourning (Lomranz, Shmotkin, Eyal, & Zohar, 1996). Tobin (1987) describes children's mixed feelings, guilt and shame coupled with relief, in relocating a parent to a nursing home. Parents, however, may feel frustration stemming from their experience as they in the past shared lodgings with their own parents and grandparents. Although parents recognize the present difference in cohorts, housing arrangements, culture, and lifestyle, some may feel rejected and unwanted, believing that cohabitation would be possible if only desired by their children (BarTur, 1993). Such beliefs may, in response, elicit

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guilt feelings and hostility in children. Zivoni (1993) found that positive intergenerational relationships had an indirect negative influence on application to a nursing home. Tobin (1987) described the importance of considering institutionalization as a family process. Tobin suggests that there will be a ªgoodº figure (e.g., social worker or intern) satisfying the family's desire for individualized care for the resident, and a ªbadº figure (e.g., administration) who could tolerate the family's anger. An elderly person's feeling of disconnection from their family may be detrimental to their mental health. Mutual ambivalence should be worked through. Intergenerational relations and the kind of daily involvement children have with the parent, family visits, and adequate contact with administration are extremely important for the well-being of the elderly and the family. In attending to their clients' problems, clinical geropsychologists sometimes have to involve the children (similar to the case of child therapy). Adult children should also be conceived as part of the social support network and in the role of caregivers, including the difficulties caregivers encounter (Stephens et al., 1990). To summarize, nursing homes, the effects of institutionalization, and some core issues in a resident's adjustment to a nursing home, have been characterized from a mental health perspective. The elderly living in a nursing home should not be mainly preoccupied with coping and survival. Their quality of life should be the highest possible according to their potential. The nursing home should provide conditions which enhance physical and mental health and promote development and growth. This, however, is not always obtained and hence it is here that adaptational issues and the role and functions of the clinical geropsychologist are dealt with. For growing numbers of aged people, especially (but not only) those who cannot live independently in the community, adjustment to a nursing home may be a major objective. The above explicated adaptational tasks actually refer to coping with aging processes and institutional effects. These tasks constitute the stage upon which the drama of life for the elderly resident is played out. They may continuously serve as ªexplosive potentialsº as well as issues around which elderly may mask aggression, frustration, and depression. Thus, it is important for the clinical geropsychologist to be aware of them. Diminishment of these factors (e.g., spacial or geographical orientations, social circles) does not necessarily depend on length of residency, but may relate to lifestyle (e.g., a resident who is not mobile enough, or has no contact with the community), coping

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strategies, and quality of life in the home. For many elderly, life in nursing homes is dull and purposeless. Stripped of external responsibilities and social roles, the importance of the outlined existential components in the daily routine grows unproportionally, consuming physical and mental energy. Yet, at the same time, developmental processes fully operate, preoccupations with health, bodily concerns, life review, family issues, social surroundings, and processes relating to identity and the self. However, these processes may not find direct expression. Conflicts are expressed through the experience and events in daily life, be they tragedies or consumption of food. The clinical geropsychologist must be familiar with these ongoing adaptational tasks, their implications, and the personal meanings attached to them so as to be able to detect and utilize them as avenues to internal life. If the foregoing may be comprehended in light of existential coping and ªsocial pathologyº (Pfeiffer, 1977), the chapter now focuses on more severe psychopathology.

scribed (sometimes inappropriately) by general practitioners. The nursing home staff also suffer from such conditions. Everitt, Field, Soumerai, and Auron (1991) note that only minor attention has been focused on the effect on nursing home staff of agitating and disordered residents' behavior which might persist in spite of ongoing pharmacological therapy, although perhaps inappropriately managed. Staff, patients, physicians, and institutions are all leverage points for further intervention to improve the delicate balance between patient behavior, staff distress, and medication use.

7.21.5 MENTAL DISORDERS IN THE NURSING HOME

7.21.5.1.1 Dementia

The extensive need for psychiatric treatment of nursing home residents has been noted above. Nursing homes report that they are admitting residents who are ªsickerº and more frail than in the past. The prevalence of psychiatric behavioral disorders in nursing homes has been estimated to range from 68 to 94% (Grossberg, Hassan, & Szwabo, 1990). Burns et al. (1993) found mental illness among elderly nursing home residents at a rate of 64%; however, only about 4.5% received any mental health treatment in a given one-month period. When they did receive treatment, it was likely to be psychotropic medication only. Manifestations of psychopathology in residents of long-term care facilities may include complaints of pain, anxieties, physical illness, impulse control problems, personality disorders, deliriums, thought disorders related to dementia, and chronic neurotic or psychotic behaviors. Evaluation of these behaviors and their differential diagnosis is complex and often not performed. Adequate treatment is prevented due to the lack of professional knowledge and facilities, limited resources, and staff. Norris, Snow-Turek, and Blankenship (1995) suggest that the environmental impact of institutionalization, as well as declining health, contributes to somatic and depressive symptomatology, as does frequent napping and use of psychotropic and sleeping medications pre-

7.21.5.1 Prevalence of Selected Syndromes and Interventions The range of psychopatology in a nursing home is similar to that of the general population. Rovner and Rabins (1985) have divided psychiatric disorders seen in nursing home into three major groups: (i) cognitive disorders (e.g., delirium and dementias), (ii) depression, and (iii) behavioral disorders.

Dementia is thoroughly presented in Chapter 10, this volume; here are highlighted some of their implications in homes for the aged. Estimates of incidence of the disease in individuals who are 80+ range from 10.8 to 47.2% (Gatz, Kasl-Godley, & Karel, 1996), hence its prevalence in many nursing homes is relatively high. As Chapter 10, this volume explicates, dementias appear in various patterns and modes of progression, a fact which carries many implications and difficulties in institutional management and care. Understanding emotions and moods of the older person suffering from dementia, correctly interpreting their behavior, and clarifying the impact of existing care practices are difficult tasks for the staff and pertain to the quality of care the institution is able to provide and the well-being of the demented (Cohen-Mansfield, 1996). Many of the demented elderly in nursing homes suffer from agitation reflected in a range of inappropriate behaviors: repetitive actions (e.g., pacing back and forth, repetition of words); socially inappropriate behavior (e.g., entering someone else's room and handling their belongings, or exposing themself nakedly); and aggressive behavior towards self or others. Often such patients walk out of the institution and cannot find their way back. Different agitating behaviors are associated with different individual characters, organicity, as well as situational characteristics. Such behavior is not

Mental Disorders in the Nursing Home only detrimental to the patient and their family, but creates fear and panic in the home where interaction is close and dense. ªHealthyº and fearful residents express discontent of not being separated from persons even at early stages of Alzheimer. Each nursing home has its own covert norms and culture which are important for staff to be able to identify it in order to comprehend residents' behavior and reduce their own distress. At various levels of dementia, aggressive behavior may be associated with poor-quality social interaction (e.g., responding to a roommate's minor invasion of personal space), or result from the patient's unsuccessful effort to interact verbally with their neighbor. Less aggressive behaviors tend to be manifested by persons who suffer from moderate to severe cognitive decline but are in relatively good physical health and under positive environmental conditions promoted by the institution. For some older persons, destructive behaviors may present a form of exercise or stimulation in the face of cognitive deterioration and reduced opportunities for other activities in the home. Various behavioral problems may occur frequently in a home inhabited by individuals suffering from a variety of illnesses, each at various levels of progression. It becomes an extremely difficult task for management to differentiate successfully and separate between such coexisting illnesses among residents. A broad range of therapeutic functions and interventions are available to the geropsychologist. Proper neuropsychological assessment (see Chapter 7, this volume) is paramount to better understanding the cause of acute behavioral problems and in recommending appropriate treatment and case management. Delirium may be common in nursing homes and differentiation should be made whether or not it results from progressive demetia. The resident with multiple medical problems and receiving many medications may be particularly vulnerable to delirium. It takes special sensitivity to assess some deteriorated behaviors but also to reveal potential abilities and preserved areas. Some patients, for example, who do not respond otherwise, may respond to music even employing their memory. While often residents and staff avoid contact with a demented patient, it is important to provide them with social contact, a comfortable environment, and appropriate stimulation in order to maintain a proper quality of life. Psychotherapeutic interventions should address the different stages of dementia. Dynamic and primarily behavioral orientations ranging from personal to group interventions, including specified groups such as Reality Orientation, have all been used success-

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fully. Other major avenues include working with the family and attending staff. Couples in the nursing home often have to be separated due to the deterioration of one of them, a traumatic event which often requires psychological intervention. The geropsychologist may advise staff regarding issues ranging from environmental safety of the wandering patient to impulse control problems, relevant neuropsychological presentations, and elevating staff distress. The various therapies should be promoted as important components of dignified management, in which the patient's entire life is respected and considered. This may also provide clues to the patient's resources that can to be drawn upon. 7.21.5.1.2 Depression Depression has been considered the major mental health problem in aging. However, a more cautious approach is being seen. Differentiation in this category is related to issues such as prevalence, etiology, relation to physical illness, biology, and stress, as well as to methodology, screening, and diagnostic approaches (Blazer, Hughes, & George, 1987; Gatz, in press; Katz, in press; Teri, 1991). Affective disorders and depression are elaborated on in Chapter 9, this volume. This disorder in the nursing home setting should be emphasised. The prevalence of depression, its symptoms, or dysphoric mood rank high among residents of nursing homes. They may be subtle and often go unnoticed and untreated leading to excess disability, morbidity, and mortality. While the signs and symptoms are often ascribed to underlying medical problems and advanced age, in fact, some of depression's more prominent characteristics may be observed in many residents: loss of appetite and weight loss; severe fatigue; sleep disturbances; changes in bowel habits and somatization; sadness; feelings of loneliness; generalized lack of interest in life; apathy; increased time spent in bed; avoiding visits; nonparticipation in communal activity; low self-esteem; increased preoccupation with death; and a gloomy evaluation of one's present and future situation. More subtle signs in residents could include: memory problems (pseudodementia); difficulty in making even minor decisions; dreams of being lost and lonely in frightening, desolate places; and crying out for help with no one responding (Pachana, Gallagher-Thompson, & Thompson, 1994). Multiple losses appear in high concentration in nursing homes, perhaps rendering depressive symptoms as almost inevitable in some such institutions. Admission to a nursing home, especially involuntary, transition, and

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relocation, is often accompanied by an increase in depressive symptoms and lowlife satisfaction (Rovner et al., 1991), although confounding factors such as declining physical health, often the cause for the move, may be involved. Newmann, Engel, and Jensen (1991) have suggested the term depletion syndrome to describe a form of depression commonly observed in older adults, primarily involving lack of interest and feeling that everything is an effort. Blazer, Burchett, Service, & George (1991) term similar symptoms minor depression. These symptoms are often observed among residents and reinforce the search for more subtle signs of depression among nursing home residents. Etiology awaits further differentiation whether such symptoms constitute late-onset disorder, are secondary to residents' deteriorating health or reactive to being institutionalized. Depressive disorders cause major distress to home and health care personnel. Residents at high risk would include those with a history of depression, poststroke individuals, new residents, those returning from hospitalization or admitted for rehabilitation, and those grieving or having severe adjustment problems. Differentiating between normal and pathological grief is critical. Also, several commonly prescribed medications can have mood-altering side effects, a significant factor when dealing with an institutionalized population which has, perhaps, the highest in intake of medical drugs. Often secondary depressions as manifestations of medical disorders are encountered. In order to provide treatment plans and direct the staff, the geropsychologist should administer diagnostic procedures, via clinical interview, symptom checklist, or more extensive testing. Although in most cases residents are referred to a psychiatrist for medication, the full range of causes for depression should be considered. These could include a variety of intrapsychic and psycho-social aspects, factors in which the geropsychologist's contribution is needed for evaluation and intervention. Effective therapies with depressive people, which also lend themselves well to the nursing setting, are behavior modification, cognitive, and psychodynamic therapies (Gallagher & Thompson, 1982). 7.21.5.1.3 Suicide Suicide, its epidemiology, risks, and prevention, have been discussed in Chapter 11, this volume. This chapter emphasizes its special danger in the nursing home population. Many nursing homes constitute an assembly of suicide risk factors, as the discussion of depression indicates (Glass & Reed, 1993). Feeling helpless

and hopeless, elderly candidates for suicide are less likely to make manipulative or suicidal gestures and they often signal their intentions, which are not always noticed. Some may, however, become unusually quiet and withdrawn. Recognizing the subtle signs of depression may require a high level of professional sensitivity. One clue is giving away valuable personal possessions. In either case, staff are often (it seems too often) ªsurprisedº by the suicidal act. The impact of suicide in an institutional perspective should be considered. Suicide in a nursing home can have an extreme impact on the residents and the staff. This may also be combated by defensive distancing. Usually it arouses anxiety, anger, and often a feeling of helplessness and inadequacy among those who were involved in the caregiving. Staff and management are often confused as death occurs (e.g., should obituaries be placed in the nursing home, should busing be arranged for funerals, etc.). There is always the threat of ªcontagionº as one suicide triggers suicidal thoughts or encourages other residents to attempt as well. This produces a threatening atmosphere in which fear of the ªnextº suicide prevails and is felt by most individuals in the home. At such times, interventions by staff may be crucial. In one nursing home six suicides were witnessed in a period of about two months. The atmosphere in the home became extremely tense. Both staff and residents were very anxious and many expressed guilt, helplessness, and desperation. Inspection revealed feelings of frustration, anger, and despair. A special intervention program was designed, including individual and group discussions in which residents were helped to deal with stressful life events and current obstacles, to ventilate, and were taught self-control and self-relaxation techniques. The psychologist's major task was to identify residents at risk and to provide immediate help for some residents, for example, those who had been friends of the suicidees or witnessed their death. A prevention program was also designed in which staff members were trained to identify signals of threat among residents, and certain security measures and technical devices (e.g., preventing accumulation of drugs, closing ªriskyº places such as roofs) were taken to prevent future suicidal events. 7.21.5.1.4 Psychotic symptoms and paraphrenia A variety of delusions, often related to progressive dementia, are seen in patients in nursing homes. More frequent are the paranoid or accusatory behaviors. Late-onset schizophrenics, in contrast to early-onset schizophre-

Mental Disorders in the Nursing Home nics, have an average life expectancy that seems to exceed that of the regular elderly population (Bienenfeld, 1990). Pharaphrenia, often regarded as late-onset schizophrenia, is usually described as having onset after the age of 60 and entailing paranoid delusions with or without auditory hallucinations, less thought disorder, and less flattening of affect. Paraphrenia, which has a relatively high incidence among nursing home residents, can also be regarded as a delusional disorder characterized by an isolated delusion and no other symptoms, and with the delusion not necessarily signaling a neurological disorder (American Psychiatric Association, 1994). Delusions in older patients, according to Post (1987), take the form of ªunshakable false beliefº with remarkably ªbanalº content. Psychological diathesis for paraphrenia often include premorbid schizoid personality disorder (Pearlson et al., 1989). Traumas earlier in life, such as parental separation, being a refugee, and childlessness, may play a role in increasing vulnerability (Gurian, Wexler, & Baker, 1992), whereas recent stress may trigger the onset of the disorder. Residents who have immigrated from other countries seem susceptible to developing delusional disorders (Ruskin, 1990). Molinari and Chacko (1983) suggest that the development of paranoid symptoms in the elderly patient is usually the result of increased use of projection as a defense against grief or perceived loss of autonomy and control, typical occurrences in nursing homes. Many residents' ideation was often related to past experiences or unresolved conflictual relationships. Mr. G., aged 82, a frail elderly, blamed his wife of adultery since she became involved in the home's activities, while he remained in the room. In an other case, a widowed woman whose two daughters died in the last 10 years and who also suffered from hearing loss and eye sight deterioration, developed a paranoid ideation that her neighbor was stealing from her. These symptoms may defensively protect the resident from painful depression that some individuals experience as a reaction to loss and dependency. Some researchers have reported that hearing loss is associated with late-onset schizophrenia or paraphrenia and frequently among dementia patients with paranoid symptoms (Gurian et al., 1992). Paranoid symptoms may thus develop as a result of mental deterioration reflecting prethreshold organic brain change, sometimes in order to fill the gap created by impaired memory (Gatz, et al., 1996). Late-onset psychotic symptoms often have an organic etiology. Therefore, a thorough

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medical and laboratory evaluation, together with a psychological one, should be obtained. A useful rule of thumb when dealing with psychotic symptoms in the nursing home is to ask to what degree these symptoms are disturbing to the patient or to the environment. Often such states are best treated nonchemically, late-onset schizophrenia does have more preservation of personality and less formal thought disorder then early-onset schizophrenia. If psychotic symptoms are disturbing, antipsychotic medication and ongoing psychiatric involvement is certainly called for. Case management interventions, such as encouraging the patient to remove from people or situations which stimulate the paranoid ideation, could be helpful. The role of the geropsychologist to could be to establish an alliance with the patient (Fried & Agassi, 1976), thus encouraging them to share thoughts about present and past experiences. When such communication can be established, the patient becomes less anxious and an ongoing treatment plan, with the consulting psychiatrist at the home, can be established. 7.21.5.1.5 Personality disorders Personality disorders are discussed in Chapter 12, this volume, This discussion is limited to highlighting aspects relevant to nursing homes. Given the residents' advanced age, difficulties in diagnosis become apparent. Properly diagnosing personality disorders is further encumbered by the impact of the institutional environment, changes in cognitive processes, sorting out chronic from acute behaviors, and difficulties in obtaining history. A lifetime pattern of pathological interpersonal relationships, the present old-age experience of losses, and institutionalizational rules, all further promote regressive psychological functioning and may elicit primitive defenses such as splitting, all of which gain a special intense quality in an environment with multiple caregivers. Personality disorders are often seen in conjunction with other disorders, in particular major or masked depressions, frequent in nursing homes. Residents with personality disorders are especially ill-equipped to cope with the stress of institutionalization. Many of the ªdifficultº or ªuncooperativeº residents in a nursing home can be diagnosed as personality disorders, sometimes coupled with cognitive decline. Such residents may manifest inappropriate emotional responses or inconsistent control of impulse behavior, including aggression and violence. Sadavoy and Fogel (1992) suggest that these patients tend to represent a vulnerable personality that be-

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comes increasingly less adaptive with new stressful events in old age due to eight critical age-specific stressors: interpersonal loss, physical disability, loss of external manifestations of the self (beauty, strength), loss of role, loss of defensive outlets; forced reliance on caretakers, confrontation with death; and conflict over the wish to live vs. the wish to die. Another major loss for such residents is the loss of resources of narcissistic gratification from others. These difficulties are often manifested in distorted ways such as self-perception oblivious to one's impact. This affects interaction with other residents and staff, and may lead to constant conflict with management. Difficulties in these individuals often result from the state in which they have to be dependent on others and to rely on them to supply their needs. They may fight for independence and autonomy in order to maintain their self-esteem by manipulating the staff, by refusing to obey rules, and acting out their anxieties and conflicts. In spite of the difficulties with such patients, they may benefit from regular psychotherapeutic contact and are able to establish an alliance with the therapist. The relationship with the psychotherapist itself may gratify narcissistic needs which otherwise might have been expressed destructively. Work with the patient's family and staff caretakers is also indicated to introduce possible case management procedures shielding such a patient from stress or encouraging real and/or perceived autonomy and control (Perlmuter & Monty, 1979). Although the major symtomatology has been outlined, it should be emphasized that the more ªbenignº disturbances and neurotic behaviors do not receive due attention, as if neuroticism disappears in old age and the elderly suffer only from cognitive difficulties, dementias, and psychosis. Reality is completely different; neurotic behavior and existential concerns are ªthere to stay,º can be treated (including with psychotherapy), and present a major component in the mental health of the elderly in general and in nursing homes in particular. Other disturbances prevailing in nursing homes, and not discussed due to lack of space, include anxiety and somatoform disorders (Stanley and Beck, this vol.), drug abuse (Blow, this vol.), sleep disorders (Ancoli-Israel, this vol.), impulse control wandering, behavioral problems, family issues, further neurotic and psychotic disturbances, as well as surrogate decision-making for nursing home residents. Having emphasized that health problems do not receive adequate treatment, a comprehensive treatment model is presented to address all the explicated mental health issues discussed.

7.21.6 A CLINICAL GEROPSYCHOLOGICAL SERVICE IN NURSING HOMES: A PROPOSED MODEL A geropsychological clinic operating in a nursing home in Isreal is described (Lomranz, 1991) and presented as a model clinic. 7.21.6.1 Setting and Clientele The clinic operates within a nursing home housing a population of 750 residents. A psychiatrist serves as consultant. The elderly residents range from those functioning independently to those needing constant nursing care. The clinic is a recognized internship center for clinical psychology interns and is associated with the Tel Aviv University's Herczeg Institute on Aging. The target clientele consists of two main categories: the residents themselves and associated significant figures, mainly family, and the professional and paraprofessional staff. The clinic's framework includes regular staff meetings, case conferences, supervision, study groups, and seminars, as well as participation in many of the nursing home conferences, including referral conferences, admission committees, and meetings planning activities for residents. 7.21.6.2 Orientation and Philosophy The philosophy constitutes the zeitgeist which prevails in the clinic and should be expressed in interaction with clientele, above and beyond the ªprofessional approach.º It is reflected in: (i) a dual focus on the image of a person, a Bopsycho-social holistic view (Engel, 1977) embedded in a humanistic approach and respect for personal dignity, and a life-span developmental psychology orientation (P. Baltes & M. Baltes, 1993). The two orientations are eminently compatible. (ii) Comprehension of the environment and the significance of person/ environment interaction; (iii) Aim: to improve mental health and upgrade the quality of life; (iv) Methods: The service adheres to a dynamic theoretical approach based on elaborations of clinical adult developmental theory (Nemiroff & Colarusso, 1990) and other eclectic clinical techniques of diagnosis and treatment. It has often been observed that mental health problems in nursing homes may go unnoticed for long periods of time. It is often only when a resident ªbecomes a nuisanceº that they are dealt with. Early detection may improve the utility of treatment. It is therefore crucial that the service adheres to outreach, prevention, and community orientations.

A Clinical Geropsychological Service in Nursing Homes: A Proposed Model 7.21.6.3 Methods The eclectic approach is tailored to the specific needs of the client. These approaches include dynamic, cognitive, and behavior modification, group methods, family and milieu systems, existential therapy, organizational, educational, and community approaches. Specific techniques found useful with the elderly are employed, including life review therapy, reminisence groups (Haight & Webster, 1995), family counseling (Brink, 1979), and educational programs and training (Garrison, 1978). These are applied to individuals, families, groups, community, staff, and interdisciplinary networks. Group work (e.g., psychotherapy, family, task groups, life review) is a major methodological component (MacLennan, Shura, & Weiner, 1988). Intervention are geared to eliminate psychopathology as well as preventive work to increase clients' sense of control and hopefulness about change. Reserve capacities are utilized, based on selection, optimization, and compensation (Baltes & Baltes, 1993; Ryff, 1989). Considerable attention is paid to assessment and diagnostics (Storandt, Siegler, & Elias, 1978). Existing diagnostic tools are adapted or modified, and specialized tools are developed in cooperation with the University Herczeg Institute on Aging. Thus, traditional and nontraditional approaches for intervention and assessment are employed. The psychologists work in cooperation with social workers, occupational, art- and physiotherapists. Special attention is given to psychosoma interaction, and ongoing communication is maintained with the medical and paramedical staff. Regular contact is held with the ªHome mother,º the caregivers, and technical departments (e.g., maintenance, cleaning, kitchen). Informal contact and interaction (discussions in the elevator, garden, etc.) are part of the approach and highly valued. All these activities also contribute to the integration of the clinic as an integral part of the nursing home.

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ing transitional, normative, or situational crises. This is mostly accomplished directly, but often indirectly (e.g., instructing a nurse, neighbor): short consultation or direction of other staff are central here; (iii) ªprevention,º consisting of two main activities of working with residents or staff on problematic issues or risk populations (e.g., groups work with isolated residents just before major holidays, or tackling staff problems of burnout) or of educational activities aimed at enriching the residents or furthering the professional development of the staff (e.g., lectures to residents on mental health or to staff on psycholpathology). Thus, the psychological services in the nursing home comprises seven domains with their respective working goals of mental health. 7.21.6.4.1 Preadmission screening Every applicant is interviewed and assessed to obtain information on cognitive as well as affective functioning and status. Thus, the service can be advise management in decisions to accept or reject an applicant. For those accepted, preadmission screening may be paramount in certifying the type of care and living facilities that the elderly requires (Smyer, 1989). While most people admitted to a nursing home have mental concerns and some physical problems, it is generally the latter which are documented and communicated to the staff, while mental or behavioral problems are rarely discussed professionally. At times, there is a tendency for the family and the older client to withhold information regarding deterioration of mental state. Such clients, once admitted, exhibit serious adjustment difficulty and, moreover, their cognitively impaired as well as affective state may deteriorate more rapidly. The psychologist can support the client and the family and can help reduce their initial anxiety, obtain their cooperation in assessing adequately the client and as a result prevent unnecessary misery and rapid decline in mental health.

7.21.6.4 Applications

7.21.6.4.2 Follow-up services

Most referrals originate from interdisciplinary staff meetings, medical and social services, or individuals recommending neighbors. A minority are self-refered. Three principles of psychological interventions of a curative, preventive or palliative nature are categorized and for the sake of convenience, termed: (i) ªtreatment,º basically consisting of a direct, shortterm, or long-term systematic psychotherapeutic approach applied to different kinds of psychopathologies; (ii) ªconsultation,º attend-

Working on the basis of data obtained in prescreening, the psychologist is later involved in assessing the follow-up of the new resident. Some residents need supportive sessions or crisis intervention, short-term therapy, focused on issues of separation and mourning over the losses they experience at the early phases of their transition to the nursing home. Others may be directed to task groups or activities in the home. The service conducts open-ended adjustment groups which focus on relocation effects during

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the first three to six months, a group in which every newcomer participates for at least several sessions. 7.21.6.4.3 Severe psychopathology Here the clinic functions as any other psychiatric setting. Patients are refered and diagnosed, and treatment is planed and carried out. Often, combined psychopharmacological and psychological treatment is administered. Individual psychotherapy is increasingly being requested by residents. 7.21.6.4.4 Family interventions A resident's family always occupies them in practice or in thought. The elderly person usually arrives at the nursing home accompanied by family members, with the adult children formally assuming ªfilialº responsibility, acting as ªparentsº as they relate to their parent and deal with staff and management. This role reversal is often likely to heighten the anxieties and difficulties of all parties concerned: children, parents, and staff. As some residents experience separation anxieties and relocation symptoms are manifested, the anxious, or guilt ridden, children may respond by engaging in acting-out behaviors. They may cause inconvenience, aggravate staff, and exhibit overdo concern. Parents, in turn, increase their fears and guilt by complaining, crying, expressing helplessness, and despair. This was the case with Mr. R., aged 88, who, prior to entering the home was functioning well, spending his time painting and sculpturing. He was forced to move to the nursing home after falling and became unable to take care of himself. He was the father of two devoted sons who encouraged him and helped him move to the home. Mr. R. seemed quiet and reserved in the admission interview. However, as soon as his sons left he became extremely anxious and restless. During his first week in the home he spent most of the day wandering around the phone box crying and calling his sons, asking them to visit. He nagged staff and other passers-by near the phone box to call his sons. His sons became concerned and paid visits a few times a day. Family sessions were held in which the children comprehended the father's separation anxieties and his intensive need for support. The sons were encouraged to talk about their own anxieties and work through their ambivalence at ªlaunchingº their father. The psychologist presented a treatment plan for the father with guidelines for the family and the nursing staff to help the father settle down and slowly shift towards self-control instead of enacting his need to control his sons. He

gradually learned how to master his anxieties, his sadness declined, and his phone calls ceased. Mr. G., 80-years old, lived in the nursing home for five years. His relationship with his only son was completely cut off, each accusing the other of ill-treating the mother/wife who passed away prior to Mr. G's move to the home. On memorial day each would come to the cemetery at a different hour. Mr. G. appeared to be well adjusted in the home until he developed a prostrate condition and feared he would die. At that point he began to long for his son who, stubbornly, refused to see him. The son had 20 hours of telephone discussions with one of the psychologists, during which he voiced his anger, discussed the role his mother played in his life, and his hate and ambivalence to his father. Only afterwards was a meeting arranged in which the two brought flowers to the mother's grave and joint treatment began. 7.21.6.4.5 From education to psychotherapy Extending educational programs to residents and their families provides a channel leading residents to self-development. Psychological education is often a condition for various ethnic, economic, and less-educated residents to become utilizers of the psychological services. Many elderly suffering in nursing homes may find it difficult to discuss personal issues and emotional problems with others, will not take the initiative to obtain psychological help, and may also refuse it when offered. One way to combat such difficulties is through offering relevant information, developing the proper atmosphere, and providing opportunities to meet therapists. Different psychologists and interns of the service provide a monthly lecture, open to residents, their families, and staff, on various aspects of the aging process, general psychology and adjustment issues in nursing homes. The psychologist then leads a discussion encouraging the audience to ask questions and to share ideas, thoughts, and feelings. Mrs. J. approached the psychologist after a lecture on intergenerational relationships, seeking advice for problems her granddaugther has with her father. In the discussion she revealed her intense identification with the granddaughter voicing anger at her son. This became a basis for her visits to the service. She then focused on personal problems and remained in psychotherapy for eight months. Mrs. W., a highly educated 92-year-old, wished to continue the lecture on ªsuccessful agingº with the ªyoung professorº (professional status being usually important, and overrated by elderly). This provided her with the opportunity to gain respect for her own knowledge and experience

A Clinical Geropsychological Service in Nursing Homes: A Proposed Model and eventually led to an extended and structured life review, after which she became more accepting of her present condition and learned new social skills. Obstacles in approaching the psychologist also reside in prejudice and stigmas about mental care, common in the older population. Public lectures, or special workshops (e.g., in communication skills, memory techniques) help the elderly, prospective client reduce anxieties and shame. Such activities, to most of which family members are also invited, may also serve as a vehicle of outreach to enhance constructive family involvement. 7.21.6.4.6 Working with nursing home staff This is a primary goal in the work of the clinic. The clinic administers intervention programs aimed at reducing staff distress, professional upgrading, promoting team work (e.g., to eliminate stress between workers in the kitchen), assisting conflict resolution between various teams and between them and management, and preventing burnout. Nursing homes often have high turnover rates and low staff morale, resulting from work pressures in dealing with threatening issues (aging, loss, illness, and death), distorted perceptions, and low intrinsic and extrinsic rewards. Psychologists in the service work with the interdisciplinary teams providing guidance, information, knowledge, and help in management of residents (e.g., how to address residents' hostile behaviors towards them), in coping with personal problems, and symptoms of burnout (increased fatigue, apathy, etc.). Workshops are conducted on improving interpersonal communication among the staff aiding managers to establish positive reinforcement techniques (Sbordone & Sterman, 1983), improving problem-solving on team building, and preventing burnout. Working educationally with different ranks of staff, the psychologist also conducts discussions, lectures, and case conferences with the various teams (e.g., medical, maintenance workers). Most interventions are based on short-term programs of two to six sessions. The geropsychologist should project an independent, often ªneutral,º professional position in the home, thus promoting authority and the ability to work successfully with the various teams, management, and residents. The clinic has witnessed turnovers and shifts in staff roles as well as changes of management often resulting in unclarity and uncertainty as to structure and management. In one such instance staff had major difficulties adjusting to a transition period between managers. Discus-

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sions with the psychologist, working as an organizational consultant, revealed an accumulation of covert anger and coalitions between different team members detrimental to ongoing work. Often, in meetings, issues concerning complains about residents reveal conflicts between different teams of the staff. In another case, a nursing team became almost ineffective. It turned out that the team was understaffed, frustrated by hard work and lack of appreciation and recognition by management, and rapidly revealed burnout syptomatology. Group discussions combined with private sessions helped them release their feelings, work through some of the communication patterns with management, and address their complaints effectively. Some of the clinic's staff are also called for consultation to other nursing homes in the vicinity. 7.21.6.4.7 A university clinic Coordinating links with the university's institute of aging and the nursing home, teaching and supervising students and interns, and cooperating in research are all part and parcel of the clinic. The staff includes postgraduate clinical psychologists who work as interns in the nursing homes, and provide supervision to undergraduate and graduate students of clinical psychology. Undergraduate students participate in a special practicum program involving them in activities which may range from friendly visits to more structured intervention, participation in group work, and providing lectures to the residents. Such liaisons with academic settings are beneficial to all parties involved and upgrade the quality of the home (Smyer & Garfein, 1988). They also encourage young students and interns to choose aging as their field of specialization (Kahana, 1986). This section concludes with some general evaluative remarks. During two years of operation, residents have changed their attitudes to psychological services. They became less skeptic, have come to recognize the importance of the clinic, and make greater use of its services. Experience suggests the recommendation that as geropsychologists, even intermediately until clinics are set up, working as individuals in nursing homes, they should: (i) establish their position as consultants in a variety of roles; (ii) dwell on diagnostics and assessment; (iii) become major referal directors; (iv) operate as coordinators between teams; (v) be clinical-community oriented; (vi) advance milieu treatment; (vii) assert their impact on policy-making in the institute; (viii) plan and utilize interdisciplinary interventions; (ix) be

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liberal in using eclectic, traditional, as well as untraditional, intervention approaches, including psychotherapy; and (x) invest in educational programs and systematically accumulating knowledge through documentation and research. The possibilities of psychotherapy in nursing homes should be emphasized as a challenge for every clinical psychologist. The goals of psychotherapy should be modified and theoretically they should consider gerontology, adult developmental processes, cognitive and medical losses and the effects of institutionalization, as well as clinical methodology. The dialectics between ªcase specificityº and ªage specificityº have to be analyzed. Short-term treatment is often required (Brink, 1979; Gallagher & Thompson, 1982), and a relational approach to transference seems conducive (Frankel, 1995). In long-term therapy, sessions could be of short duration and may be conducted in the residents' personal environment (their room, or in the ward). Long-term psychotherapy often provides the resident with continuity assuring them of the therapist's availability as a secure base (Bowlby, 1980). Many problems of the aged person are fit for intrapsychic and interpersonal exploration and lend themselves to life review, development, and growth. While psychotherapy is always tailored to the specific case, its possible gains with the aged are (in the proper perspective) as unlimited as they are with younger populations. Psychotherapy should be considered as a viable option for the elderly (Shmotkin, Eyal, & Lomranz, 1989). The pleasure and growth in working with the suitable aged can be tremendously gratifying for all parties.

7.21.7 FUTURE PROSPECTS There is undoubtedly an increasing need for mental health services in nursing homes. As the nursing home industry develops, this need intensively grows. Existing mental health facilities need to be expanded and improved, urgently, to answer neglected and increasing needs. Unfortunately, psychologists, not to mention geropsychological clinics, rarely are found in nursing homes. Also, the nursing home setting is ill-prepared to accept and employ psychologists. The absence of systematic assessment procedures, diagnosis and evaluation, consultations, therapy, and other appropriate interventions have a high cost. Unfortunately, there is a pronounced shortage of psychologists in gerontological clinical work in general (Gatz, 1995; Gatz et al., 1985). Clinical psychology as a discipline is still largely child-oriented and

continues to reflect ªprofessional ageismº (Butler & Lewis, 1982), especially with respect to nursing homes. The many misconceptions about the the older person (e.g., lack of energy, motivation, rigidity, and resistance to change) still remain after many decades and affect the ªreluctant psychologistº who is unwilling to work with the elderly. Working with the elderly still seems to be rated by colleagues as having low professional status (Knight, Reinhart, & Field, 1982), all the more so in a nursing home. Psychologists may also tend to shrink from interdisciplinary collaboration and conflict (e.g., with psychiatrist, social workers, or other paraprofessionals). Working in a nursing home is often regarded as depressing and difficult since illness and death, helplessness, and hopelessness are confronted continuously. What then are the future prospects? To meet the crucial challenge, a broader perspective should be adopted which associates geropsychology more strongly with clinical psychology at large and considers policy issues (Kane & Kane, 1990). Basic changes are recommended as stated in the following: (i) the discipline of clinical psychology has to further modify its developmental approach to include adulthood and aging; (ii) theory construction in clinical gerontology while thoroughly based on gerontology also needs to further integrate prevalent clinical theory (e.g., object relations); (iii) clinical methodology in geropsychology, on the aforementioned basis, should be eclectic and modified in goals and methods to fit the elderly population; (iv) policy should be further planned and policy makers have to present, perhaps more aggressively, the damage to nursing homes in cost-effective terms and develop reimbursement systems; (v) academic education and training has to be expanded intensively to include clinical geropsychology; (vi) governmental regulations should include the request for in-home psychological services in nursing homes as obligatory; and (vii) nursing homes should become academic-associated institutions, and clinics, as certified training placements and research units, should operate in each. The major goal of the clinical gerontologist in nursing homes should be to contribute to a fundamental change which would render the various institutions as authentic ªhomesº in which residents could actualize their potentials for positive mental health, live with dignity, enhance their well-being, and live creatively. For that purpose, which to a certain extent will determine the kind of society that is built, the discipline of psychology, on its various domains, is expected to mobilize itself to change and meet that challenge.

References 7.21.8 REFERENCES American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baltes, M. M. (1982). Environmental factors in dependency among nursing home residents: A social ecology analysis. In T. A. Wills (Ed.), Basic processes in helping relationships. New York: Academic Press. Baltes, P. B., & Baltes, M. M. (Eds.) (1993). Successful aging: Perspectives from the behavioral sciences. Cambridge, UK: Cambridge University Press. Bar-Tur, L. (1993). Adjustment to home for the aged as a developmental crisis in old age. Gerontologia, 62, 48±57. Bienenfeld, D. (Ed.) (1990). Verwoerdt's clinical geropsychiatry (3rd ed.). Baltimore: Williams & Wilkins. Birren, J. E., & Renner, V. J. (1980). Concepts and issues of mental health and aging. In J. E. Birren (Ed.), Handbook of mental health and aging (pp. 3±33). Englewood Cliffs, NJ: Prentice-Hall. Blazer, D., Burchett, B., Service, C., & George, L. K. (1991). The association between age and depression among the elderly: An epidemiological exploration. Journal of Gerontology: Medical Sciences, 46, M210±215. Blazer, D. G., Hughes, D. C., & George, L. K. (1987). The epidemiology of depression in an elderly community population. Gerontologist, 27, 281±287. Bowlby, J. (1980). Loss. New York: Basic Books. Brink, T. L. (1979). Geriatric psychotherapy. New York: Human Sciences Press. Burns, B., Wagner, H. R., Taube, J. E., Magaziner, J., Permutt, T., & Landerman, L. R. (1993). Mental health service use by the elderly in nursing homes. American Journal of Public Health, 83, 331±337. Butler, R. N. (1975). Why survive? Being old in America. New York: Harper & Row. Butler, R. N., & Lewis, M. (1982). Aging and mental health. London: Merrill. Cohen, G. D. (1980). Prospects for mental health and aging. In J. E. Birren & R. Sloane (Eds.), Handbook of mental health and aging (pp. 971-993). Englewood Cliffs, NJ: Prentice-Hall. Cohen, C. (1991). The chronic mentally ill elderly: Service research issues. In E. Light & B. Lebowitz (Eds.), The elderly with chronic mental illness (pp. 194±219). New York: Springer. Cohen-Mansfield, J. (1996). Trends in the treatment of frail elderly persons. Paper presented in the Herczeg Research Institute on Aging, Tel Aviv University, Israel. Colerick, E. J., & George, L. K. (1986). Predictors of institutionalization among caregivers of patients with Alzheimer's disease. Journal of the American Geriatrics Society, 34, 493±498. Donahue, W. (1978). What about our responsibility for the abandoned elderly? The Gerontologist, 18, 102±111. Eisdorfer, C., & Cohen, D. (1982). Mental health care of the aging: A multidisciplinary curriculum for professional training. New York: Springer. Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129±136. Everitt, D. E., Field, D. R., Soumerai, S. S., & Avron, J. (1991). Resident behavior and staff distress in the nursing home. Journal of American Geriatrics Society, 39, 792±798. Farrari, N. (1963). Freedom of choice. Social Work, 8, 105±106. Firestone, I. J., Lichman, C. M., & Evans, J. R. (1980). Privacy and solidarity: Effects of nursing home accommodation on environmental perception and sociability preferences. International Journal of Aging and Human Development, 1, 221±241. Frankel, S. (1995). Intricate engagements. London: Jason Aronson.

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Freedman, V. (1996). Family structure and the risk of nursing home admission. Journal of Gerontology: Social Sciences. 51B, S61±S69. Fried, Y., & Agassi, J. (1976). Paranoia: A study in diagnosis. Dordrecht, The Netherlands: Reidel. Gallagher, D. E., & Thompson, L. W. (1982). Treatment of major depressive disorders in older outpatients with brief psychotherapies. Psychotherapy: Theory, Research and Practice, 19, 482±490. Garrison, J. (1978). Stress management training for the elderly: A psychoeducational approach. Journal of the American Geriatrics Society, 26, 397±403. Gatz, M. (1989). Clinical psychology and aging. In M. Storandt & G. R. VandenBos (Eds.), The adult years: Continuity and changes (pp. 79-114). Washington, DC: American Psychological Association. Gatz, M. (Ed.) (1995). Emerging issues in mental health and aging. Washington, DC: American Psychological Association. Gatz, M. (1998). Towards a developmentally-informed theory of mental disorder in older adults. In J. Lomranz (Ed.), Handbook of mental health and aging. New York: Plenum. Gatz, M., Kasl-Godley, J. E., & Karel, M. J. (1996). Aging and mental disorders. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (4th ed.). San Diego, CA: Academic Press. Gatz, M., Popkin, S., Pino, C., & VandenBos, G. R. (1985). Psychological interventions with older adults. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (2nd ed., pp. 755±785). New York: Van Nostrand Reinhold. Gatz, M., & Smyer, M. A. (1992). The mental health system and older adults in the 1990s. American Psychologist, 47, 741-751. Glass, J. C., & Reed, S. E. (1993). To live or to die: A look at elderly suicide. Educational Gerontology, 19 (8), 767±778. Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. New York: Anchor. Goplerud, E. (1979). Unexpected consequences of deinstitutionalization of the mentally disabled elderly. Community Psychology, 7, 315±328. Groger, L. (1994). Decision as a process: A conceptual model of black elders nursing home placement. Journal of Aging Studies, 8, 77±94. Grossberg, G. T., Hassan, R., & Szwabo, P. A. (1990). Psychiatric problems in the nursing home. St. Louis University geriatric grand rounds. Journal of the American Geriatric Society, 38 (8), 907±917. Gurland, B. J. (1973). Abroad clinical assessment of psychopathology in the aged. In C. Eisdorfer & M. P. Lawton (Eds.), The psychology of adult development and aging (pp. 343±377). Washington, DC: American Psychological Association. Gurian, B. S., Wexler, D., & Baker, E. H. (1992). Late-life paranoia: Possible association with early trauma and infertility. International Journal of Geriatric Psychiatry, 7, 277±284. Gutmann, D. (1994). Reclaimed powers: Men and women in later life. Evanston, IL: Northwestern University Press. Haight, B., & Webster, J. (Eds.) (1995). The art and science of reminiscing: Theory, research methods and applications. London: Taylor & Francis. Halpert, E. (1991). Aspects of a dilemma of middle age: Whether or not to place aged failing parents in nursing home. Psychoanalytic Quarterly, 60, 426±449. Hansson, R., & Carpenter, B. (1994). Relationships in old age. Coping with the challenge of transition. New York: Guilford. Hirschfeld, M., & Fleishman, R. (1990). Nursing home care for the elderly. In R. L. Kane, G. Evans, & D. Macfadyn (Eds.), Improving the health of older peopleÐA

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world view (pp. 473±490). Oxford, UK: Oxford University Press. Jahoda, M. (1958). Current concepts of positive mental health. New York: Basic Books. Johnson, C. L., & Grant, L. A. (1985). The nursing home in American society. Baltimore: Johns Hopkins University Press. Kahana, B. (1986). A proposal to establish a Ph.D program in clinical-research gerontology. Cleveland, OH: Cleveland State University. Kane, R. L., & Kane, R. A. (Eds.) (1982). Values and long term care. Lexington, MA: Lexington. Kane, R. L., & Kane, R. A. (1990). Health care for older people: Organizational and policy issues. In R. H. Binstock & L. K. George (Eds.) Handbook of aging and social sciences (3rd ed., pp. 415±437) San Diego, CA: Academic Press. Katz, I. (in press). Depression as a pivotal component of secondary aging. In J. Lomranz (Ed.), Handbook of mental health and aging. New York: Plenum. Knight, B., Resnhart, R., & Field, D. (1982). Senior outreach services: A treatment oriented outreach team in community mental health. The Gerontologist, 22, 544±547. Knight, B. G., Santos, J., Teri, L., & Lawton, M. P. (1995). Introduction: The development of training in clinical geropsychology. In B. G. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults: Implications for training and practice in geropsychology. (pp. 1±8). Washington, DC: American Psychological Association. Lawton, M. P. (1980). Housing the elderly: Residential quality and residential satisfaction. Research on Aging, 2, 309±328. Lawton, M. P. (1985). Housing and living environments of older people. In R. Binstock & E. Shanas (Eds.), Handbook of aging and social sciences (pp. 450±478). New York: Reinhold. Lawton, M. P., & Cohen, J. (1974). The generality of housing impact on the well-being of older people. Journal of Gerontology, 29, 194±204. Lewis, M. A., Cretin, S., & Kane, R. L. (1985). The natural history of nursing home patients. Gerontologist, 25, 382±388. Lieberman, M., & Tobin, S. (1983). The experience of old age. Stress, coping and survival. New York: Basic Books. Lomranz, J. (1991). Mental health in homes for the aged and the clinical psychology of aging: Implementation of a model service. Clinical Gerontologist, 10, 47±71. Lomranz, J. (1995). Thus we live forever taking leave: The launching stage in the Israeli family. Social Behavior and Personality, 28, 287±302. Lomranz, J., Shmotkin, D., Eyal, N., & Zohar, Y. (1996). Launching themes in Israeli fathers and mothers. Journal of Adult Development, 3, 159±170. Lomranz, J., Shmotkin, D., & Vardi, R. (1991). The equivocal meanings of time. Current Psychology: Research and Reviews, 10 (1 & 2), 3±20. MacLennan, B., Shura, S., & Weiner, M. (Eds.) (1988). Group psychotherapies for the elderly. Madison, WI: International Universities Press. Molinari, V., & Chacko, R. (1983). The classification of paranoid disorders in the elderly: A clinical problem. Clinical Gerontologist, 1, 31±37. Moos, R., & Lemke, S. (1985). Specialized living environments for the older people. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (pp. 864±889). New York: Reinhold. National Center for Health Statistics (1983). The national nursing home survey: 1977. Summary for the United States. Washington, DC: Government Printing Office. Nemiroff, R., & Colarusso, C. (Eds.) (1990). New dimensions in adult development. New York: Basic Books.

Neulinger, J. (1981). To leisure: An introduction. Boston, MA: Allyn and Bacon. Newman, F. L., Griffin, B. P., Black, R. W., & Page, S. E. (1989). Linking level of care to level of need: Assessing the need for mental health care for nursing home residents. American Psychologist, 44, 1315±1324. Newmann, J. P., Engel, R. J., & Jensen, J. E. (1991). Changes in depressive symptom experiences among older women. Psychology and Aging, 6, 212±222. Norris, M. P., Snow-Turek, A. L., & Blankenship, L. (1995). Somatic depressive symptoms in the elderly: Contribution or confound? Journal of Clinical Geropsychology, 1, 5±17. Pachana, N., Gallagher-Thompson, D., & Thompson, L. W. (1994). Assessment of depression. In M. P. Lawton & J. A. Teresi (Eds.), Annual review of gerontology and geriatrics: Focus on assessment techniques (vol. 14, pp. 234±256). New York: Springer. Palmore, E. (1976). Total risk of institutionalization among the aged. Gerontologist, 16, 504±507 Pearlson, G. D., Kreger, L., Rabins, P. V., Chase, G. A., Cohen, B., Wirth, J. B., Sclaepfer, T. B., & Tune, L. E. (1989). A chart review study of late-onset and early-onset schizophrenia. American Journal of Psychiatry, 146, 1568±1574. Perlmuter, L., & Monty, R. (Eds.) (1979). Choice and perceived control. Hillsdale, NJ: Erlbaum. Pfeiffer, E. (1977). Psychopathology and social pathology. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (pp. 650±671). New York: Van Nostrand. Post, F. (1987). Paranoid and schizophrenic disorders among the aging. In L. L. Carstensen & B. A. Edelstein (Eds.), Handbook of clinical gerontology (pp. 43±56). New York: Pergamon. Reinardy, J. R. (1992). Decisional control in moving to a nursing home: Postadmission adjustment and well-being. The Gerontologist, 32, 96±103. Rovner, B. W., German, P. S., Brant, L. J., Clark, R., Burton, L., & Folstein, M. F. (1991). Depression and mortality in nursing homes. Journal of the American Medical Association, 265, 993±996. Rovner, B. W., & Rabins, P. V. (1985). Mental illness among nursing home patients. Hospital Community Psychiatry, 36, 119±120. Rowles, G. D. (1979). The last new home. In S. M. Golant (Ed.), Location and environment of elderly population. Washington, DC: Winston Rodin, J., & Langer, E. (1977). Long term effects of a control-relevant intervention with the institutional aged. Journal of Personality and Social Psychology, 35, 897±902. Ruskin, P. (1990). Schizophrenia and delusional disorders. In D. Bienfeld (Ed.), Verwoerdt's clinical geropsychiatry (pp. 125±136). Baltimore: Williams & Wilkins. Ryff, C. D. (1989). Beyond Ponc de Leon and life satisfaction: New directions in quest of successful aging. International Journal of Behavioral Development, 12, 35±55. Sadavoy, J., & Fogel, B. (1992). Personality disorders in old age. In: J. E. Birren, R. B. Sloan, & G. D. Cohen (Eds.). Handbook of mental health and aging (2nd ed.) (pp. 433±462). New York: Academic Press. Sbordone, R. J., & Sterman, L. T. (1983). The psychologist as a consultant in a nursing home: Effect on staff morale and turnover. Professional Psychology: Research and Practice, 14, 240±250. Schaie, K. W., & Willis, S. L. (1996). Adult development and aging (4th ed). New York: HarperCollins. Shmotkin, D., Eyal, N., & Lomranz, J. (1989). Motivations and attitudes of clinical psychologist regarding treatment of the elderly. Research report, The Sapir Foundation, Tel Aviv University, Israel.

References Smyer, M. A. (1989). Nursing homes as a setting for psychological practice: Public policy perspectives. American Psychologist, 44, 1307±1314. Smyer, M. A., & Garfein, A. (1988). Effective assessment approaches. In M. A. Smyer, M. Cohn, & D. Brannon (Eds.), Mental health consultation in nursing homes (pp. 64±81). New York: New York University Press. Stephens, M. A., Crowther, J., Hobfoll, S., & Tennenbaum, D. (Eds.) (1990). Stress and coping in later-life families. New York: Hemisphere. Storandt, M., Siegler, I., & Elias, M. (Eds.) (1978). The clinical psychology of aging. New York: Plenum. Teri, L. (1991). Behavioral assessment and treatment of depression in older adults. In P. A. Wisocki (Ed.), Handbook of clinical behavior therapy with the elderly client (pp. 225±244). New York: Plenum. Timko, C., & Moos, R. H. (1990). Determinants of interpersonal support and self-direction in group residential facilities. Journal of Gerontology: Social Sciences, 45, S184±S192. Tobin, S. S. (1987). A structural approach to families. In T. H. Brubaker (Ed.), Aging, health and the family: Long-

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term care (pp. 42±55). Newbury Park, CA: Sage. Tobin, S., & Lieberman, M. (1976). Last home for the aged: Critical implications of institutionalization. San Francisco: Jossey-Bass. US Senate, Special Committee on Aging. (1987). Developments in Aging, 1986 (Vols. 1±3). Washington, DC: US Government Printing Office. Wantz, M. S., & Gay, J. E. (1981). The aging process: A health perspective. Cambridge, MA: Winthrop Publishers. Winnicot, D. W. (1953). Transitional objects and transitional phenomena. Collected papers: Through pediatrics to psychoanalysis, 1958, (pp. 229±242). New York: Basic Books. World Health Organization (1964). Basic documents (15th ed.). Geneva, Switzerland: Author. Wright, L. K. (1988). A reconceptualization of the ªnegative staff attitudes and poor care in nursing homesº assumption. The Gerontologist, 28, 813±820. Zivoni, M. (1993). Intergenerational relationships of the elderly and attitudes to residential facilities. Gerontologia, 61, 18±32.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

7.22 Family Caregiving: Research Findings and Clinical Implications STEVEN H. ZARIT, ADAM DAVEY, ANNE B. EDWARDS, ELIA E. FEMIA, and SHANNON E. JARROTT Pennsylvania State University, University Park, PA, USA 7.22.1 INTRODUCTION

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7.22.2 BASIC ISSUES IN FAMILY CAREGIVING

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7.22.3 CAREGIVING AS AN ONGOING PROCESS: CAREERS OF CAREGIVERS

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7.22.4 CAREGIVING STRESS: PROCESSES OF PROLIFERATION AND CONTAINMENT

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7.22.5 CAREGIVING IN A FAMILY CONTEXT

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7.22.6 THE PERSPECTIVE OF THE CARE RECIPIENT

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7.22.7 RESEARCH ON FAMILY CAREGIVING

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7.22.8 CAREGIVING AND FAMILY RELATIONSHIPS

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7.22.9 NORMATIVE FAMILY RELATIONSHIPS IN LATER LIFE

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7.22.9.1 Family Structure and Caregiving 7.22.9.2 Caregiver±Care Recipient Relationships 7.22.9.3 Social Support from Family and Other Informal Sources

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7.22.10 SECONDARY STRESSORS: COMPETING ROLES AND STRESS PROLIFERATION

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7.22.11 OUTCOMES OF CAREGIVING: HEALTH AND MENTAL HEALTH EFFECTS

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7.22.12 CLINICAL RESEARCH AND SERVICES

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7.22.13 RESPITE SERVICES

513 514 514 515

7.22.13.1 Adult Day Care 7.22.13.2 In-Home Respite 7.22.13.3 Institutionalization and its Consequences 7.22.14 CLINICAL SERVICES

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7.22.15 CONCLUSIONS

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7.22.16 REFERENCES

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the family has been the main source of help to the elderly, but in previous eras when most people did not survive to old age, families' involvement in providing care to parents or grandparents tended to be limited and brief. The

7.22.1 INTRODUCTION Family care of disabled older people has emerged as one of the most important clinical and social issues in an aging society. Historically

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demographic revolution of the late twentieth century has resulted in more people surviving to ages when rates of disability are high. As a result, increasing numbers of older people need at least some help to manage activities of daily living. The most frequent source of that help is the family. Providing care to a disabled elder poses considerable challenges to the family. Care needs may place physical strain on caregivers or may impinge on already full schedules of work and family responsibilities. The dependency of a spouse or parent can also intensify long-standing family problems, or overwhelm the psychological resources of caregivers. Formal social and health services can reduce the burden of care on families, but can also introduce new strains or problems. Clinicians can make timely and effective interventions to mobilize the family's resources, address family conflict, and maximize the ability of both the family and the disabled older person to meet the challenge of disability. This chapter will present an overview of research on family caregiving and clinical interventions to relieve strain on the family. The chapter begins by introducing basic concepts to provide a foundation for examining research findings and clinical approaches. Three main areas of research on family caregiving are reviewed: how family relationships set the context for caregiving and in turn are affected by it, role conflict in caregiving, particularly, between employment and caregiving, and how the stresses of caregiving influence mental and physical health. The chapter concludes by examining clinical interventions and services designed to relieve stress on families and research on their effectiveness.

7.22.2 BASIC ISSUES IN FAMILY CAREGIVING In this section the emergence of family caregiving as a major social issue is reviewed, and four issues are presented which guide understanding of this phenomenon: (i) caregiving as a career; (ii) stress proliferation and containment; (iii) the family context of caregiving; and (iv) the care recipient's perspective. Caregiving has become an important concern because of the convergence of several social trends. The developed countries of the world are aging societies, that is, increasing proportions of their populations are 65 years of age and older. In fact, the fastest growing segment of the population is the ªoldest old,º people aged 80 years or over (Kinsella & Taeuber, 1993). Most older people live independently with few or no

physical limitations, but the likelihood of disability increases with advancing age. By age 85 years, 60% of the population has at least some degree of disability which requires regular, ongoing assistance (Zarit, Johansson, & Berg, 1995). Among 85-year-olds with no disabilities, approximately 30% develop problems over the next two years, and another 30% do so in the following two years. Clearly, there is a growing risk of disability at very advanced ages. How the aging of the population leads to increased risk of disability can be illustrated by the example of Alzheimer's disease. Although this disease can occur in people as young as 40 years of age, the greatest risk of incidence is after 75 (Johansson & Zarit, 1995; Jorm, Kortem, & Henderson, 1987; Kokman, Chandra, & Schoenberg, 1988). When most people in a society did not survive to 65, let alone 75 or 85, a disease such as Alzheimer's had a trivial impact. The dementia syndrome has been described since antiquity, but it has only assumed importance since the 1950s as large numbers of people have survived to the ages of greatest risk. For people surviving to their mid-80s, the cumulative risk of developing dementia due to any cause before death may be as high as 47% (Johansson & Zarit, 1995). The result is that many older people require considerable assistance for a period of time before their death. Extension of the average life span has meant that people have, on average, a longer period of active life. They are able to live independently into their 70s, 80s, and even in some cases 90s. But the factors which have led to improved life expectancy, better medical care and improved public health, may also be contributing to a prolonging of the period of disability at the end of life. The Expansion of Morbidity Hypothesis (Cassel, Rudberg, & Olshansky, 1992) posits that people now survive longer with chronic diseases and with greater amounts of disability. While unequivocal data to support this hypothesis are not available, it is widely apparent that people with severe disabilities can survive for long periods of time. To cite one example, 50% of a sample of dementia patients (with varying diagnoses) were alive 11 years after the first onset of symptoms, and just under 40% survived more than 14 years (Aneshensel, Pearlin, Mullan, Zarit, & Whitlatch, 1995). This long duration of morbidity is an important factor in the heavy caregiver burden placed on families and society. The net result of these trends is that more older people need help for longer periods of time than ever before. At the same time, families' resources for providing help have probably diminished somewhat. The most likely person to give assistance is a surviving

Caregiving as an Ongoing Process: Careers of Caregivers husband or wife, but that person will also usually be elderly and may have disabilities which limit the amount or type of help that can be provided. Because of historic trends toward smaller family size, there are, on average, fewer children available to share the care of a disabled parent. Daughters and daughters-inlaw have previously provided much of the assistance to elders, but with women's participation in the workforce, fewer full-time homemakers are available to take on caregiving responsibilities. Finally, historically high divorce rates in many Western countries weaken family ties and may diminish the amount of help available when a parent becomes disabled. Divorce in the parents' generation may have left strained or weakened ties with children, while divorce among children may result in their having fewer resources to commit to the care of an aging parent (Webster & Herzog, 1995). These sociodemographic trends provide the context for caregiving. Four important concepts set the stage for discussion of research and clinical interventions: (i) caregiving as an ongoing, evolving process; (ii) stress proliferation and containment in caregiving; (iii) family systems theory; and (iv) the importance of addressing the needs of both caregiver and care recipient.

7.22.3 CAREGIVING AS AN ONGOING PROCESS: CAREERS OF CAREGIVERS Caregiving involves an ongoing process, in which problems change and the caregiver's perceptions of problems also evolve. Just as the care recipient's disorder can span several years, caregiving also has a long duration. The tendency for studies to capture caregivers only at one point in time often obscures the temporal structure of what has come before and what lies ahead. To describe this process, Pearlin (1993) has introduced the construct of caregiving careers, that is, that caregiving is a role involving certain predictable expectations and transitions. Using findings from a longitudinal study of caregivers of dementia patients (Aneshensel et al., 1995; Pearlin, 1993), Pearlin and his colleagues suggest three distinct phases in a caregiver's career. First is the period of role acquisition, during which caregivers recognize the growing disability in their relative and make the decision to take on the caregiving role. In progressive disorders such as dementia, this recognition develops gradually. Families frequently will

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ignore the growing signs of disability or hope that their relative will snap out of it and return to normal. A physician's diagnosis or a critical event, such as the patient getting lost or mishandling a sum of money, often changes how the family views the situation, although caregivers may still fluctuate in their acknowledgment of disability and their relative's need for assistance. The tendency in dementing illnesses for patients to deny their problems or disabilities, especially as the disease progresses (e.g., Kaszniak, 1996), undoubtedly contributes to families' ambivalence in recognizing the disorder and taking on care responsibilities. The second phase in the caregiving career is role enactment, during which caregivers provide regular, ongoing assistance to their relative. Role enactment includes providing care to people in the home, and also in institutional settings. As we will see below, caregiving does not end at the institution's door. Families remain involved in care. While placement relieves some stresses, it introduces other problems and challenges for the family (Zarit & Whitlatch, 1992). The transition from home to institution may also be one of the most stressful times for families. Most of the available research addresses the period of role enactment, especially concerning caregivers providing care in the home. The third phase in caregiving is disengagement, which is marked by the patient's death. Although psychological disengagement sometimes occurs sooner, death of the patient is a critical turning point that has complex effects on caregivers. Death of the patient is frequently welcomed when it brings release from a long, painful or deteriorated condition. Yet it also forces caregivers to re-examine and reorient their lives. Grief follows a predictable course, with symptoms greatest following the patient's death, and then gradually diminishing, although some caregivers remain distressed for a sustained period of time (Aneshensel et al., 1995). Caregiving, then, should not be viewed as a static event that takes place for a limited duration of time. It is an ongoing process with some predictable demands and transitions. The pressures on the family depend to some extent on the phase of caregiving. Likewise, the type of clinical intervention will depend on whether caregivers are assuming the role, are in the midst of performing extensive caregiving activities, or are trying to reconstitute their lives following their relative's death. (For a description of varying clinical interventions over the full course of caregiving, see Zarit & Zarit, in press.)

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7.22.4 CAREGIVING STRESS: PROCESSES OF PROLIFERATION AND CONTAINMENT Caregiving has generally been viewed from the perspective of stress theory. Stressors represent all of the conditions, experiences, and activities that are problematic for people by thwarting their efforts, threatening their wellbeing, and disrupting otherwise stable systems (Aneshensel et al., 1995; Pearlin, Mullan, Semple, & Skaff, 1990). Chronic stress creates a state of perpetual arousal that taxes the individual's usual ability to adapt to the environment, and so compromises their ability to reach sought-after goals (Lazarus & Folkman, 1984). A specific model is used to guide exploration of caregiving. The stress process model, developed by Pearlin and his colleagues (Aneshensel et al., 1995; Pearlin et al., 1990) has been used to guide a major longitudinal investigation of caregivers of dementia patients. This model identifies three major components in caregivers' experiences: primary stressors, secondary stressors and outcomes (see Figure 1). Primary stressors evolve directly from the needs of the patient and represent the actual tasks of caregiving. These stressors are called primary because they are intimately associated with the root of the stress, namely, the chronic disabilities of the care recipient (Pearlin et al., 1990). Examples of primary stressors are behavioral problems, memory problems, and

difficulties carrying out activities of daily living (ADLs). Coupled with the objective conditions of caregiving are the caregiver's subjective appraisals of the memory problems, behavioral disturbances, and ADL deficits. Some primary stressors are more problematic or challenging than others and so can affect coping skills and erode caregiver self-efficacy (Kinney & Stephens, 1989). Pearlin et al. (1990) specifically identify feelings of overload and role captivity, that is, a sense of being trapped in the caregiving role, as primary subjective stressors. They also propose that the caregiver's sense of loss of the relationship with the care recipient should be considered a primary stressor. Evolving out of the primary stressors are the secondary stressors. Although termed secondary, these stressors are of no less importance. They represent the way in which primary stressors encroach upon and disrupt other areas of the caregiver's life, and thus are more variable and individual in their manifestation. Secondary stressors include family conflict, financial strain (e.g., reduced financial resources as a result of caregiving) and work conflict. They also involve psychological dimensions, such as diminished self-esteem and a feeling of loss of self, that the caregiver's identity has been absorbed totally in the caregiving role (Skaff & Pearlin, 1992). Long-term exposure to stressors can produce a variety of physiological and psychological changes, or what are termed outcomes in the

Family Relationships: History, Quality, Type, Support and Conflict

PRIMARY STRESSORS: Care tasks Loss of relation Hassles Overload

SECONDARY STRESSORS: Competing roles Loss of self

RESOURCES: Coping, Assistance Figure 1

A model of caregiving stress and family relationships.

OUTCOMES: Depression, Anger, Poor health

The Perspective of the Care Recipient stress process model. Among the outcomes that have been studied are depression, anger, wellbeing and a variety of indicators of health. These outcomes occur as chronic stress which results in disruptions of people's homeostatic mechanisms that overwhelm their coping resources. Stressors, however, do not have a fixed or constant effect on outcomes. The caregiving literature has documented considerable variability in how caregivers adapt to similar circumstances (e.g., Aneshensel et al., 1995; Haley, Levine, Brown, & Bartolucci, 1987; Wright, Clipp, & George, 1993; Zarit, Todd, & Zarit, 1986). The relation of stressors and outcomes is described in the stress process model in terms of two mechanisms: stress proliferation and stress containment (Aneshensel et al., 1995). Stress proliferation describes how the stressors involved in caregiving infiltrate and disrupt other areas of the caregiver's life. Primary stressors lead in varying degrees to secondary stressors, which in combination lead to negative outcomes. Stress proliferation is greatest when caregivers are assisting someone with higher levels of behavior problems and when there is a greater subjective effect of these stressors, for example, when caregivers feel overwhelmed or trapped in their role (Aneshensel et al., 1995; Haley et al., 1987; Zarit et al., 1986). Stress containment, in turn, describes how the caregiver's use of resources may limit or circumscribe the effects of stressors. How caregivers cope with specific problems as well as the amount of social and financial resources available to them can protect them from some of the adverse effects of stress. The outcome of a particular configuration of caregiving stressors is variable. The amount of variance in caregiver outcomes, such as depression, that is accounted for by any particular stressor, for example, the patient's behavior problems or the amount of family conflict, is statistically significant but relatively modest (Aneshensel et al., 1995). Instead, outcomes depend on the extent of proliferation or containment. The implications of this framework for clinical intervention are twofold. First, clinicians need to assess which primary and secondary stressors are present in a given situation. Caregiving and caregivers' resources are sufficiently varied so that the constellation of problems and stressors will differ considerably from one family to another. Rather than assuming that a constellation of stressors will be overwhelming or that a caregiver will necessarily experience work or family conflict, clinicians need to conduct an assessment to identify the specific proliferation of stress in the

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caregiver's life. Second, the goal of clinical interventions is to reduce sources of stress proliferation and enhance the caregiver's resources that lead to containment. Although it may not be possible to change the patient's underlying disability or to alter the primary stressors on caregivers, interventions can modify their impact on the caregiver's life (Whitlatch, Zarit, & von Eye, 1991). In the sections below, research is highlighted which suggests which factors are associated with greater or less stress for family caregivers and which may be amenable to clinical intervention. 7.22.5 CAREGIVING IN A FAMILY CONTEXT Stress theory is useful for characterizing the problems and challenges faced by caregivers, but it does not take into account the specific family context in which caregiving occurs. The relationship between caregiver and care recipient and their relationships with other family members should be considered. A family systems perspective focuses on what roles and functions a person performed within the family as well as the quality of these relationships (Zarit, Orr, & Zarit, 1985). Because of illness and disability, the care recipient can no longer perform certain activities and functions for the family. A spouse caregiver, for example, may experience the loss of a confidant and sexual partner, and may have to take over activities that his/her spouse previously performed in the household. Besides these specific losses, care recipients and caregivers have varying amounts of prestige and influence in the family, which affects how much help and assistance other people will provide. Children who view a caregiving mother as extremely competent may not view her as needing help. Conversely, a mother who is viewed as needy or lacking competency may get too much help or a mixture of criticism and assistance. Caregiving can also reawaken or intensify long-standing conflicts in the family. 7.22.6 THE PERSPECTIVE OF THE CARE RECIPIENT Lost in much of the caregiving literature is the perspective of the person receiving care. In part, this omission is due to the extensive focus on providing care to people with dementia, who lose the ability to report their experiences reliably as the disease progresses. This exclusion, however, means that the care recipient's perspective often is overlooked. Care recipients can continue to provide some types of help,

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assistance, or comfort to the caregiver, even in cases of moderate to severe dementia. The care recipient's well-being and needs should be considered along with the caregiver's, in decisions about living arrangements and care. It is important to consider whose interests are being represented when making a clinical intervention. What is good for the family may, in some circumstances, not be in the patient's best interest. The clearest example is nursing home placement, which relieves strain on families but puts the dementia patient at risk for a variety of adverse outcomes, including an increased risk of mortality (Aneshensel et al., 1995). Though often omitted from research, the patient's perspective needs to be incorporated consistently into clinical intervention. 7.22.7 RESEARCH ON FAMILY CAREGIVING The following review of the research literature focuses on the stress process and family relationships. It starts by emphasizing caregiving in its family context, and the relationships of caregiver and care recipient to one another and to other family members. One of the main secondary stressors, is then considered, that is, when there is strain or conflict between caregiving and employment. Finally, consideration is given to what is known about the effects of caregiving on physical and mental health and some of the correlates of negative outcomes. 7.22.8 CAREGIVING AND FAMILY RELATIONSHIPS In this section, attention is focused on caregivers and their family relationships. Two primary themes underlie the organization of this section. First, family caregiving arises within a long-standing, often life-long, relationship. As a result, the caregiving relationship can be seen as an extension of the prior relationship history and its associated pattern of interactions. Second, informal caregiving is best understood when considered as a system, rather than as the characteristics of a single individual or a single relationship. As suggested by the stress-process model outlined above, events within the caregiver±care recipient relationship can have consequences, both positive and negative, for other familial relationships and caregiver wellbeing. Despite the vast literature on family caregiving, surprisingly little is known about its effects on family relationships. In this section, the effects of caregiving on the relationship between caregiver and care recipient are

considered, as well as the effects of caregiving on relationships outside the primary caregiving dyad, particularly between the caregiver and his or her spouse and siblings. Most is known about caregivers who are the spouses or children of the care recipient. Siblings sometimes take care of a brother or sister, and other relatives and even nonkin may take on the caregiving role (e.g., Cicirelli, 1985, 1992), but little is known about how caregiving affects these relationships.

7.22.9 NORMATIVE FAMILY RELATIONSHIPS IN LATER LIFE Recognition of the importance of family relationships in later life has spawned a large body of research examining normative patterns of intergenerational exchanges. Overwhelmingly, this literature has demonstrated that older adults typically remain both active donors and recipients of support until very late in life. In this intergenerational context, older adults generally give more to their adult offspring than they, in turn, receive (Eggebeen & Wilhelm, 1995; Zarit & Eggebeen, 1995). Reciprocity and the balance of exchanges have received particular attention because of their potential influence on psychological wellbeing (e.g., Ingersoll-Dayton & Antonucci, 1988). Using a large, nationally representative Canadian sample, Hirdes and Strain (1995) found a curvilinear relationship between age and the balance of instrumental exchanges between generations with the greatest balance occurring at midlife. Morgan, Schuster, and Butler (1991) examined the balance of exchange between older parents and their adult offspring as a function of parents' age. They found that parental giving and receiving declined with increasing parent age, but that older adults typically continued to give more than they received beyond age 85. Unlike Hirdes and Strain (1995), who focused only on instrumental exchanges, Morgan et al. (1991) also considered emotional support, which partially accounts for these observed differences. Related to intergenerational exchanges are norms of filial responsibility. Hamon and Blieszner (1990) report that older parents and their children strongly endorse expectations of filial responsibility in times of need. There is ample evidence that these norms are robust across a wide variety of cultures and family structures (e.g., Brody, Johnsen, & Fulcomer, 1984; Chow, 1983; Fadel-Girgis, 1983; Hanson, Sauer, & Seelbach, 1983; Kendig & Rowland, 1983; Kivett & Atkinson, 1984; Maeda, 1983; Weihl, 1983; Worach-Kardas, 1983).

Normative Family Relationships in Later Life It appears that these cultural norms are readily translated into action, with relationships with adult children assuming greater importance for older adults in later life. Field and Minkler (1988) report that frequency of contact with adult children remains high from early to late old age. Whereas interactions with friends and their perceived importance decreases, satisfaction with relationships with children increases across the same period.

7.22.9.1 Family Structure and Caregiving Caregiving grows out of these normative patterns of intergenerational exchange and interaction. Strong social norms govern who is most likely to become a caregiver. By any estimation, gender is the single strongest predictor of who will become a caregiver, with women comprising approximately 70% of all caregivers (Aneshensel et al., 1995; Stone, Cafferata, & Sangl, 1987). Most research has suggested that caregivers assume their role hierarchically within the family structure. Married individuals will turn first to a spouse for assistance in times of need. In the absence of a spouse, adult children are the next choice, followed by siblings, more distant relatives, and finally neighbors and friends (e.g., Penning, 1990). Wives, daughters, and daughters-in-law are the most common female caregivers, and husbands the most common male caregivers, followed distantly by sons (Aneshensel et al., 1995; Stone et al., 1987), who are only likely to assume the caregiving role in the absence of a female sibling (Horowitz, 1985). In most caregiving situations, one person takes over the primary responsibility, providing the most help or spending the most time with the care recipient. Other family members may also provide considerable assistance. Although sons do not frequently assume the role of primary caregiver, they often give considerable help to their sisters. Similarly, a parent caring for his or her spouse will typically receive help from children. The relationships between primary and secondary caregivers are an important source of support, but can also be a focal point for conflict and disagreement (Semple, 1992). In studies of how siblings take responsibility for care tasks, Matthews (1987; Matthews & Rosner, 1988) found that family structure (birth order, number of siblings, gender composition), history of parent-child affectional ties, and extrafamilial roles (employment status, marital status, and geographic proximity) all influence which sibling provides parent care (see also Brody, 1990). In families with two or more adult daughters, shared care was the norm, whereas

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sons consistently appeared to play less central roles. According to Matthews (1995), both adult daughters and sons draw upon cultural norms for gender-appropriate behavior in shaping their caregiving behavior. Adult daughters are viewed as being primarily responsible for caregiving activities regardless of the actual division of labor, and their brothers' contributions to caregiving are seen as peripheral and unimportant. Another important distinction in the caregiving situation is whether or not the caregiver and care recipient share the same household (Chappell, 1990; Tennstedt, Crawford, & McKinley, 1993; Townsend, Noelker, Deimling, & Bass, 1989). Spouse caregivers usually live in the same household, but children may or may not live with a parent. An important source of crosscultural differences is the extent to which aged parents and their adult children share a household (SundstroÈm, 1992; Davey et al., 1996). In some countries such as the USA, rates of shared households have been relatively high, with children frequently taking in a disabled parent. In other countries, such as Sweden, twogeneration households have been quite rare. The implications of shared or separate households are considerable. A shared household probably places more continuous strain on family members and has been found to result in higher levels of stress (Townsend et al., 1989). In contrast, some different problems confront families who provide care to a parent in a different household, including needing to coordinate help that may be brought into the home, and worrying about the safety of the elder when no one is around. A special situation is trying to provide care at a long distance, which can be a source of considerable anxiety to children. Marital status of parents and their children have emerged as important predictors of caregiving and intergenerational exchange. Specifically, parental divorce has been shown to affect the quality of relationships and frequency of contact between fathers and their adult children and the frequency of contact with mothers (Webster & Herzog, 1995). In general, the effects of divorce were much greater for fathers than for mothers (Cooney & Uhlenberg, 1990; White, 1992). Disruption in adult children's marital status has also been found to relate to lower levels of help given to elderly parents, perceptions that parents need less assistance, and a lower sense of filial obligation to provide assistance (Cicirelli, 1983). A study by Brody and her colleagues (Brody, Litvin, Albert, & Hoffman, 1994) elaborates upon these findings, suggesting that

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daughters' marital status can have considerable effects on the amount of care they provide to an older parent. In particular, never-married and widowed daughters were found to provide the greatest proportion of care needed by a frail older parent by themselves. Never-married daughters, in particular, were most likely to be sole caregivers for their elderly parents. Conversely, married daughters were more likely to receive assistance with care tasks from informal sources, and divorced daughters were more likely to report using formal services. 7.22.9.2 Caregiver±Care Recipient Relationships The relationship between caregiver and care recipient is an important and often overlooked aspect of these situations. Probably the most important distinction is between cognitivelyintact people who can maintain some continuity in their relationships with caregivers, and those suffering from dementia. Providing care to an elderly relative with dementia presents stressors which differ in fundamentally important ways from situations in which cognition is spared, or recovery is possible. When comparing caregivers of people with dementia but no physical limitations to caregivers of people with functional disabilities but no cognitive deficits, Birkel (1987) found that the former experienced much higher levels of care-related stress. In a comparison of caregivers of relatives with dementia and of relatives with cancer, Clipp and George (1993) found that dementia caregivers reported poorer self-rated health, greater substance use, poorer emotional health, reduced social functioning, and poorer financial status, even when the effects of employment status, age, and duration of illness were controlled. Wright (1993) compared a small, nonrepresentative sample of Alzheimer's disease (AD) caregiving couples with well couples across a variety of dimensions. The study is unique in that she considered the perspective of both members having each report on specific aspects of their marriage. AD caregivers reported decreased companionship and difficulty dealing with changes in sexual intimacy. Wright also found that ratings of past marital happiness were associated with current valuing of the afflicted spouse as a unique individual, but not with future commitment, which was lower among caregiving spouses. Majerovitz (1995) found a relationship between family adaptability and outcomes for caregivers of dementia patients. Caregivers who reported high adaptability in their families had lower depression, even when there were high

levels of care-related stressors. She also reported that low-adaptability spouses were more likely to cling to an unrealistic role for their cognitively-impaired spouse, expecting their partner to continue to meet former expectations. While these data are cross-sectional, they suggest that caregivers with more realistic expectations of their demented spouse are likely to experience fewer negative consequences as a result of the care they provide. In spousal relationships, relationship quality between the caregiver and care recipient may also play a role in the decision to institutionalize. Pruchno, Michaels, and Potashnik (1990b) found that spouses reporting a better quality of relationship with the care recipient reported less desire to institutionalize, but this finding did not extend to actual decisions regarding institutionalization. By the same token, however, desire to institutionalize was a strong predictor of actual institutionalization, suggesting that an indirect link may exist. These findings offer support to the idea that there is something uniquely debilitating about losing a spouse to dementia as compared to another terminal illness in which cognitive functioning is typically spared. Because dementing illness results in deterioration in cognition and behavior, patients lose the ability to participate in the family or to have a say about the course of their own care. Caregiving becomes completely one-sided, with the patient unable to reciprocate in any way and, often, unable even to acknowledge the help that is provided. The progressive course of these disorders means that families face a somewhat predictable pattern of deterioration. Care of patients who are cognitively intact is not without its stresses; rather, care demands do not have the unrelenting pattern found in dementia and care recipients can acknowledge and show appreciation for the assistance they receive. Families caring for someone with another type of major psychiatric disorder may experience similar levels of distress as caregivers of dementia patients (Pearson, Verma, & Nellett, 1988). It may be that disorders which involve behavioral and emotional disturbances, and which are more disruptive of the usual family relationships, have the greatest impact on caregivers. The past relationship between children and their parents has considerable influence on caregiving experiences. Feelings of attachment and obligation have both been found to predict the amount of help daughters provided to their older parents (Cicirelli, 1993). Those who reported stronger feelings of attachment experienced lower levels of burden, whereas those who reported higher levels of obligation experienced higher levels of

Normative Family Relationships in Later Life burden. Thus, children providing care out of a sense of obligation rather than affection may experience greater negative consequences as a result. There are other important implications of the quality of prior relationships for the caregiving experience. Caregivers with a poor relationship with the care recipient are less likely to assume the caregiving role and, if they do, to experience more stress within it (Whitlatch & Noelker, in press). In an intriguing study by Uchino, Kiecolt-Glaser, and Cacioppo (1994), higher ratings of pre-illness affection for the care recipient were associated with lower heart rate reactivity, a physiological indicator of stress, measured two years later. Walker, Martin, and Jones (1992) examined the role of intimacy in predicting adult daughters' and mothers' perceived costs and benefits of caregiving. Adult daughters' feelings of intimacy were associated with fewer feelings of having insufficient time for extra-caregiving activities, less frustration with caregiving, and less anxiety about providing care. For mothers receiving care, intimacy was related to less anger and resentment about the care they received. Other research has found conflict in the caregiver±care recipient relationship to be associated with greater caregiver strain and negative affect (Sheehan & Nuttall, 1988). Townsend and Franks (1995) found that adult childrens' perceptions of relationship quality with their parent was an important mediator between the parent's cognitive impairment and the adult child's well-being. In their study of 90 adult±child caregivers, perceived closeness was associated with lower levels of reported caregiver burden and a greater sense of caregiving efficacy. Their study also underscores the importance of conflict in the relationship, which was associated with higher levels of stress, efficacy, and depression. While most research has examined quality of the relationship, Aneshensel and her colleagues (1995) looked at the extent to which caregivers reported the loss of their relationship with a relative suffering from dementia. As their relative's disease progressed, caregivers reported a greater loss of the relationship. This sense of loss continued to play a role even after the patient's death. Caregivers who had previously reported a greater loss recovered more quickly than those who still held onto the relationship. One extreme outcome of a poor relationship between caregiver and care recipient is violence directed toward the elderly care recipient. In a study of 236 caregivers to a relative with dementia, Pillemer and Suitor (1992) examined predictors of violence and violent feelings

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toward the care recipient. With regard to care recipient characteristics, they found that both violent behaviors and disruptive behaviors were associated with caregivers' greater fear of becoming violent with their relative. Violent behaviors by the care recipient were also associated with a greater likelihood of actual violence on the part of the caregiver. Caregivers who lived with their relative were more likely to report being afraid of acting violently toward their relative, and spouse caregivers were more likely to have acted violently toward their relative than adult children. Thus, there is evidence to suggest that aspects of the past and present relationship quality between caregivers and care recipients play an important role in the caregiving experience, and that these characteristics have an effect, for both spouses and adult children, on the burden experienced as a result of caring. 7.22.9.3 Social Support from Family and Other Informal Sources One of the most important sources of help to caregivers is the assistance and emotional support provided by other family members. Although actual estimates vary widely, there is general consensus that a majority of caregivers have support in their role from a secondary caregiver (e.g., Aneshensel et al., 1995; Stone et al., 1987; Tennstedt, McKinlay, & Sullivan, 1989). Social relationships can also involve conflict, and it has been suggested that negative social interactions can have greater impact on satisfaction with social support than measures of support received from others (e.g., Krause, 1995). In many instances, the same relationship can be a source of support and conflict. Clipp and George (1990a) report considerable stability in the social support caregivers receive over a one-year period. They also report a lack of relationship between objective needs (dementia symptoms, duration of caregiving) and social support received. In other words, some families provide support whether the need for help is great or small, while other families do not help much at all, whatever the circumstances. Thompson and colleagues (Thompson, Futterman, Gallagher-Thompson, & Lovett, 1993) examined potential differential effects of various types of social support in predicting measures of caregiver burden. Reduced social participation with friends and family was the most consistent social support predictor of the burden indicators they considered (see also, Haley et al., 1995). Specifically, higher levels of social participation were associated with lower levels of burden, having a less restricted social

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life, and a less negative relationship with the care recipient. That social support may also come with associated costs to caregivers was also indicated by their research. Caregivers who received material aid or financial assistance tended to report more negative interactions with family and friends. Using longitudinal data, Aneshensel and her colleagues (1995) expanded on this theme that different types of support are related to different outcomes. Using the stress process model described earlier, they found that instrumental support from informal helpers (family and friends) can contain the experience of overload that results from primary stressors, whereas emotional support is not effective to this end. Similarly, instrumental support reduces proliferation of stress into other important roles held by the caregiver, such as work. Emotional support appears to be most effective in containing the effects of stress on outcomes such as depression. For caregivers who are married, their relationship with a husband or wife can be both a source of support or a point of increased strain, as they experience conflicting demands on their time and energy. In an intriguing study, Creasey and his colleagues (Creasey, Meyers, Epperson, & Taylor, 1990) investigated how caring for a parent or parent-in-law with AD affected the relationship between husband and wife with each other and with their parents and children. Women caring for a parent (or parent-in-law) experienced a loss of support both from their husband and parent. Support from their own children, however, was not affected by caregiving, nor did their involvement lead to increases in negative interactions with their spouse or parent. Their husbands reported less support from parents, but not from wives or children. Suitor and Pillemer (1992; see also Franks & Stephens, 1996) found, not surprisingly, that when husbands provided emotional support to caregiving wives, marital satisfaction was higher. Conversely, marital satisfaction was lower when husbands hindered their wives' caregiving in some way. Caregiving grows out of a relationship with a long history and previously well-established expectations for interactions. There is evidence that this history has a substantial influence on the caregiving experience. As the nature of the caregiver±care recipient relationship changes, positive and negative interactions in other important family relationships can also be found. How much the support from others helps caregivers depends on how and what type of support are given, in a complex, but comprehensible fashion. Support from family and friends is a readily available resource for

caregivers, which is not limited to the working hours of formal service agencies, nor bound by bureaucratic rules. Finding ways to increase support to caregivers while reducing conflict is an important goal for clinical intervention, as we shall discuss later. 7.22.10 SECONDARY STRESSORS: COMPETING ROLES AND STRESS PROLIFERATION Caregivers have dimensions in their lives outside the demands of caregiving. These other roles can create additional stress on the caregiver, or they can help to alleviate the stress of caregiving, depending on the nature and quality of these outside roles. In the model guiding this chapter, these outside influences fall under the term secondary stressors. Secondary stressors contain both role strains and intrapsychic strains. Role strains may arise from family, work or informal responsibilities outside of the caregiving situation, but are generated or aggravated by the demands of caregiving (Aneshensel, Pearlin, & Schuler, 1993). These stressors include family conflict, work-caregiving conflict, and economic strain. Intrapsychic strains involve dimensions of selfconcept and psychological states. There are two main hypotheses regarding the effect of different roles on the well-being of a person. The scarcity hypothesis proposes that additional roles create strain. Goode (1960) introduced the concept of role strain, or the difficulty in meeting expected role demands. In this view, role strain is seen as normal and even inevitable; therefore, the task for everyone is to discover ways to reduce this strain. This corresponds to the competing commitment perspective within the caregiving literature. This concept focuses on the time dimension of the conflicts among multiple roles, and assumes that the other roles of caregivers create further demands on the caregivers' time (Stoller & Pugliesi, 1989). In contrast to the scarcity hypothesis, Sieber (1974) introduced the expansion hypothesis, that there are positive effects of accumulating additional roles. Even though the obligations of a role may be taxing, the rights gained within that role may negate any detrimental outcomes that might occur because of the acquisition of the role. One way in which multiple roles might compensate for role strain is by allowing people to fall back on successes in one role if they fail within another. A number of studies have found that occupying multiple roles is associated with better overall well-being (Thoits, 1983; Verbrugge, 1983).

Secondary Stressors: Competing Roles and Stress Proliferation One important focus of multiple roles is on daughters who balance caregiving with being a wife and mother. Studies by Stephens and her colleagues (Stephens, Franks, & Townsend, 1994; Stephens & Franks, 1995) have identified both positive and negative consequences of these multiple roles. An important feature of these studies is that they examine how each role has stresses and rewards, which affect how one role might affect the other. Both stress and rewards in the role of mother were associated, respectively, with positive and negative affect reported by caregivers. Stress and rewards in the role of wife were also associated with ratings of physical health. Quality of the marital relationship can also have important consequences for the effects of caregiving on adult daughters, and vice versa. Stephens and Franks (1995) examined positive and negative perceptions that one role (either caregiving or spousal) had affected the other (ªspilloverº). Whereas positive spillover from the role of wife to caregiver was only related to higher levels of marital satisfaction, positive spillover from the caregiver to wife role was associated with lower levels of depression and greater positive affect. Conversely, negative spillover from wife to caregiver roles was associated with less positive affect and lower marital satisfaction; negative spillover from caregiver to wife roles was associated with significantly greater depression. The main area in which these competing hypotheses about multiple roles have been explored is work and caregiving. Work has a central role in many people's lives and the difficulties that balancing work and caregiving responsibilities pose make it a particularly challenging issue. The rapid increase in the number of working women in first-world nations has made work and caregiving conflict an important social issue, as well as a consideration in clinical situations. An unusual longitudinal study of work and caregiving documents the increased rate at which women are combining both roles. This study examined a group of women who were originally interviewed in 1956 and then interviewed again 30 years later about caregiving histories (Moen, Robison, & Fields, 1994). Over 60% of the women in the study were caregivers to relatives with disabilities at some time in their lives. In this study, women were as likely to combine working and caregiving as they were to be only caregivers. Women seem to be adding to their roles rather than giving up a role when a new role must be acquired. Working and caring for an elderly relative produces some special challenges and issues. When studying mothers and their daughter caregivers, Brody and Schoonover (1986) found

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that mothers received the same amount of help whether their daughters worked or not. But when employed women were compared with their nonemployed sisters, significant differences were found in the amount of help given when their parents' functional status was poor, with working women providing less assistance (Matthews, Werkner, & Delaney, 1989). Working women, then, are often providing extensive help in the caregiving role, but there are limits to their ability to help, which become evident in situations involving more extensive disabilities. The question of whether an employed woman should make adjustments to her employment situation or quit her job is one that many caregivers face. A sizable number of caregivers leave their jobs within three months of becoming a caregiver (Franklin, Ames, & King, 1994). Leaving a job or reducing work hours is the most dramatic change that a caregiver can make in order to deal with the competing demands of work and caregiving. Workers generally try to rearrange their schedules or reduce their hours before leaving the job (Mutschler, 1994). There are many different factors that contribute to the decision or need to leave a job because of caregiving responsibilities. Caregivers who leave their jobs or reduce their work hours tend to have relatives who have more severe disabilities (Brody, Kleban, Johnsen, Hoffman, & Schoonover, 1987) and have faced work constraints for a longer period of time (Mutschler, 1994). Reports of strain are common among working caregivers (Mutschler, 1994; Scharlach & Boyd, 1989). But there is the question of what contributes to that strain. The four main predictors of conflict between work and caregiving are: (i) the elderly family member's emotional health; (ii) the number of caregiving tasks performed by the caregiver; (iii) the presence of children in the caregiver's residence; and (iv) having caregiving responsibilities when beginning at the current job (Gibeau & Anastas, 1989). In addition, sociodemographic variables such as the employee's gender, marital status, household income, job status, occupation, and flexibility of work schedule are related to employees' levels of absenteeism and stress (Neal, Chapman, Ingersoll-Dayton, Emlen, & Boise, 1990). Other studies have found that the severity of disability of the elderly relative and the intensity of the caregiving responsibilities are related to work and caregiving conflict (Gibeau & Anastas, 1989). Beyond the simple distinction between working and nonworking caregivers, the type of occupation has an effect on strain or burden. Mutschler (1994), for example, reports that production workers have less opportunity to

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adjust their work and care demands than workers in executive, sales, or clerical positions. The relationship between experiences in the employment role and caregiving stress may be more complicated than originally thought. As was the case when balancing roles of caregiver, mother, and wife, the dual commitments of work and caregiving involve rewards as well as stress. High satisfaction with work seems to be associated with fewer depressive symptoms, except for those caregivers who experience high levels of caregiving stress (Martire, Stephens, & Atienza, 1997). The number of hours that a caregiver worked is associated with negative outcomes under conditions of high caregiver stress. Martire, et al. (1997) also found that women working part-time experienced poorer physical health and less positive affect than those women who were working full-time. One reason for this may be the increased amount of time that full-time workers are away from the impaired relative (Brody, 1990; Scharlach, 1994). Another reason may be that full-time work provides greater knowledge, benefits, and support (Matthews et al., 1989). Workers tend to be interested in work benefits that are designed to make work and caregiving easier. The ideas for benefits that generated the most interest were respite care, flexible work hours, reduced hours without reduced benefits, adult day care, and job sharing. Caregivers using formal services understood that the availability of those services was critical if they were to maintain their employment and meet their family member's need for care (Gibeau & Anastas, 1989). In summary, the findings from research on competing roles indicate that the additional roles that a caregiver occupies can result in both stress proliferation and containment. In order to get a complete understanding of the challenges that the caregiver faces, it is necessary to understand the quality of the roles and the rewards as well as stresses that the various responsibilities bring. Advising a caregiver, for example, to reduce her work responsibilities before having a clear picture of the entire caregiving situation would be ill advised. Rather, the challenge in clinical situations can be to find ways to balance competing roles more effectively and to minimize the spillover of stress from one activity to another.

7.22.11 OUTCOMES OF CAREGIVING: HEALTH AND MENTAL HEALTH EFFECTS Caregiving is a uniquely stressful event. Being a long-term caregiver has been found to be

associated with a variety of negative outcomes. The consensus among studies examining physical and mental health outcomes is that a majority of caregivers report feeling physically and emotionally distressed (Anthony-Bergstone, Zarit, & Gatz, 1988; Brodaty & HadziPavlovic, 1990; Clipp & George, 1990b; George & Gwyther, 1986; Haley, Levine, Brown, Berry, & Hughes, 1987; Kinney & Stephens, 1989). Several studies report higher levels of psychological morbidity among caregivers compared to noncaregiving samples of the population. Anthony-Bergstone and her colleagues (1988) noted the increased feelings of hostility, anger, and anxiety among caregivers as compared to the general population. An Australian study showed that mean scores on the General Health Questionnaire (GHQ), a measure of psychological morbidity, were higher in the caregiving sample and among caregiving spouses than the general population or other subsamples of caregivers (Brodaty & Hadzi-Pavolovic, 1990). Women caregivers generally report higher levels of psychological distress than men (Anthony-Bergstone et al., 1988; Zarit & Whitlatch, 1992). Schulz, Visintainer, and Williamson (1990) reviewed several studies showing the psychiatric morbidity effects of caregiving. In studies using self-report measures such as the Beck Depression Inventory (BDI) or the Center for Epidemiological Studies Depression Scale (CES-D), three general conclusions emerged. First, greater severity of the care recipient's problems is linked to more depressive symptomatology. Second, women have higher rates of depression than men. Third, the more representative the caregiving population, the lower the rate of depression. Thus, caregivers drawn from specific subsamples such as daughters taking care of severely demented relatives or those seeking help from a service program show higher rates of depression symptoms. A second group of studies has used clinical assessment tools (e.g., the Schedule for Affective Disorders and Schizophrenia Interview) which yield rates of clinical diagnoses of depression and other problems. These studies have found that caregivers frequently meet diagnostic criteria for depression or other diagnoses (e.g., Cohen & Eisdorfer, 1988; Drinka, Smith, & Drinka, 1987; Goldman & Luchins, 1984). In one of the most comprehensive studies of this kind, Gallagher and colleagues (Gallagher, Rose, Rivera, Lovett, & Thompson, 1989) found prevalence rates for depression ranging from 31% for men to 46% for women. These studies provide strong evidence that caregivers are at risk of increased psychiatric symptoms and clinical disorders.

Outcomes of Caregiving: Health and Mental Health Effects The model of the stress process described earlier in the chapter illustrates how primary and secondary stressors can have a cumulative effect on caregiver mental well-being and physical health. Among the primary stressors, behavior problems are most likely to lead to adverse outcomes for family caregivers. The common behavior problems identified by caregivers as difficult or stressful for them are incontinence of the bowel and/or bladder, crying easily, hiding things, acting restlessly or agitated, and becoming irritable, angry, or accusatory (Haley & Pardo, 1989). These behavioral problems require vigilance, surveillance, and control on the part of the caregiver. Pruchno and Resch (1989) found that asocial and disoriented behaviors on the part of the care recipient are associated with greater burden, decreased social participation, and less satisfaction with caregiving. For forgetful behaviors, the consequences for caregiver's mental health increase at first, and then diminish as the severity of behavior problems increases, suggesting a curvilinear relationship between the two. In a study of depression in dementia caregivers, Redinbaugh, MacCallum, and Kiecolt-Glaser (1995) found that caregivers who experienced chronic depression over a three-year period reported their relative's behavior as more problematic, and had higher levels of upsetting social support than nondepressed caregivers or caregivers who had experienced a transient depressive episode during the course of the study. Vitaliano and colleagues (Vitaliano, Young, Russo, Romano, & Magana-Amato, 1993) were interested in examining the possibility that caregiver behaviors, specifically in the form of expressed emotion, were predictive of subsequent care recipient behaviors one and a half years later. Controlling for initial levels of problem behaviors, dementia patients who were cared for by an individual with high levels of expressed emotion displayed significantly more negative behaviors at follow-up. These findings are significant because caregiver expressed emotion is correlated with higher levels of depression, suppressed anger, and lower life satisfaction (Bledin, MacCarthy, Kiupers, & Woods, 1990; Vitaliano et al., 1993). Burden, guilt, inadequacy, and negative perceptions of patient mood and functioning are words that describe the motivation to engage in caregiving activity (Hadjistavropoulos, Taylor, Tuokko, & Beattie, 1994). Lack of time, lack of help, and difficulty in managing patient behavior describe the caregiver's ability to engage in the caregiving process. These stressors have a cumulative impact on caregiver well-being.

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Two broad domains have been investigated for the extent to which they buffer or contain the stressors of caregiving: social support and coping. The role of social support was reviewed earlier. Coping resources potentially represent an important way of containing stress. Research in this area has identified some promising leads on what type of coping strategies are more effective, but limitations in current research make it difficult to draw firm conclusions. Pruchno and Kleban (1993) studied the relative effectiveness of emotion-focused vs. problem-focused coping strategies in mediating stress experienced by caregivers to an institutionalized relative. Their findings suggest that, contrary to coping research in other caregiving contexts (e.g., Stephens, Norris, Kinney, Ritchie, & Grots, 1988), emotion-focused coping was associated with better mental health than problem-focused coping. These findings highlight the importance of recognizing caregiving as a chronic stressor which is less amenable to change than many other situations. As a result, caregivers may be more successful if they focus on dealing with their responses to the situation than if they take a more traditional, instrumental approach. Williamson and Schulz (1993) examined the relationship between a number of coping strategies and the burden experienced across three domains of the caregiving relationship: dealing with memory deficits, loss of communication, and the decline of a loved one. Their results suggest that different strategies are more and less successful, depending on the specific domain. Use of wishfulness as a coping strategy was related consistently to the experience of greater burden for all three stressors considered. Similarly, use of direct action strategies in response to memory deficits was associated with greater depression. Strategies which are more successful for caregivers included using relaxation as a way of coping with memory problems and seeking support to deal with loss of the relationship with the care recipient. Finally, acceptance of the situation was associated with lower depression related to loss of a loved one and loss of communication. Gignac and Gottlieb (1996) considered caregivers' use of 12 kinds of coping strategies in dealing with specific behavior problems exhibited by the care recipient. They found considerable variation in the kinds of strategies caregivers used over a five-month period, suggesting that caregivers modify their approach to dealing with stressors over time. Caregivers who focused on gaining insights into how their coping strategies affected the relationship with the care recipient, both in attributing behavior problems to the disease process and in

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understanding the contingencies between caregiver and care recipient behaviors reported lower levels of stress at follow-up, even when initial levels of stress were controlled. Thus, the effects of coping are complex. Strategies which attempt to change elements of the disease process are unsuccessful and perhaps even harmful. Conversely, strategies which focus on acceptance of changes in the caregiver± care recipient relationship appear much more helpful. Again, support seeking can be helpful in this regard. One of the most comprehensive examinations of the determinants of mental health problems of caregivers was conducted by Aneshensel et al. (1995). Using a longitudinal panel of caregivers of dementia patients, they were able to examine how changes in stressors were related to increased or decreased mental health symptoms over a four-year period of time. Stress proliferation took place when primary stressors, such as behavior problems or ADL disabilities, led to feelings of overload or role captivity (see above). Thus, there needed to be both the occurrence of specific care-related problems and a subjective sense that those problems were overwhelming. In those instances, secondary stressors such as work or family conflict were more likely to emerge, as were mental health problems. In turn, receiving more informal social support from family and better coping, specifically higher feelings of mastery, resulted in some containment of stress. These results suggest that both objective indicators of the patient's disabilities and caregivers' subjective evaluation of their impact are needed to understand the processes leading to depression and other mental health problems. Reports that caregiving is associated with high rates of psychiatric symptoms are probably not surprising, given the multiple pressures experienced. More intriguing are the results of studies which suggest that caregivers may be at risk of poorer health or even increased risk of mortality. There is less consistency across studies in reporting health effects, but sufficient evidence has been found to suggest there is at least some risk. Studies of the effects of caregiving on health generally focus on self-reported problems, although a few investigations have used more objective indicators. Caregivers generally report they are in poorer health than age-matched controls (e.g., Pruchno & Potashnik, 1989; Schulz et al., 1990). In a nationally-representative sample from the USA, one-third of women caregivers reported fair or poor health compared to only one-fifth of age-matched peers (Stone et al., 1987). Other studies (e.g., Haley et al., 1987; Pruchno & Potashnik, 1989) have

found that caregivers visit their physicians more often and use more prescription drugs compared to noncaregivers. These results, however, have not been confirmed in other studies of medical service use (e.g., George & Gwyther, 1986; Kiecolt-Glaser et al., 1987). Finally, several studies have found specific increases in health problems, such as respiratory illnesses, hypertension, and cardiovascular disease (Moritz, Kasl, & Ostfeld, 1992; Schulz et al., 1990; Wright et al., 1993). Undoubtedly, the response of caregivers to chronic caregiving stress can follow the patterns of the general adaptation syndrome (Selye, 1976). Caregivers are exposed to a great deal of rage, grief, despair, and other intense emotions that can have effects on the blood and heart as well as clinical depression and anxiety. Caregivers may also exert a great deal of physical effort that can raise blood pressure and initiate atherosclerotic responses. The most common risk factors for health problems include being a spouse caregiver (Wright et al., 1993), living arrangements (Pratt, Wright, & Schmall, 1987), financial strain, and the intensity of primary stressors and secondary stressors. As stated before, these risk factors become detrimental to health when they are chronic. One of the most intriguing findings linking chronic stress to health problems is that caregivers of dementia patients may experience changes in immune system functioning. In investigations which examined caregivers and a sample of matched controls, Kiecolt-Glaser and her colleagues (Keicolt-Glaser et al., 1987; Kiecolt-Glaser, Dura, Speicher, Trask, & Glaser, 1991) found that caregivers had poorer immune function, and these changes were linked to higher rates of illness in some subjects. Caregivers' health problems may increase due to compromised self-care and health behavior (Brodaty & Hadzi-Pavlovic, 1990; Kwee, Zarit, Edwards, Davey, & Jarrott, 1995; Lieberman & Fisher, 1995). Caregivers may not go to the doctor when ill, or may not get enough rest or exercise. Nutritional intake can be affected, with some caregivers not getting adequate nutrition and others eating too much. Other caregivers may smoke more, use alcohol excessively, or even take tranquilizing medications prescribed for the patient. Consistent with the stress process model, compromised health behavior follows a model of competing demand whereby caregivers are faced with dwindling resources of energy, time, and money, and so must choose between self-care and care of their relative (Kwee et al., 1995). Often, caregivers feel no choice but to neglect their own health to continue to give care to their loved one (Bunting, 1989). Neglected self-care then acts

Respite Services as a mediating variable between stressors and the outcome of physical and mental health. The process by which mental and physical health are affected as a result of caregiving stressors is admittedly complex. Uncertainties in causal directionality of independent and dependent variables and the possible existence of feedback loops due to the dynamic nature of an elder's disabilities add to the difficulty of making causal statements. Based on findings of the research, a theoretical model can be summarized as follows: the relative's illness creates the environment of primary stressors that proliferate or spillover to the creation of secondary stressors. Primary stressors, as represented by the mental and physical hardships of caregiving (e.g., motivation and ability), have both a main effect and a mediated effect (through secondary stressors) on caregiver mental and physical health. The secondary stressors that result are manifested through the caregiver's inability to take proper physical and mental care of him/ herself because of a lack of energy or time. Prolonged exposure to primary and secondary stressors affects well-being. Research suggests a lagged relationship between depression and physical health, with depression leading to greater levels of physical illness (Pruchno, Kleban, Michaels, & Dempsey, 1990a). In this framework, healthfulness is the result of continually achieving the best possible adaptation to the environment and involves interdependent physical, psychological, and social aspects (Capra, 1982). Illness occurs if stress pushes the system away from balance in response to environmental influences. To regain balance, the individual depends on his/her physical and mental response mechanisms. Because of the extensive demands that caregiving places on primary caregivers, it is not surprising that some fail to adapt to changing environmental situations and so experience severe disruption and breakdown. The challenge now is twofold: to identify the factors that protect good health in caregivers, and to design interventions that alleviate chronic stress at points in time before the body becomes ill. Although the negative outcomes of caregiving have been emphasized, these adverse effects are sometimes balanced by positive experience. Feelings of gain, a growing sense of competency, or satisfaction with having met one's obligations or done a job well can offset the negative consequences (Aneshensel et al., 1995; Lawton, Brody, & Saperstein, 1989a). For some caregivers, fulfilling an obligation in the ways they define it is more important than putting themselves at risk of health problems or depression. Clinicians need to recognize that these commitments represent deeply-held

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beliefs, and not neurotic guilt (although that can be a motivator for some people). Successful clinical interventions involve helping caregivers explore and sometimes redefine their commitments, rather than confrontation over what the clinical decides is inappropriate or irrational. Solutions may also involve finding better ways of fulfilling a commitment, as described in the following sections. 7.22.12 CLINICAL RESEARCH AND SERVICES The unprecedented stress associated with family caregiving warrants an organized response to help share a portion of the burden. At the broadest level, it is in the interest of society to encourage families to provide care, since that reduces the demand for more expensive institutional care. From the care recipient's perspective, being cared for at home for as long as possible is usually preferred. Families as well usually prefer to do as much as they can to help older family members. Clinical interventions can be organized with two goals in mind. Interventions can be used to bring in new resources in ways that directly relieve families of a portion of their responsibilities. Respite services such as adult day care or home help serve this function. The most extensive new resource is an institutional setting, which takes over most of the care. Interventions can also build up the caregiver's own abilities for managing the situation more effectively. The review that follows, will look first at respite services, including institutional care, and the benefits and drawbacks for families. It will then consider clinical interventions for caregivers. 7.22.13 RESPITE SERVICES Respite services for caregivers of elderly relatives with dementia are widely advocated by professionals and sought after by caregivers. While there is no clear definition of what services comprise respite, day care, in-home help, and short- and long-term institutionalization are some of the most frequently used services. Respite is designed to serve both caregiver and patient. With the growing awareness that institutional care is often not optimal for older people, respite services have been promoted as a means by which impaired elders could remain in the community longer while reducing the cost of care provision. Despite reports of high satisfaction with respite services (e.g., Burdz, Eaton, & Bond, 1988; Kosloski, Montgomery, & Borgotta 1990;

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Lawton et al., 1989a, 1989b; Montgomery & Berkeley-Caines, 1989; Montgomery & Borgatta, 1985), there has not been much evidence of the benefits for caregivers or patients. Some investigations have found little impact of respite services, leading to the suggestion that these programs may be of no value to the family (Callahan, 1989). These negative findings, however, may be the consequence of poor programing or low or inconsistent levels of service utilization. This section describes different respite services and considers outcomes of and obstacles to utilization.

7.22.13.1 Adult Day Care Adult day care programs are designed for individuals with dementia or other mental or physical disabilities. They provide the patient with a few hours of supervised, structured activity, and give the family caregiver time to rest or perform other chores and responsibilities. Typically an individual will attend a day care program two to three days each week for about five hours each day (Weissert et al., 1990). Program activities include orientation exercises, socializing, and reminiscing. Programs frequently provide services such as health screening, podiatrist and eye doctor visits, and prescription administration. Out-of-home care allows the caregiver to stay at home and enjoy their privacy or have time with other family members (Montgomery, 1995). Day care gives the patient the opportunity to meet others and have a change of scenery and activities while remaining in a safe environment. Despite reports that caregivers are very satisfied with day care (Burdz et al., 1988; Lawton et al., 1989a, 1989b; Miller, Gulle, & McCue, 1986; Sands & Suzuki, 1983), benefits for the caregiver are equivocal. Some research supports the idea that day care usage results in improved physical and mental health, better relationships, and increased confidence in caregiving abilities among family caregivers (Montgomery & Borgatta, 1985; Scharlach & Frenzel, 1986). Other studies, however, have found that day care has little or no effect on caregiver burden or well-being (Burdz et al., 1988; Lawton et al., 1989b; Montgomery & Borgatta, 1989). The effects, or lack thereof, of day care programs on caregiver burden may depend on the characteristics of the individual in the caregiving situation (Montgomery, 1995). Caregivers' employment, health, or responsibility for another family member could affect utilization and mediate the benefits of a day care program. Failure to find benefits may also be due to low

utilization of programs. For example, Lawton et al. (1989a) found no effects of program participation on caregiver burden, but the caregivers in the program utilized day care less than once a month. Inability to control how much families utilize day care prevents firm conclusions being drawn about the benefits of adult day care. Some caregivers find the programs too inaccessible (MaloneBeach, Zarit, & Spore, 1992), and some relatives would rather remain at home. Preliminary results from a large-scale trial of adult day care for dementia are more promising (Zarit, Stephens, Townsend, & Greene, 1996). In this study, caregivers received adequate amounts of respite (at least two days per week) from well-developed programs with expertise in care of dementia patients. Measures were also developed to be specific to the strains likely to be addressed by this kind of respite care. Results showed that caregivers using day care experienced lower feelings of overload, decreased anger and depression, and increased well-being compared to a control sample not receiving day care or other respite services. These results suggest that well-designed day care programs may relieve stress on caregivers.

7.22.13.2 In-Home Respite Respite services provided in the home include attendance to the patient's physical needs, such as bathing and feeding, and ªsittingº with the patient, either for a short period or overnight. Providers may include a companion, homemaker, home health aide, or a nurse (Isett, Kraus, & Malone, 1984). Levels of in-home care can be low or high, for a short or an extended period of time. Home respite is intended for patients who still live alone and need assistance, and for the coresiding caregiver of a more dependent patient. Reports on benefits of in-home respite for the caregiver are generally positive. In-home care eliminates the need for transportation and may be scheduled with some flexibility (Montgomery, 1995). Benefits of in-home respite for the caregiver include improved mood (Gwyther, 1989) and decreased time spent in caregiving activities (Berry, Zarit, & Rabatin, 1991). In addition to being satisfied with in-home help, caregivers usually want more of it. At the conclusion of a 12-month program during which respite services were available, Lawton et al. (1989b) found that all caregivers in the study wanted more respite than any other class of services. MaloneBeach et al. (1992) also reported that caregivers wanted more help in the home.

Respite Services Caregivers using in-home help have also voiced concerns with the services provided. Complaints about in-home help have focused on the qualifications, reliability, and continuity of respite providers, and availability and flexibility of scheduling (MaloneBeach et al., 1992; Montgomery, 1995). Obstacles to use of in-home respite include bureaucracy and disengagement of the caregiver from the service system (MaloneBeach et al.). Caregivers report that the structure of the service system is too narrow as it often does not meet all of the patient's or caregiver's needs. Caregivers also report that the system is unaccommodating of changes in patients' conditions unless they fit into the service levels of a schedule fixed by the respite program. These studies, which were conducted in the USA, may not capture caregivers' experiences in countries that provide better access to and coordination of services. Although many consider in-home respite a means by which family caregivers may keep their relative with dementia in the community longer, use of respite is sometimes associated with short- or long-term institutionalization (Montgomery 1995; Montgomery & Borgatta, 1985; Montgomery & Kosloski, 1990). Lawton et al. (1989b) reported that caregivers who spent the most time and effort caregiving were most likely to use respite, particularly nursing home respite. As caregivers learn to be more comfortable sharing the burden of caregiving, it may become more acceptable to them to place their relative in an institution (Montgomery, 1995). An alternative explanation is that respite services are a stepping stone to institutionalization in the progression of the patient's illness.

7.22.13.3 Institutionalization and its Consequences Short-term institutionalization offers overnight respite for family caregivers and provides skilled nursing for the patient. A short-term admission may be scheduled every couple of weeks for two to three nights or less frequently for one to two weeks (Montgomery, 1995). While short-term institutionalization offers the benefit of an extended period of respite, it tends to be less flexible than in-home care. Institutions cannot usually offer emergency respite because of the cost of keeping a bed free (Scharlach & Frenzel, 1986). Some patients have difficulty adjusting to a new environment (Mace & Rabins, 1981), and some will resist institutional respite for fear that it is a permanent placement (Montgomery, 1995). In a study of two weeks of institutional respite, Burdz et al. (1988) expected dementia patients to show increased problems

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due to the confusion of being in a new environment. The patients, however, demonstrated significant decreases in problem behaviors, and caregivers rated the program as highly beneficial, though few said their situation had improved after the program. Even with an extended break from caregiving, short-term institutionalization frequently precedes longterm placement (Montgomery & Borgatta, 1989). Placement of a relative in a long-term care facility may be viewed as a final release of caregiver stress and responsibility, but it is accompanied by its own stressors (Townsend, 1990; Zarit & Whitlatch, 1992). Institutionalization may ease some of the strain of everyday care, but many caregivers continue to provide assistance even after transferring their relative to an institution. While primary stressors such as feelings of overload decrease following placement, feelings of depression and other mental health indicators are often unchanged (Zarit & Whitlatch, 1992). MaloneBeach et al. (1992) found that family caregivers with a relative in a nursing home reported that their relative still needed additional services not provided in the nursing home. Caregiving strains may persist for as long as four years after placement (Aneshensel et al., 1995). The high levels of satisfaction which caregivers report with all respite services is encouraging. However, the results of empirical studies indicate that respite services do not reduce caregiver burden and stress consistently. A major problem in these studies has been low rates of use of services, which is often related to barriers to or problems in service delivery. Availability and accessibility is another obstacle to service utilization. For example, waiting lists at US day cares are more common than in Sweden where the municipality provides sufficient access to day programs (Jarrott, Zarit, Berg, & Johansson, 1996). Flexibility of scheduling and services are essential, along with personal contact with a case worker and regular care providers. Once caregivers are taken off a waiting list and admitted to a program, many patients attend sporadically because hours or transportation are inconvenient (Montgomery, 1995). Cost and clear guidelines on qualifications for different services need to be provided along with the support which permits all those in need of assistance to receive it. Despite caregivers' concerns about respite programs and the inconsistent findings of benefits, families overwhelmingly say it is important to them and most would like more respite. Respite services may need to be considered for their long-term effects

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(Fortinsky & Hathaway, 1990). Greene and Coleman (1990) suggest that available services may serve a preventive function, so that stress on the family does not reach an overwhelming level. Other families, however, consider caregiving a personal responsibility and only look for assistance when they have reached their own limits. More active recruitment of family members early in their caregiving career may result in greater long-term relief from burden and stress. Perhaps when caregivers feel more comfortable turning to respite services for assistance, utilization will be greater and effects will be evident. 7.22.14 CLINICAL SERVICES Clinical protocols have been developed to lower stress on family caregivers by increasing their ability to manage care-related problems and improving their access to help from other family members and from formal services (e.g., Zarit, Orr, & Zarit, 1985; Zarit, 1996). These interventions build on existing research by identifying modifiable aspects of the stress process. As observed, behavior problems do not have a fixed or constant effect on caregiver outcomes. By improving how caregivers manage behavior disturbances, the impact of these problems will be reduced and caregivers will experience less stress. Similarly, increasing support from and reducing conflict with other family members should lead to improvements in the caregiver's situation. A model for clinical interventions is shown in Figure 2. As with any intervention, the starting point is assessment. Assessment focuses on both care recipient and caregiver and serves several functions. First, it is important to confirm the care recipient's disabilities and to make sure that treatable components have not been overlooked. Symptoms of memory loss sometimes have treatable causes and should not be assumed to be due to dementia, unless an appropriate medical and neuropsychological examination has been conducted. Second, the clinician can assess the specific problems, disabilities, and strengths of the care recipient. Although the focus is often on decrements, care recipients may retain some abilities and resources, even when suffering from dementia or other progressive disorders. Strengths can include activities the person currently is able to perform, or past interests and activities that may be possible to enhance in the present situation. Third, the assessment should indicate which problems are stressful for the caregiver. As emphasized throughout this chapter, caregivers experience potential stressors in different ways. What is difficult for one person may not

be so for another. That includes management of specific behaviors, such as incontinence or wandering, or handling potential conflicts between caregiving and work or other roles. Finally, the clinician should consider the extent to which the care recipient can participate in a clinical intervention, either jointly with the caregiver, or separately. There have been reports that short-term counseling and support groups are helpful for dementia patients in the earlier stages of their illness (Teri, 1994; Zarit & Zarit, in press). For cognitively intact people, a wide range of clinical interventions might be appropriate. Following the initial assessment, clinicians can draw upon three treatment strategies when working with caregivers: increasing the caregiver's understanding of the patient's illness and disabilities; problem solving to manage daily care-related problems; and support. A starting point for interventions is often to increase caregiver's understanding of the care recipient's illness. Families often have questions that have not been answered by medical personnel, or they have trouble understanding the implications of a diagnosis. Often they will have questions about the possibilities for treatment. An important facet of understanding the disorder is learning to view changes in the patient's behavior as part of the disease process. In disorders like dementia that have considerable impact on behavior, families often misunderstand or misinterpret common problems. They may, for example, believe that a patient asks the same question over and over to annoy the caregiver or to get attention, or because of laziness. Families should be encouraged to look at why someone with a memory-impairing disease would behave this way. They should also avoid reasoning or arguing with patients over factual issues. Patients may insist that they want to see their long-deceased mothers, or to go home, when they are already at home. Experience shows that caregivers cannot persuade patients they are mistaken. In fact, reminding patients that their mothers are dead is often upsetting, since they experience it as a new loss, and the result is more agitation. Instead, families are encouraged to think about why someone with memory loss would behave this way, and what they must be feeling at this time. Although families cannot respond effectively to the content of these types of communications, they can respond to the underlying emotions, for example, by providing comfort or reassurance, or by reminiscing about the patient's mother. Increasing the caregiver's understanding of problem behaviors flows naturally into a more formal approach to problem solving. Problem

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Clinical Services

Assessment

Treatment Strategies

Treatment Modalities

Understanding the illness

Counseling

Problem Solving

Family Meetings

Support

Support Groups

Figure 2

A model of intervention with caregivers.

solving can be used to address persistent troubling behaviors. Drawn from contemporary behavior therapy, problem solving involves a series of steps to identify causes and reinforcers of current problems and to generate and implement possible solutions (see Table 1). The starting point is to pinpoint a specific behavior or problem (e.g., agitation, depressed behaviors), and to have the caregiver observe it over a period of several days. Caregivers should note when the problem occurs, what went before it (antecedents), and what followed the behavior (reinforcers). This step provides a baseline of how often the problem occurs, against which interventions can be measured. It also identifies how the behavior may function. In dementia, for example, agitated behavior typically follows a period of inactivity or napping and is reinforced by attention. Once a pattern is identified, the caregiver can be encouraged to think about strategies to change or head off the problem. Strategies need to be specific and practical and within the ability of the caregiver to manage. Caregivers may have difficulty selecting a solution. In that case, they can compare different strategies with the method of pros and cons, by which they write down advantages and drawbacks of each approach (including doing nothing). Planning and rehearsing the solutions before trying them out heads off problems if the plan is not realistic. After implementing a solution, caregivers should continue monitoring how often the

problem occurs in order to evaluate how successful this strategy has been. Although it is a behavior technique, problem solving is compatible with the use of medications. In fact, medications to control behavior or mood should be considered as one of the possible strategies for intervention. If the caregiver obtains a baseline of the frequency of the targeted problem before a medication is introduced, then it will be possible to get an accurate evaluation of the effectiveness of treatment. As clinicians know, medications often have uncertain and variable effects. Neuroleptics are widely used for control of behavior problems in the elderly, but they are not consistently effective or sometimes work for a while and then lose their effectiveness (Schneider, Pollock, & Lyness, 1990). By viewing medications as one of several possible

Table 1

The problem solving process. Stage

1 Pinpoint a behavior and assess when it occurs and how often 2 Identify antecedents and consequences 3 Identify possible strategies 4 Select a strategy (use pros and cons) 5 Plan and rehearse implementing the strategy 6 Try out strategy and evaluate

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strategies and carefully monitoring their effectiveness, clinicians can develop more rational treatment approaches. Problem solving can also be used to identify antecedents and consequences of caregiver stress. Rather than pinpointing a specific behavior problem, caregivers can note when they feel the most stress, and what has led up to that. Sometimes, it will be revealed that no one problem or behavior is overwhelming. Instead, the accumulation of small stressors without a break leads to difficulties. Solutions can then focus on how the caregiver can prevent the build up of stress, such as arranging for respite care. The third treatment strategy is support. Clinicians can provide support directly with empathy for the caregiver and a nonjudgmental attitude. Interventions can also work to increase support and understanding from family and friends, and to gain more help from formal service providers. Clinicians can help families address the perceived and actual obstacles in respite services. Three intervention modalities have been used with caregivers: one-to-one counseling; family meetings; and support groups. Each brings a different element to treatment. Short-term counseling can provide caregivers with the opportunity to explore their situation in depth and to consider the options and alternatives available to them in a supportive and nonjudgmental situation. Family meetings offer the opportunity to address directly areas of conflict and misunderstanding in the family and to build support and assistance for the primary caregiver. Support groups give caregivers the opportunity to discuss their situation with other people in similar situations. Groups may be an efficient means of sharing information and learning about new approaches and strategies. Several studies document the effectiveness of these approaches. Whitlatch, Zarit, and von Eye (1991) found that caregivers receiving individual counseling and a family meeting had lower stress than people receiving only a support group or who were on a waiting list. In a series of studies, Toseland and his colleagues (Toseland, Rossiter, Peak, & Smith, 1990) have also found that counseling is more effective in the short run for relieving a caregiver's distress than support groups. Mittelman and her colleagues (1993; 1995) developed a comprehensive intervention program that combines individual and family counseling during an initial four-month period, followed by sustained treatment in a support group. Caregivers in the treatment group had lower burden and distress and placed their relatives in nursing homes at a lower rate than people in a control group (see also, Whitlatch,

Zarit, Goodwin, & von Eye, 1995). These findings demonstrate the effectiveness of planned interventions designed to lower the stress of family caregivers. By increasing caregivers' skills in managing problems and stressors and bringing in new resources to support the caregiver whenever possible, clinicians can provide substantial assistance even in the face of a deteriorating condition. Through these interventions, caregivers can function as well as possible, while providing an optimal care environment for their relative. Timely use of these interventions may be cost-effective by preventing the breakdown of the family caregiving system, and encouraging a rational use of respite services, including institutional care when that is appropriate.

7.22.15 CONCLUSIONS One of the major features of an aging society is that families are caring for disabled elders more often and for longer periods of time than ever before. There is considerable individual variability in how caregiving is handled and experienced, but it is typically stressful for the primary family helper and sometimes for the extended family network. The phenomenon of caregiving cannot be captured within a single measure of burden or stress. Rather, the many dimensions involved in the family's responses and the types of different stressors or problems caregivers experience have been observed. The stress of caregiving is an ongoing process, which evolves as the demands of care change and as caregivers develop new understanding, utilize different resources, or become overwhelmed by the unrelenting problems they face. The challenge for the future is to find ways to support families so that they can provide highquality, personalized care without excessive strain on themselves. The cost of care for social and health programs for the elderly has become an increasing problem for those countries with a significant proportion of their populations over age 65 years. As the number of elderly increase, cost-efficient means of providing care that do not sacrifice quality are needed. The responsibility for care cannot fall exclusively on families, because the burdens are too great, nor on society, since the cost will be too high. There need, instead, to be partnerships that find creative ways of sharing care, and which address the needs of both care recipient and caregiver. What shape those alliances will take, or the best models of working to support families, remain to be discovered. A small, but growing, clinical literature suggests that timely and wellconceived clinical interventions can be an

References important part of this partnership, helping families develop better strategies for managing a patient's disabilities and regulating the stress on themselves. 7.22.16 REFERENCES Aneshensel, C. S., Pearlin, L. I., Mullan, J. T., Zarit, S. H., & Whitlatch, C. J. (1995). Profiles in caregiving: The unexpected career. New York: Academic Press. Aneshensel, C. S., Pearlin, L. I., & Schuler, R. H. (1993). Stress, role captivity, and the cessation of caregiving. Journal of Health and Social Behavior, 34, 54±70. Anthony-Bergstone, C. R., Zarit, S. H., & Gatz, M. (1988). Symptoms of psychological distress among caregivers of dementia patients. Psychology and Aging, 3, 245±248. Berry, G. L., Zarit, S. H., & Rabatin, V. X. (1991). Caregiver activity on respite and nonrespite days: A comparison of two service approaches. The Gerontologist, 31, 830±835. Birkel, R. C. (1987). Toward a social ecology of home-care households. Psychology and Aging, 2(3), 294-301. Bledin, K. D., MacCarthy, B., Kuipers, L., & Woods, R. T. (1990). Daughters of people with dementia: Expressed emotion, strain, and coping. British Journal of Psychiatry, 157, 221-227. Brodaty, H.,. & Hadzi-Pavlovic, D. H. (1990). Psychosocial effects on carers of living with persons with dementia. Australian and New Zealand Journal of Psychiatry, 24, 351±361. Brody, E. M. (1990). Women in the middle: Their parentcare years. New York: Springer. Brody, E. M., Johnsen, P. T., & Fulcomer, M. C. (1984). What should adult children do for elderly parents? Opinions and preferences of three generations of women. Journal of Gerontology, 39, 736±746. Brody, E. M., Kleban, M. H., Johnsen, P. T., Hoffman, C., & Schoonover, C. B. (1987). Work status and parent care: A comparison of four groups of women. The Gerontologist, 27, 201±208. Brody, E. M., Litvin, S. J., Albert, S. M., & Hoffman, C. J. (1994). Marital status of daughters and patterns of parent care. Journals of Gerontology, 49, S95-S103. Brody, E. M., & Schoonover, C. B. (1986). Patterns of parent-care when adult daughters work and when they do not. The Gerontologist, 26, 372±381. Bunting, S. M. (1989). Stress on caregivers of the elderly. Advances in Nursing Science, 11, 63-73. Burdz, M. P., Eaton, W. O., & Bond, J. B., Jr. (1988). Effect of respite care on dementia and nondementia patients and their caregivers. Psychology and Aging, 3, 38±42. Callahan, J.J., Jr. (1989). Play it again, SamÐThere is no impact. Gerontologist, 29, 5±6. Capra, F. (1982). Wholeness & health. In The turning point: Science, society and the rising culture. (pp. 305±330). New York: Bantam Books. Cassel, C. K., Rudberg, M. A., & Olshansky, S. J. (1992). The price of success: Health care in an aging society. Health Affairs, (Summer), 87±99. Chappell, N. L. (1991). Living arrangements and sources of caregiving. Journals of Gerontology, 46, S1±S8. Chow, N. W. (1983). The Chinese family and support of the elderly in Hong Kong. The Gerontologist, 23, 584±588. Cicirelli, V. G. (1983). A comparison of helping behavior to elderly parents of adult children with intact and disrupted marriages. The Gerontologist, 23, 619±625. Cicirelli, V. G. (1985). The role of siblings as family caregivers. In W. J. Sauer & R. T. Coward (Eds.), Social support networks and the care of the elderly: Theory,

519

practice, and research (pp. 93±107). New York: Springer. Cicirelli, V. G. (1992). Siblings as caregivers in middle and old age. In J. W. Dwyer & R. T. Coward (Eds.), Gender, families, and elder care (pp. 84±104). Newbury Park, CA: Sage. Cicirelli, V. G. (1993). Attachment and obligation as daughters' motives for caregiving behavior and subsequent effect on subjective burden. Psychology and Aging, 8, 144±155. Clipp, E. C., & George, L. K. (1990a). Caregiver needs and patterns of social support. Journals of Gerontology, 45, S102±S111. Clipp, E. C., & George, L. K. (1990b). Psychotropic drug use among caregivers of patients with dementia. Journal of the American Geriatrics Society, 38, 227±235. Clipp, E. C., & George, L. K. (1993). Dementia and cancer: A comparison of spouse caregivers. The Gerontologist, 33, 534±541. Cohen, D., & Eisdorfer, C. (1988). Depression in family members caring for a relative with Alzheimer's disease. Journal of the American Geriatric Society, 36, 885±889. Cooney, T. M., & Uhlenberg, P. (1990). The role of divorce in men's relations with their adult children after midlife. Journal of Marriage and the Family, 52, 677±688. Creasey, G. L., Myers, B. J., Epperson, M. J., & Taylor, J. (1990). Couples with an elderly parent with Alzheimer's disease: Perceptions of familial relationships. Psychiatry, 53, 44±51. Davey, A., Kwee, E. E., Shea, D. G., Zarit, S. H., SundstroÈm, G., Berg, S., & Smyer, M. A. (1996, November). How much do families help? Cultural and policy perspectives. Paper presented at the annual meeting of the Gerontological Society of America, Washington, DC. Drinka, T. J., Smith, J., & Drinka, P. J. (1987). Correlates of depression and burden for informal caregivers of patients in a geriatrics referral clinic. Journal of the American Geriatrics Society, 35, 522±525. Eggebeen, D. J., & Wilhelm, M. O. (1995). Patterns of support given by older Americans to their children. In S. A. Bass (Ed.), Older and active: How Americans over 55 are contributing to society (pp. 122±168). New Haven, CT: Yale University. Fadel-Girgis, M. (1983). Family support for the elderly in Egypt (1983). The Gerontologist, 23, 589±592. Field, D., & Minkler, M. (1988). Continuity and change in social support between young-old and old-old or veryold age. Journals of Gerontology, 43, P100±P106. Fortinsky, R. & Hathaway, T. (1990). Information and service needs among active and former family caregivers of persons with Alzheimer's Disease. The Gerontologist, 30, 604±609. Franklin, S. T., Ames, B. D., & King, S. (1994). Acquiring the family eldercare role: Influence on female employment adaptation. Research on Aging, 16, 27±42. Franks, M. M., & Stephens, M. A. P. (1996). Social support in the context of caregiving: Husbands' provision of support to wives involved in parent care. Journals of Gerontology, 51B, P43±P52. Gallagher, D., Rose, J., Rivera, P., Lovett, S., & Thompson, L. W. (1989). Prevalence of depression in family caregivers. The Gerontologist, 29, 449±456. George, L. K., & Gwyther, L. P. (1986). Caregiver wellbeing: A multidimensional examination of family caregivers of demented adults. The Gerontologist, 26, 253±259. Gibeau, J. L., & Anastas, J. W. (1989). Breadwinners and caregivers: Interviews with working women. Journal of Gerontological Social Work, 14, 19±40. Gignac, M. A. M., & Gottlieb, B. H. (1996). Caregivers' appraisals of efficacy in coping with dementia. Psychology and Aging, 11, 214±225. Goldman, L. S., & Luchins, D. J. (1984). Depression in the

520

Family Caregiving: Research Findings and Clinical Implications

spouses of demented patients. American Journal of Psychiatry, 14, 1467±1468. Goode, W. J. (1960). A theory of strain. American Sociological Review, 25, 483±496. Greene, V. L., & Coleman, P. D. (1995). Direct services for family caregivers: Next steps for public policy. In R. A. Kane & J. D. Penrod (Eds.) Family are giving in an aging society: Policy perspectives (pp. 46±63). Thousand Oaks, CA: Sage Gwyther, L. P. (1990). Barriers to service utilization among Alzheimer's patients and their families (Report to the US Congress, Office of Technical Assessment, National Technical Information Service #PB89±225205. Durham, NC: Duke University Center on Aging. Hadjistavropoulos, T., Taylor, S., Tuokko, H., & Beattie, B. L. (1994). Neuropsychological deficits, caregivers' perception of deficits, and caregiver burden. Journal of the American Geriatrics Society, 42, 308±314. Haley, W. E., Levine, E. G., Brown, S. L., & Bartolucci, A. A. (1987). Stress, appraisal, coping and social support as predictors of adaptational outcome among dementia caregivers. Psychology and Aging, 2(4), 323±330. Haley, W. E., Levine E. G., Brown, S. L., Berry, J. W., & Hughes, G. H. (1987). Psychological, social, and health consequences of caring for a relative with senile dementia. Journal of the American Geriatrics Society, 35, 405±411. Haley, W. E., & Pardo, K. M. (1989). Relationship of severity of dementia to caregiving stressors. Psychology and Aging, 4, 389±392. Haley, W. E., West, C. A. C., Wadley, V. G., Ford, G. R., White, F. A., Barrett, J. J., Harrell, L. E., & Roth, D. L. (1995). Psychological, social, and health impact of caregiving: A comparison of black and white dementia family caregivers and noncaregivers. Psychology and Aging, 10, 540±552. Hamon, R. R., & Blieszner, R. (1990). Filial responsibility expectations among adult child-older parent pairs. Journals of Gerontology, 45, P110±P112. Hanson, S. L., Sauer, W. J., & Seelbach, W. C. (1983). Racial and cohort variations in filial responsibility norms. The Gerontologist, 23, 626±631. Hirdes, J. P., & Strain, L. A. (1995). The balance of exchange in instrumental support with network members outside the household. Journals of Gerontology, 50B, S134±S142. Horowitz, A. (1985). Sons and daughters as caregivers to older parents: Differences in role performance and consequences. The Gerontologist, 25, 612±617. Ingersoll-Dayton, B., & Antonucci, T. C. (1988). Reciprocal and nonreciprocal social support: Contrasting sides of intimate relationships. Journals of Gerontology, 43, S65±S73. Isett, R. D. Krauss, C., & Malone, M. (1984). A study of the Intercommunity Actions, Inc. In-home respite care project. Unpublished manuscript. Mid-Atlantic Long Term Care Gerontology Center. Jarrott, S. E., Zarit, S. H., Johansson, L., & Berg, S. (1996, June). A comparison of day care in Sweden and the United States. Paper presented at the Nordic Gerontology Congress, Helsinki, Finland. Johansson, B., & Zarit, S. H. (1995). Prevalence and incidence of dementia in the oldest old: A longitudinal study of a population-based sample of 84-90 year-olds in Sweden. International Journal of Geriatric Psychiatry, 10, 359±366. Jorm, A. F., Korten, A. E., & Henderson, A. S. (1987). The prevalence of dementia: A quantitative integration of the literature. Acta Psychiatry Scandinavia, 76, 465±479. Kaszniak, A. W. (1996). Preparing for treatment of the elderly: Assessment. In S. H. Zarit & B. Knight (Eds.), A guide to psychotherapy and aging: Clinical intervention in

a life stage context. Washington, DC: APA Books. Kendig, H. L., Rowland, D. T. (1983). Family support of the Australian aged: A comparison with the United States. The Gerontologist, 23, 643±649. Kiecolt-Glaser, J. K., Dura, J. R., Speicher, C. E., Trask, O. J., & Glaser, R. (1991). Spousal caregivers of dementia victims: Longitudinal changes in immunity and health. Psychosomatic Medicine, 53, 345±362. Kiecolt-Glaser, J. K., Glaser, R., Shuttleworth, E. C., Dyer, C. S., Ogrocki, P., & Speicher, C. E. (1987). Chronic stress and immunity in family caregivers of Alzheimer's Disease victims. Psychosomatic Medicine, 49, 523±535. Kinney, J. M., & Stephens, M. A. P. (1989). Hassles and uplifts of giving care to a family member with dementia. Psychology and Aging, 4, 402±408. Kinsella, K., & Taeuber, C. M. (1993). An aging world II. International Population. Reports P95/92±3. US Department of Commerce, Economics, and Statistics Administration, Bureau of the Census, Government Printing Office, Washington, DC. Kivett, V. R., & Atkinson, M. P. (1984). Filial expectations, association, and helping as a function of number of children among older rural-transitional parents. Journal of Gerontology, 39, 499±503. Kokmen, E., Chandra, V., & Schoenberg, B. S. (1988). Trends in incidence of dementing illness in Rochester, Minnesota, in three quinquennial periods, 1960±1974. Neurology, 38, 975±980. Koslowski, K. D., Montgomery, R. J. V., & Borgotta, E. F. (1990). Predicting nursing home utilization: Is this the best we can do? In S. M. Stahl (Ed.), The legacy of longevity: Health and health care in later life. Newbury Park, CA: Sage. Krause, N. (1995). Negative interaction and satisfaction with social support among older adults. Journals of Gerontology, 50B, P59±P73. Kwee, E. E., Zarit, S. H., Edwards, A. B., Davey, A., & Jarrott, S.E. (1995, November). Caregiver's healthseeking behavior: Impact of the intensity of stressors. Poster presented at the Fortyeighth Annual Meeting of the Gerontological Society of America, Los Angeles, CA. Lawton, M. P., Brody, E. M., & Saperstein, A. R. (1989a). A controlled study of respite services for caregivers of Alzheimer's patients. The Gerontologist, 29(1), 8±16. Lawton, M. P., Brody, E. M., Saperstein, A. R., & Grimes, M. (1989b). Respite services for caregivers: Research findings for service planning. Home Health Care Services Quarterly, 10(1/2), 5±32. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lerner, M. J., Somers, D. G., Reid, D., Chiriboga, D., & Tierney, M. (1991). Adult children as caregivers: egocentric biases in judgements of sibling contributions. The Gerontologist, 31, 746±755. Lieberman, M. A., & Fisher, L. (1995). The impact of chronic illness on the health and well-being of family members. The Gerontologist, 35, 94±102. Mace, N. L. & Rabins, P. V. (1981). The 36-hour day: A family guide to caring for persons with Alzheimer's disease, related dementing illness and memory loss in later life. Baltimore: Johns Hopkins University Press. Maeda, D. (1983). Family care in Japan. The Gerontologist, 23, 579±583. Majerovitz, S. D. (1995). Role of family adaptability in the psychological adjustment of spouse caregivers to patients with dementia. Psychology and Aging, 10, 447±457. MaloneBeach, E. E., Zarit, S. H., & Spore, D. L. (1992). Caregivers' perceptions of case management and community-based services: Barriers to service use. The Journal of Applied Gerontology, 11(2), 146-159. Martire, L. M., Stephens, M. A. P., & Atienza, A. A. (in

References press). The Interplay of work and caregiving: Relationships between role satisfaction, role involvement and caregivers' well-being. Journals of Gerontology: Social Sciences, 52B, S279-S289. Matthews, S. H. (1987). Provision of care to old parents: Division of responsibility among adult children. Research on Aging, 9, 45±60. Matthews, S. H. (1995). Gender and the division of filial responsibility between lone sisters and their brothers. Journals of Gerontology, 50B, S312±S320. Matthews, S. H., & Rosner, T. T. (1988). Shared filial responsibility: The family as the primary caregiver. Journal of Marriage and the Family, 50, 185±195. Matthews, S. H., Werkner, J. E., & Delaney, P. J. (1989). Relative contributions of help by employed and nonemployed sisters to their elderly parents. Journal of Gerontology: Social Sciences, 44, S36±S44. Miller, D. B., Gulle, N. & McCue, F. (1986). The realities of respite for families, clients and sponsors. The Gerontologist, 26, 467±470. Mittelman, M. S., Ferris, S. H., Shulman, E., Steinberg, G., Ambinder, A., Mackell, J., & Cohen, J. (1995). A comprehensive support program: Effect on depression in spouse-caregivers of AD patients. The Gerontologist, 35, 792±802. Mittelman, M. S., Ferris, S. H., Steinberg, G., Shulman, E., Mackell, J. A., Ambinder, A., & Cohen, J. (1993). An intervention that delays institutionalization of Alzheimer's disease patients: Treatment of spouse-caregivers. Gerontologist, 33, 730±740. Moen, P., Robison, J., & Fields, V. (1994). Women's work and caregiving roles: A life course approach. Journal of Gerontology, Social Sciences, 49, S176±S185. Monahan, D. J., & Hooker, K. (1995). Health of spouse caregivers of dementia patients: The role of personality and social support. Social Work, 40, 305±314. Montgomery, R. J. V. (1995). Examining respite care: Promises and limitations. In D. E. Biegel, & R. Schulz (Series Eds.) & R. A. Kane & J. D. Penrod (Vol. Eds.), Family Caregiver Applications Series: Vol. 5. Family caregiving in an aging society (1st ed., pp. 29±45). Thousand Oaks, CA: Sage. Montgomery, R. J., & Berkeley-Caines, L. (1989). Effects of in-home volunteer respite services on caregivers: A final report to Detroit Catholic Social Services. Detroit, IL: Wayne State University Institute of Gerontology. Montgomery, R. J. V., & Borgatta, E. (1985). Family support project: Final report to the administration on aging. Seattle, WA: University of Washington Montgomery, R. J. V., & Borgatta, E. (1989). The effects of alternative support strategies on family caregiving. The Gerontologist, 29, 457±464. Montgomery, R. J. V., & Kosloski, K. (1990, November). Adult children and the nursing home decision. Paper presented at the Fifty-second Annual Meeting of the National Council on Family Relations, Seattle, WA. Morgan, D. L., Schuster, T. L., & Butler, E. W. (1991). Role reversals in the exchange of social support. Journals of Gerontology, 46, S278±S287. Moritz, D. J., Kasl, S. V., & Berkman, L. F. (1989). The health impact of living with a cognitively impaired elderly spouse: Depressive symptoms and social functioning. Journals of Gerontology, 44, S17±S27. Moritz, D. J., Kasl, S. V., & Ostfeld, A. M. (1992). The health impact of living with a cognitively impaired elderly spouse: Blood pressure, self-rated health, and health behaviors. Journal of Aging and Health, 4, 244±267. Mutschler, P. H. (1994). From executive suite to production line: How employees in different occupation manage elder care responsibilities. Research on Aging, 16, 7±26.

521

Neal, M. B., Chapman, N. J., Ingersoll-Dayton, B., Emlen, A. C., & Boise, L. (1990). Absenteeism and stress among employed caregivers of the elderly, disabled adults, and children. In D. E. Biegel & A. Blum (Eds.), Aging and caregiving: Theory, practice, and research ( pp. 160±183). Newbury Park, CA: Sage. Pearlin, L. I. (1993). The social contexts of stress. In L. Goldberger & S. Breznitz (Eds.), Handbook of stress: Theoretical and clinical aspects (2nd ed., pp. 303±315). New York: Free Press. Pearlin, L., Mullan, J., Semple, S., & Skaff, M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583±594. Pearson, J., Verma, S., & Nellett, C. (1988). Elderly psychiatric patient status and caregiver perceptions as predictors of caregiver burden. The Gerontologist, 28, 79±83. Penning, M. J. (1990). Receipt of assistance by elderly people: Hierarchical selection and task specificity. The Gerontologist, 30, 220±227. Pillemer, K., & Suitor, J. J. (1992). Violence and violent feelings: What causes them among family caregivers? Journals of Gerontology, 47, S165±S172. Pratt, C. P., Wright, S., & Schmall, V. (1987). Burden, coping, and health status: A comparison of family caregivers to community dwelling and institutionalized Alzheimer's patients. Journals of Gerontological Social Work, 20, 99±112. Pruchno, R., & Kleban, M. H. (1993). Caring for an institutionalized parent: The role of coping strategies. Psychology and Aging, 8, 18±25. Pruchno, R. A., Kleban, M. H., Michaels, E., & Dempsey, N. P. (1990a). Mental and physical health of caregiving spouses: Development of a causal model. Journals of Gerontology: Psychological Sciences, 45, P192±199. Pruchno, R. A., Michaels, J. E., & Potashnik, S. L. (1990b). Predictors of institutionalization among Alzheimer disease victims with caregiving spouses. Journals of Gerontology: Social Sciences, 45, S259±S266. Pruchno, R. A., Peters, N. D., Kleban, M. H., & Burant, C. J. (1994). Attachment among adult children and their institutionalized parents. Journals of Gerontology: Social Sciences, 49, S209±S218. Pruchno, R. A., & Potashnik, S. L. (1989). Caregiving spouses physical and mental health in perspective. Journal of the American Geriatrics Society, 37, 697±705. Pruchno, R. A., & Resch, N. L. (1989). Aberrant behaviors and Alzheimer's disease: Mental health effects on spouse caregivers. Journals of Gerontology, 44, S177±S182. Redinbaugh, E. M., MacCallum, R. C., & Kiecolt-Glaser, J. K. (1995). Recurrent syndromal depression in caregivers. Psychology and Aging, 10, 358±368. Reis, M. F., Gold, D. P., Gauthier, S., Andres, D., & Markiewicz, D. (1994). Personality traits as determinants of burden and health complaints in caregiving. International Journal of Aging and Human Development, 39, 257±271. Sands, D., & Suzuki, T. (1983). Adult day care for Alzheimer's patients and their families. The Gerontologist, 23(1), 21±23. Scharlach, A. E. (1994). Caregiving and employment: Competing or complementary roles? The Gerontologist, 34, 378±385. Scharlach, A. E., & Boyd, S. L. (1989). Caregiving and employment: Results of an employee survey. The Gerontologist, 29, 382±387. Scharlach, A. E., & Frenzel, C. (1986). An evaluation of institution-based respite care. The Gerontologist, 26, 77±82. Schneider, L.S., Pollock, V. E., & Lyness, S. A. (1990). A metaanalysis of controlled trials of neuroleptic treatment

522

Family Caregiving: Research Findings and Clinical Implications

in dementia. Journal of American Geriatrics Society, 38, 553±563. Schulz, R., Visintainier, P., & Williamson, G. M. (1990). Psychiatric and physical morbidity effects of caregiving. Journals of Gerontology: Psychological Sciences, 45, P181±191. Selye, H. (1976). The stress of life (Rev. ed.) (Preface and pp. 1±39). New York: McGraw Hill. Semple, S.J. (1992). Conflict in Alzheimer's caregiving families: Its dimensions and consequences. The Gerontologist, 32, 648±655. Sheehan, N. W., & Nuttall, P. (1988). Conflict, emotion, and personal strain among family caregivers. Family Relations, 37, 92±98. Sieber, S. D. (1974). Toward a theory of role accumulation. American Sociological Review, 39, 567±578. Skaff, M. M., Pearlin, L. I. (1992). Caregiving: Role engulfument and the loss of self. The Gerontologist, 32 (5), 656±664. Stephens, M. A. P., & Franks, M. M. (1995). Spillover between daughters' roles as caregiver and wife: Interference or enhancement? Journals of Gerontology, 50B, P9±P17. Stephens, M. A. P., Franks, M. M., & Townsend, A. L. (1994). Stress and rewards in women's multiple roles: The case of women in the middle. Psychology and Aging, 9, 45±52. Stephens, M. A. P., Norris, V. K., Kinney, J. M., Ritchie, S. W., & Grotz, R. C. (1988). Stressful situations in caregiving: Relations between caregiver coping and wellbeing. Psychology and Aging, 3, 208±209. Stoller, E. P., & Pugliesi, K. L. (1989). Other roles of caregivers: Competing responsibilities or supportive resources. Journals of Gerontology: Social Sciences, 44, S231±S238. Stone, R., Cafferata, G. L., & Sangl, J. (1987). Caregivers of the frail elderly: A national profile. The Gerontologist, 27, 616±626. Strawbridge, W. J., & Wallhagen, M. I. (1991). Impact of family conflict on adult child caregivers. The Gerontologist, 31, 770±777. Suitor, J. J., & Pillemer, K. (1992). Status transitions and marital satisfaction: The case of adult children caring for elderly parents suffering from dementia. Journal of Social and Personal Relationships, 9, 549±562. SundstroÈm, G. (1992). Care by families: An overview of trends. Caring for Frail Elderly People, Social Policy Studies, 14. Paris: OECD. Tennstedt, S. L., Crawford, S., & McKinlay, J. B. (1993). Determining the pattern of community care: Is coresidence more important than caregiver relationship? Journals of Gerontology: Social Sciences, 48, S74±S83. Tennstedt, S. L., McKinlay, J. B., & Sullivan, L. M. (1989). Informal care for frail elders: The role of secondary caregivers. The Gerontologist, 29, 677±683. Teri, L. (1994). Behavioral treatment of depression in patients with dementia. Alzheimer Disease and Associated Disorders, 8(3), 66±74. Thoits, P. A. (1983). Multiple Identities and psychological well-being: A reformulation and test of the social isolation hypothesis. American Sociological Review, 48, 174±187. Thompson, E. H., Jr., Futterman, A. M., CallagherThompson, D., Rose, J. M., & Lovett, S. B. (1993). Social support and caregiver burden in family caregivers of frail elders. Journals of Gerontology, 48, S245±S254. Toseland, R. W., Rossiter, C. M., Peak, T., & Smith, G. C. (1990). Comparative effectiveness of individual and group interventions to support family caregivers. Social Work, 35, 209±217. Townsend, A. (1990). Nursing home care and family caregivers' stress. In M. A. P. Stephens, J. H. Crowther, S. E. Hobfall, & D. L. Tennenbaum (Eds.), Stress and

coping in later life families (pp. 267±285). Washington, DC: Hemisphere. Townsend, A. L., & Franks, M. M. (1995). Binding ties: Closeness and conflict in adult children's caregiving relationship. Psychology and Aging, 10, 343±351. Townsend, A., Noelker, L., Deimling, G., & Bass, D. (1989). Longitudinal impact of interhousehold caregiving on adult children's mental healith. Psychology and Aging, 4, 393±401. Uchino, B. N., Kiecolt-Glaser, J. K., & Cacioppo, J. T. (1994). Construals of preillness relationship quality predict cardiovascular response in family caregivers of Alzheimer's disease victims. Psychology and Aging, 9, 113±120. Verbrugge, L. M. (1983). Multiple roles and physical health of women and men. Journal of Health and Social Behavior, 24, 16±30. Vitaliano, P. P., Young, H. M., Russo, J., Romano, J., & Magana-Amato, A. (1993). Does expressed emotion in spouses predict subsequent problems among care recipients with Alzheimer's disease? Journals of Gerontology, 48, P202±P209. Walker, A. J., Martin, S. S. K., & Jones, L. L. (1992). The benefits and costs of caregiving and care receiving for daughters and mothers. Journals of Gerontology, 47, S130±S139. Webster, P. S., & Herzog, A. R. (1995). Effects of parental divorce and memories of family problems on relationships between adult children and their parents. Journals of Gerontology, 50B, S24±S34. Weihl, H. (1983). Three issues from the Israeli scene. The Gerontologist, 23, 576±578. Weissert, W. G., Elston, J. M., Bolda, E. J., Zelman, W. N., Mutran, E., & Mangum, A. B. (1990). Adult day care: Findings from a national survey. Baltimore, MD: Johns Hopkins University Press. White, L. (1992). The effect of parental divorce and remarriage on parental support for adult children. Journal of Family Issues, 13, 234±250. Whitlatch, C. J., & Noelker, L. S. (in press). Caregiving and caring. In J. E. Birren (Ed.), Encyclopedia of gerontology. New York: Academic Press. Whitlatch, C.J., Zarit, S.H., & von Eye, A. (1991). Efficacy of interventions with caregivers: A reanalysis. The Gerontologist, 31, 9±14. Whitlatch, C. J., Zarit, S. H., Goodwin, P. E., & von Eye, A. (1995). Influence of the success of psychoeducational interventions on the course of family care. Clinical Gerontologist, 16, 17±30. Williamson, G. M., & Schulz, R. (1993). Coping with specific stressors in Alzheimer's disease caregiving. The Gerontologist, 33, 747±755. Worach-Kardas, H. (1983). The Polish family tradition. The Gerontologist, 23, 593±596. Wright, L. K. (1993). Alzheimer's disease and marriage: An intimate account. Newbury Park, CA: Sage. Wright, L., Clipp, E., & George, L. (1993). Health consequences of caregiver stress. Medicine Exercise Nutrition and Health, 2, 181±195. Zarit, J. M., & Zarit, S. H. (in press). Til death do us part. In R. P. Halgin & S. K. Whitbourne (Eds.) Partners in change: Growth through the therapeutic process. New York: Oxford University Press. Zarit, S.H. (1996). Clinical interventions for family caregiving. In S. H. Zarit & B. Knight (Eds.), A guide to psychotherapy and aging: Clinical intervention in a life stage context. Washington, DC: APA Books. Zarit, S. H., & Eggebeen, D. J. (1995). Parent child relationships in adulthood and old age. In M. H. Bornstein (Ed.), Handbook of parenting: Vol. 1. Children and parenting (pp. 119±140). Mahwah, NJ: Lawrence Erlbaum. Zarit, S. H., Johansson, B., & Berg, S. (1993). Functional

References impairment and co-disability in the oldest old. Journal of Aging and Health, 5, 291±305. Zarit, S. H., Orr, N. K., & Zarit, J. M. (1985). The hidden victims of Alzheimer's Disease: Families under stress. New York: NYU Press. Zarit, S. H., Stephens, M. A. P., Townsend, A. & Greene, R. (1996, November). Adult day care and the relief of caregiver strain. Paper presented at the annual meeting

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of the Gerontological Society of America, Washington, DC. Zarit, S. H., Todd, P. A., & Zarit, J. M. (1986). Subjective burden of husbands and wives as caregivers: A longitudinal study. The Gerontologist, 26, 260±266. Zarit, S. H. & Whitlatch, C. J. (1992). Institutional placement: Phases of the transition. The Gerontologist, 32, 665±672.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

7.23 Rehabilitation in Old Age: Psychosocial Issues CLEMENS TESCH-ROÈMER Ernst Moritz Arndt University, Greifswald, Germany and HANS-WERNER WAHL German Center for Research on Aging at the University of Heidelberg, Germany 7.23.1 INTRODUCTION

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7.23.2 GENERAL PRINCIPLES AND GEROPSYCHOLOGICAL ESSENTIALS OF REHABILITATION IN OLD AGE

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7.23.2.1 General Principles 7.23.2.2 Geropsychological Essentials of Rehabilitation in Old Age 7.23.3 PSYCHOSOCIAL ISSUES AND STRATEGIES OF REHABILITATION IN OLD AGE 7.23.3.1 Assessment Issues 7.23.3.1.1 Activities of daily living and instrumental activities of daily living 7.23.3.1.2 Performance vs. reserve capacity 7.23.3.2 Restoration of Functional Independence 7.23.3.2.1 Functional independence as basic objective of geriatric rehabilitation 7.23.3.2.2 Contributions from clinical geropsychology 7.23.3.3 Cognitive Retraining 7.23.3.3.1 Intelligence training 7.23.3.3.2 Memory training 7.23.3.3.3 Reality orientation training 7.23.3.4 Psychotherapeutic Intervention 7.23.3.5 Considering Motivation and Compliance Issues 7.23.3.5.1 Motivation 7.23.3.5.2 Compliance 7.23.3.5.3 Impact of the social network on motivation and compliance 7.23.3.6 The Role of Social Support 7.23.3.6.1 Effects of social support 7.23.3.6.2 Mobilizing social support 7.23.3.7 Ecological Aspects of Rehabilitation 7.23.3.7.1 Person±environment fit as critical for rehabilitation 7.23.3.7.2 Considering objective and subjective environmental aspects within the everyday world 7.23.3.7.3 New technologies and their rehabilitation potential

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7.23.4 PSYCHOSOCIAL REHABILITATION ISSUES WITH RESPECT TO PARTICULAR CLIENT GROUPS 538 7.23.4.1 Stroke Patients 7.23.4.1.1 Critical issues of rehabilitation 7.23.4.1.2 Effects of rehabilitation and challenges in the future 7.23.4.2 Arthritis Patients

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7.23.4.2.1 Physical therapy 7.23.4.2.2 Psychological interventions 7.23.4.3 Sensory Impaired Elderly 7.23.4.3.1 Hearing impairment 7.23.4.3.2 Visual impairment 7.23.4.4 Demented Elderly 7.23.5 PRACTICAL ISSUES, RESEARCH QUESTIONS, AND ETHICAL PROBLEMS 7.23.5.1 Practical Issues 7.23.5.2 Research Questions 7.23.5.3 Ethical Problems

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7.23.6 SUMMARY

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7.23.7 REFERENCES

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7.23.1 INTRODUCTION Aging is associated with an increase in acute and chronic illness with serious consequences for daily living. To give the reader an idea of how prevalent these self-limiting conditions are in old age, the following empirical findings (Ebrahim, 1992; Kemp,1985) are used. The percentage of persons with arthritis increases from 1% for the less than 17 years old group to about 25% for the (noninstitutionalized) over 65 years old group. Heart conditions increase from 2.4% for the under 17 group to 23.4% for the over 65 group (these rates are significantly higher depending on the mode of data collection [self-reports versus medical expert rating; Jette, 1996). Visual and hearing disorders also increase dramatically with age. About one third of all persons 65 and older exhibits a significant hearing loss; about 8% suffer from severe agerelated visual impairment. The prevalence of mental disorders also increases with age. The percentage of persons with major depression is about 11%; the percentage of elderly with at least some degree of dementia also hovers around 11%. Strokes, degenerative neurological disorders, pulmonary disorders, and most orthopedic disabilities increase with age at a similar rate. Also, there is convergent evidence that these prevalence rates increase dramatically from the young-old to the old-old and the oldest-old and are especially high in institutionalized settings (e.g., Jette, 1996; Suzman, Willis, & Manton, 1992; Schneekloth & MuÈller, 1995). Whereas acute illnesses normally can be treated quite adequately in many old and very old persons, the burden of chronic illness (as well as the disabilities and functional losses in daily life that result from them) have become one of the most dramatic challenges for society, for gerontology in general, and for rehabilitation with elderly clients in particular. If our basic goal is to engender a ªgoodº life into old age by fostering ªactive life expectancyº among

the elderly (e.g., Crimmins, Hayward, & Saito, 1996), then rehabilitative work as the process of maximizing abilities after a disabling event (Kemp, 1996) gains crucial importance for the individual as well as for society. Nevertheless, the burden imposed by chronic conditions, and the rehabilitative efforts to counteract them, deserve a highly differentiated analysis. Oversimplifying statements, whether positive or negative with respect to the power of rehabilitation to improve the lives of the elderly, are detrimental to research and can wreak havoc with the hopes and fears of the frail and chronically ill elderly and their families. On the one hand, the metamorphosis of gerontology from a decline and deficit view of old age toward a competence view that stresses the potentials and reserve capacities of old age has influenced significantly the field of geriatric rehabilitation. The body of empirical evidence underscores the success of rehabilitation in the elderly with respect to stroke, arthritis, cardiovascular disease, and falls (e.g., Andrews, 1987; Harris, O'Hara, & Harper, 1995; Kemp, 1985, 1996; Meier-Baumgartner, Nerenheim-Duscha, & GoÈrres, 1992; Rubenstein et al., 1984; SchuÈtz, 1993; Tallis, 1992). In addition, there is evidence that rehabilitation leads to better outcomes in the short and long run as compared to traditional medical treatment. On the other hand, convergent evidence from longitudinal and catamnestic studies show that the success of rehabilitation is tempered by everyday factors; further deterioration due to the underlying disease process, a lack of rehabilitation capacity in the homecare setting, poor ecological circumstances, or dependence-supporting behavior of the social environment (e.g., Horgas, Wahl, & Baltes, 1996; Meier-Baumgartner et al., 1992; Wahl & Baltes, 1993) can have a lasting, negative impact on the rehabilitation process. With this in mind, it is accepted broadly in the academic field that rehabilitation with the elderly deserves additional research efforts in order to maximize its efficiency. For example,

General Principles and Geropsychological Essentials of Rehabilitation in Old Age special problems that arise when treating the elderly must be considered, such as multimorbidity, concomitant cognitive impairments, reduced social networks, poor ecological conditions, longer time periods to regain certain functions, and lowered motivation (ªI am too old; this is not worth the effort.º). There is also general consensus within the professional field that rehabilitation truly deserves a multidisciplinary approach. The multiprofessional team should include high quality medical personnel, a psychiatrist, well-educated nursing staff, physical therapists, occupational therapists, speech pathologists, social workers, nutritionists, audiologists, and optometricians as well as experts in housing, design, and technical devices (Kemp, 1996; Saltz, 1995; Zeiss & Steffen, 1996). There is additional consent that rehabilitation of the elderly should take place in different settings such as the hospital, day-care center, home health care, and nursing home settings. What is stressed in this chapter is that psychology as a research and applied field is essential to geriatric rehabilitation in all of these settings. The critical importance of addressing geropsychological and psychosocial issues in the field of geriatric rehabilitation is underscored by the two contrasting theoretical approaches briefly alluded to above. With respect to the competence view of rehabilitation in old age, the emergence and application of psychological intervention techniques such as behavioral or cognitive training programs has broadened significantly the scope of rehabilitation in different settings (in the nursing home setting in particular; e.g., Hussian & Davis, 1985; Wisocki, 1991). Also, there is general consensus that the differential success of rehabilitation programs has as much to do with underlying psychological and social issues (e.g., motivational issues, personality traits, sense of self-efficacy, ability to mobilize social support) as with the ªobjectiveº severity of the disease process. With respect to the limits and the fragility of rehabilitation success, the psychosocial perspective points to crucial aspects such as inadequate housing, certain neighborhood characteristics, and the attitudes and behaviors of significant others who may undermine the elderly's striving toward independent functioning (Baltes, 1996). This chapter was written by two geropsychologists and thus presupposes that rehabilitation with the elderly can be effectively provided if a multidisciplinary and multiprofessional approach is applied. The task is to highlight the psychological and psychosocial perspective within geriatric rehabilitation. This is done in four sections: (i) general principles and

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geropsychological essentials of rehabilitation, (ii) psychosocial issues and strategies of rehabilitation with older adults (assessment issues, restoration of functional independence, cognitive retraining, psychotherapeutic intervention, motivation and compliance, role of social support, ecological aspects), (iii) psychosocial issues with respect to particular client groups (stroke, arthritis, the sensory impaired, demented patients), and (iv) final consideration of practical, research-related, and ethical problems of rehabilitation in old age. 7.23.2 GENERAL PRINCIPLES AND GEROPSYCHOLOGICAL ESSENTIALS OF REHABILITATION IN OLD AGE 7.23.2.1 General Principles Rehabilitation is required whenever an impairment or a disability causes permanent, widespread disruption of the normal fit between person and environment. Central to understanding rehabilitation is the distinction between impairment, disability, and handicap (World Health Organization, 1980). Impairment is any loss or abnormality of psychological, physiological, or anatomical structure or function. Disability is any restriction, due to impairment, which limits the ability to perform an activity in the manner or within the range considered normal for a human being. Handicap is defined as a disadvantage resulting from an impairment or disability that limits or prevents the fulfillment of a role appropriate to a person's age, gender, social, and cultural circumstances. For example, a stroke might lead to pathological changes in the brain and quite often to unilateral paralysis (impairment). These stroke-induced impairments are responsible for deteriorations in walking, manual dexterity, memory, and speech performance (disability). These disabilities in turn lead to social consequences for the individual, preventing the person from participating in social roles and activities (handicap). Rehabilitation can be regarded as a problemsolving and educational process aimed at reducing the disability and handicap experienced by someone as a result of disease, one that is always limited by the resources available (World Health Organization, 1980). Hence, rehabilitation is a set of procedures located between acute medical treatment and prevention. Of course, curable diseases should be treated medically, but whenever possible one should prevent disease instead of dealing with disabling and handicapping consequences. This statement is by no means trivial, as

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epidemiological data on stroke shows. Preventive measures are responsible for decreasing incidence rates for cardiovascular stroke (e.g., Svanborg, 1988; see also Fries, 1990). Nevertheless, rehabilitation is necessary in those cases where prevention or medical treatment are not effective. Hence, the focus of rehabilitative interventions is not the (underlying) disease but the functional level (e.g., Kemp, 1996). A medical diagnosis, that is knowledge about a certain impairment, does not necessarily imply knowledge about resulting disabilities and handicaps. Indeed, pronounced discrepancies in the emotional or functional outcomes between different patients suffering from ªobjectivelyº comparable diseases are more often the rule than the exception and require careful attention. Rehabilitation is not only aimed at restoring the patients' rights, privileges, reputation, and/ or proper condition, but also at realizing their potential, reablement, and resettlement (Ebrahim, 1992). However, rehabilitation with the elderly does not necessarily mean restitutio ad integrum (complete cure of disease, full elimination of handicap) but quite often restitutio ad optimum (improving functional capability and maximizing wellness). According to Williams (1984), rehabilitation in old age may be characterized as a set of techniques as well as a point of view or a philosophy. In accordance with this philosophy, the primary aim of rehabilitation is to restore an individual to their former functional status, or to maintain or maximize independent functioning (Lee & Itoh, 1990; Williams, 1994). Getting elderly clients to transfer themselves from the bed to a wheelchair may thus be a great rehabilitation success and have tremendous impact on the elderly persons' perception of life. At younger ages, the main goal of rehabilitation is the restoration of the individual's capacity to resume family and work roles. However, these are not necessarily the main goals of rehabilitation in old age. Rather, functional independence (self care and instrumental activities of daily living), the cultivation of leisure activities, and a sense of well-being, that is, improvement of life quality, are the main objectives of rehabilitation in old age (Andrews, 1991; Kemp, 1996; Mosqueda, 1996). The general goals of geriatric rehabilitation are to control the underlying disease process, prevent secondary disabilities, restore functional abilities, facilitate the patient's adaptation, educate the patient regarding impairment, and modify or otherwise prepare the environment (Kemp, 1985; Saudan, 1990). The process of rehabilitation can be divided into five formal components (Ebrahim, 1992; Wade, 1992):

(i) Assessment. In addition to medical diagnosis, the identification, analysis, and measurement of problems in terms of disabilities and handicaps is an essential first step in the rehabilitation process. (ii) Planning. This is extremely important in setting long-term, intermediate, and short-term goals. It is necessary to involve the patient as early and as intensively as possible in this planning procedure, since the acceptance of rehabilitation goals is important for motivation and compliance. (iii) Treatment. Having identified the problems and formulated goals, the proper intervention should take place in order to reduce disability and minimize handicap. Treatment might consist of interventions aimed at the restoration of functional independence, cognitive retraining, psychotherapy or mobilization of social support. (iv) Care. Although rehabilitation is aimed at restoring maximal functional capacity, very often care is necessary to support elderly persons and alleviate the consequences of disability. (v) Evaluation. Great importance, although not a standard procedure in many rehabilitation settings, is the careful evaluation of the effectiveness of intervention which should consist of individual reassessment during or after the rehabilitation process (GoÈrres, 1994). Psychosocial and clinical-psychological issues play an important role in all of these components. Thus, rehabilitation should be based on a comprehensive psychological profile of the elderly client that includes neuropsychology evaluation as well as the assessment of personality, emotional-motivational functions and personal goals ((i) and (ii) above, assessment and planning). Individuals also need psychological support in order to cope with the existential crises normally following the onset of disability; treatment should focus on fostering behavioral, cognitive, and emotional changes, working on specific coping strategies, promoting self-esteem, improving family relations, and mobilizing other social network resources ((iii) and (iv) above; treatment and care). Finally, everyday life after rehabilitation should not only be seen in terms of functional gains but also in terms of life quality (subjective well-being, self-efficacy, and positive future expectations; (v) above; evaluation). The goals of geriatric rehabilitation call for a thorough understanding of clinical psychology. Likewise, concepts from geropsychology and lifespan developmental psychology are fundamental to any rehabilitative endeavor. In the following pages, the theoretical foundations of geriatric rehabilitation are reviewed in

General Principles and Geropsychological Essentials of Rehabilitation in Old Age some detail, before turning to psychosocial issues and strategies of rehabilitation with the elderly. 7.23.2.2 Geropsychological Essentials of Rehabilitation in Old Age In practice, rehabilitation efforts will only be effective when essential concepts from gerontological and geropsychological research have been given due consideration. Because aging is a lifelong process, it is suggested that lifespan developmental psychology is crucial to gerontology and can contribute greatly to these conceptual essentials (e.g., Baltes, 1987; Lehr, 1993; 1996; Thomae, 1979). First of all, the rehabilitation of the elderly should not be based on chronological age (or old age) per se but on aging. That is, the emphasis should lie on aging as a dynamic process which can be characterized, like any period of the lifespan, as the simultaneous occurrence of potentials and limits, gains and losses, continuity and change (Baltes, 1987; Thomae, 1979). A variety of studies within geropsychology and developmental psychology stresses the elderly person's potential for growth and development, contrasting starkly with a one-sided picture of mere decline (for overview, see Kruse, 1987; Lehr, 1996). Even when faced with severe competence losses, elderly persons are not reactive, helpless, or passive; instead, the majority of these elderly use a whole scope of coping strategies to deal actively and differentially with threats to their independence and life quality. Rehabilitation of the elderly should thus count on these coping capabilities to address severe illnesses or disabilities. Also, a major task of rehabilitation lies in the reactivation of the elderly person's potential to deal actively with their health threats, thereby regaining as much independent functioning in everyday life as possible. The strategy of selective optimization with compensation is a general adaptational tool to counteract detrimental health changes (e.g., Baltes & Baltes, 1990). From this point of view, rehabilitation in old age can be understood as the transmission of powerful compensation techniques and a mutual search for selective optimization opportunities (particularly in those cases in which the impairment and resulting disabilities can only be altered marginally). To conclude, rehabilitation in old age must base itself upon the insight that elderly persons possess certain fundamental physical and mental potentials (Kruse, 1992); agism must be scoured thoroughly from the rehabilitation effort. Furthermore, the pronounced interindividual variability of the elderly must also be con-

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sidered. Persuasive empirical indications from cognitive, personality, and social network research, show that heterogeneity is one of the defining criteria of the aged population (e.g., Nelson & Dannefer, 1992). The general implication for rehabilitation is that a highly individualized approach is necessary. In particular, there is reason to assume that the estimation of the rehabilitation potential deserves an individual point of view and can be significantly different even when the underlying disease (such as a certain type of stroke) is relatively similar between cases (Kruse, 1992). The mere fact that some individuals possess lifelong expertise in particular areas (whereas other individuals do not) may have tremendous implications for rehabilitation. The acknowledgment of variability also points to the need that rehabilitation efforts should not only focus on impairments and disabilities but also on remaining capacities and competencies. Rehabilitative work must also view aging as an inherently biographical process (Lehr, 1996; Kruse, 1992; Thomae, 1996). Old age is a significant part of the individual biography and life course. Over the course of their lives, individuals develop particular attitudes and coping styles in dealing with everyday challenges and critical life events, such as the onset of severe health problems. Rehabilitation must not neglect these personal styles in dealing with illnesses; it may mean the difference between gaining a powerful tool to understand the idiosyncrasies of the elderly individual and jeopardizing the success of the rehabilitative effort. Individual development, biographical experiences, and evaluative standards also stress the importance of understanding the subjective interpretations assigned to competence losses in everyday life. It is commonplace in clinical work for subjective evaluations of illnesses, impairments, and disability to differ significantly from the ratings of physicians, clinical psychologists, and other professionals involved in the rehabilitation process. One consequence of these discrepancies can be that different goal attainment priorities between the elderly in rehabilitation and their professional surroundings emerge which may delay or even undermine rehabilitation success. According to leading scholars in the field of lifespan developmental psychology (e.g., Baltes, 1987), aging must also be seen as a contextual phenomenon. One set of powerful factors is social influence. It is known from a body of classical work in gerontology that the course of aging is influenced by the way social networks have been arranged and maintained. Also that social contact means, on the one hand, mutual exchange, personal warmth, the opportunity to

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give and to receive, and in a sense even physical and cognitive training. On the other hand, social surroundings may hinder the elderly individual from using or exercising capabilities and may thus contribute to a decline in functioning. Rehabilitation should always consider the social embeddedness of aging processes, especially with regard to severe health problems. Thus, there is a need to integrate significant others in the rehabilitation process. These persons represent concrete links with the everyday world in which the elderly person will return; they may deserve training and education about how to interact with the elderly person after the rehabilitation program. Aging is, however, also aging in place, that is, aging is also influenced by the physical environment (e.g., Lawton & Nahemow, 1973; Parmelee & Lawton, 1990; Saup, 1993; Wahl, 1992). Rehabilitation has to consider the simple fact that elderly faced with severe losses in competence do not normally age in clinical or institutional settings but in their own ªworldº at home. From this perspective, it is one of the challenges of rehabilitation to intervene as effectively as possible (which, in many cases, can only be done in a formal rehabilitation setting) but nevertheless as close to the everyday world of the elderly person as possible. Finally, a very important construct in the rehabilitation of the aged stems from lifespan developmental psychology: plasticity (e.g., Baltes, 1987; Kruse, 1992). This term signifies that the course of aging is not predetermined or fixed, regardless of whether the process in question is one of ªnormalº aging or aging coupled with serious illnesses and disabilities. For example, cognitive training studies have underlined clearly the potential for significant gains which can sometimes exceed the level of untrained younger persons (Baltes, 1993; see also below). So-called control-enhancing interventions have proven their physical and psychological benefits even in frail elderly populations like nursing home residents (e.g., Rodin, 1986). Aging obviously is not a fixed and predetermined process but is subject to many different types of influences which may lead to differential outcomes. Rehabilitation may thus be regarded as one of the most powerful attempts to systematically influence aging organisms challenged by chronic disease processes. In conclusion, the fact is emphasized that the fundamental principles and concepts of geriatric rehabilitation rest upon clinical as well as geropsychological insights. This should be kept in mind as some of the main psychosocial issues and strategies of rehabilitation in old age are discussed.

7.23.3 PSYCHOSOCIAL ISSUES AND STRATEGIES OF REHABILITATION IN OLD AGE 7.23.3.1 Assessment Issues There is wide agreement that only comprehensive geriatric assessment (CGA) can serve as a basis for successful rehabilitative work with the elderly (e.g., Stuck, Siu, Wieland, Adams, & Rubenstein, 1992). Although not expressed explicitly in this widely used term, the assessment of psychological functioning is as a very important part of CGA. Furthermore, geropsychological knowledge and research can contribute to the shortcomings of CGA as it is commonly conducted in most rehabilitation settings. It should be mentioned that the aim of this section is not to give a complete overview of cognitive and neuropsychological assessment (which undoubtedly is also critical with respect to geriatric rehabilitation and its outcomes; see Chapter 7, this volume; see also Franzen & Martin, 1996; Rentz, 1991); instead, issues beyond the assessment of cognitive functioning will be discussed (cf. Lawton & Teresi, 1994). Comprehensive geriatric assessment has at least three major tasks: (i) to measure individual functional capacity, that is, losses as well as competencies at the beginning and during the course of the rehabilitation process; (ii) to contribute to the planning and prognosis of rehabilitation; and (iii) to serve as a tool for quality assurance and evaluation. To fulfill these tasks, CGA is basically aimed at the differential description of disease-related impairments to everyday life and functioning (see again the functional approach as one general principle of rehabilitation, above). 7.23.3.1.1 Activities of daily living and instrumental activities of daily living One core issue of CGA is thus the estimation of decline and competence in activities of daily living (ADL) of varying complexity. In most research and practical work, basic ADL such as the capacity for eating, washing, or dressing are differentiated from instrumental activities of daily living (IADL), such as shopping, phone use, banking, or the intake of medications. A whole range of rather similar scales for the measurement of ADL and IADL can be found in the psychological literature. With respect to the basic ADL, the Barthel index has found wide use in geriatric rehabilitation (Mahoney & Barthel, 1965); prototypical IADL are represented in the widely applied Lawton and Brody scale (Lawton & Brody, 1969). All of these scales are short and easy to apply. However, there are also problems: for one, the

Psychosocial Issues and Strategies of Rehabilitation in Old Age assessment of functional capacity is based mostly on face validity and still lacks theoretical foundation. It is thus strongly argued for closer links between the ADL/IADL literature (including their respective assessment devices in the clinical setting) and emerging theoretical and empirical research on everyday competence (e.g., Baltes, Maas, Wilms, & Borchelt, 1996; Willis, 1991, 1996). In particular, this latter work supports the notion that everyday competence depends heavily on personal and environmental variables that lie beyond chronic illness conditions such as cognitive performance and environmental barriers. One assessment implication of this insight is the need to ªdiagnoseº the physical environment and always interpret a given degree of competence or impairment in everyday functioning (as assessed based on the common ADL/IADL approach) as the result of a transaction between personal capabilities and environmental circumstances. Furthermore, the existing everyday competence literature suggests that basic ADL and IADL are fundamentally different: the former are closely linked to basic physical capacity, whereas the latter depend heavily on motivation and socialization (e.g., preparing meals in elderly men). Second, functional capacity and thus the assessment of everyday performance should not only be focused on ADL and IADL; the capacity to solve everyday problems effectively (Willis, 1996) and to perform leisure activities in the social and nonsocial domain deserve to be assessed as well (e.g., Baltes et al., 1996) in order to gain a comprehensive picture of the everyday implications of chronic disablement. 7.23.3.1.2 Performance vs. reserve capacity ADL/IADL scales can measure performance in functioning but not remaining reserve capacity, that is the individual's potential for further growth, which can be activated during the rehabilitation process. Although there is no via regia to approach this issue (which is a crucial one for planning the rehabilitation process), one important aspect in this regard is to consider the personality characteristics of the elderly client (see below). Obviously, it would not make very much sense to expect that the reactivation of remaining reserve capacities always occurs under ideal personal and environmental conditions. Although it is always possible to alter personality (e.g., by psychotherapeutic intervention) or modify the social and physical surroundings, an adequate and realistic estimation of the current personal and living situation of the elderly client is indispensable. For example,

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anamnestic exploration should not only focus on the medical history but also on personal motivations, biographical key experiences with relevance for the coping with the current rehabilitation process, subjective evaluations of personal competencies, and coping styles (see the geropsychological essentials of rehabilitation described above). Another important area encompasses personality variables such as introversionÐextraversion or anxiety. Both of these variables probably influence the rehabilitation process in different ways. For example, the personality characteristic of introversion versus extraversion may strongly influence the motivation to regain mastery over daily living tasks. Also, trait as well as state anxiety may undermine rehabilitation and transferral to the home situation if not taken seriously. The results of all of these assessments can be crucial for the development of the final rehabilitation plan. Rehabilitation should always be done in close cooperation with the individual because the implementation of relevant goals and strategies depends heavily on the client's insight, motivation, and compliance. According to the contextuality of the aging process and the docility of the chronically ill organism to ªpressingº environmental conditions (as stated quite early on in the so-called Environmental Docility Hypothesis, see Lawton & Simon, 1968), assessment should also include the description of the physical home environment (see, for example, Regnier & Pynoos, 1987). Also, the measurement of rehabilitation outcome should be regarded as more than mere ADL/IADL improvement. The basic aim of rehabilitation to contribute to life quality in general deserves the assessment of subjective well-being, depressivity, or of mood states as well (Kemp, 1996). 7.23.3.2 Restoration of Functional Independence 7.23.3.2.1 Functional independence as basic objective of geriatric rehabilitation The restoration of functional independence can be regarded as one of the most important, though not the only, objective of geriatric rehabilitation. Independent functioning in daily life is highly valued within (Western) society; hence, the preservation or restoration of independence represents one of the most important life goals of most elderly. Basic ADL functions to be considered are self-care (such as eating, drinking, dressing, grooming, washing, and controlling urination and bowel movements) and mobility (getting in and out of bed, chair, or toilet, walking, and climbing stairs). For community dwelling elderly per-

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sons, being capable of performing instrumental activities of daily living is extremely important (doing household chores, shopping, cooking). There is also reason to assume that independent functioning in these daily living tasks is associated closely with related personal variables such as perceptions of control, selfefficacy, and competency; thus, personal autonomy can contribute much to good psychological adaptation in the course of aging. Obviously, the majority of efforts within the multiprofessional team, such as physical or occupational therapy, is aimed toward improving functional capacity. It must once again be emphasized here that this goal does not necessarily entail the restoration of full independence. As Kemp (1996) has put it, to manage the step from ªmaximum assistº to ªpartial assistº can mean a dramatic gain for the elderly individual as well as their social environment. Most importantly, this ªsmallº step can enable the individual to remain in a private household situation and to avoid relocation to a nursing home setting. Reliance upon functional criteria in rehabilitation is reliance upon personal variables, and the latter repeatedly have proven themselves superior to mere medical diagnoses in the prediction of important outcome variables (e.g., nursing home entry, daily life quality, life satisfaction, and even mortality; e.g., Kemp, 1996). 7.23.3.2.2 Contributions from clinical geropsychology It would be shortsighted, however, to view the restoration of independence solely from a physical training perspective. Although bodily functions such as gross and fine mobility are important for performance of ADL and IADL (and should, thus, be trained by different means during geriatric rehabilitation), there is reason to assume that psychological factors are important as well. One factor is cognitive performance (e.g., Baltes et al., 1996; Willis, 1991); cognitive retraining can contribute significantly to the regaining of everyday competence. Also, since striving toward independence has much to do with the motivational and goaldirectedness of each client, counseling and psychotherapeutic interventions can maximize the effects of medically-oriented treatments such as physical therapy and training in basic mobility (see respective sections below). The restoration of functional independence in daily living tasks is also a prototypical case for the effectiveness of behavioral modification techniques based on social-learning principles, that is, it underscores the worth of a genuinely psychological intervention strategy. A whole

body of research has demonstrated that such techniques (e.g., the use of different reinforcement procedures) can contribute significantly to the maintenance or restoration of functional independence in the elderly (e.g., Hasselkus, 1989; Smyer, Zarit, & Qualls, 1990; Wisocki, 1991). These approaches have particular rehabilitative value in institutionalized settings. Not long ago, the institutionalized elderly more or less led passive, sheltered lives under custodial care. In the 1990s, there is a basic consensus that institutions should be able to promote successful aging; they are not only expected to provide a secure and prosthetic environment, but also to stimulate autonomy (Baltes, Wahl, & Reichert, 1991). As was shown in a research program, the etiology and maintenance of dependence in institutions is related closely to the social environment, that is, the dependence-supportive behavior of staff and others in institutionalized settings. The systematic change of these interaction patterns by means of cognitive and behavioral training with staff led to a significant increase in the independent functioning of nursing home residents (e.g., Baltes & Wahl, 1996). Because a strong tendency has been found toward independence-supportive behavior within the home health setting (e.g., Baltes & Wahl, 1992), rehabilitative efforts based on cognitive and behavioral motivations should not be reserved solely for institutional settings. Functional loss is thus not only a characteristic of the person but always a feature person±environment interchange. Naturally, this fact carries implications for rehabilitation. Disability may be reduced by increasing personal competence, changing situational demands, or employing effective compensation strategies (e.g., simplification or redesign of the task; see also Dixon & BaÈckman, 1995). Due to practical constraints in terms of time, effort, or money, rehabilitation aimed toward the restoration of functional independence thus is forced frequently to make a decision of what is more promising, that is, to change the person, to change the environment, or to change the task performance itself. Assessment issues like the ones described above (i.e., information pertaining to the elderly client as well as their social and physical environment) is particularly helpful in selecting the best possible from these alternatives.

7.23.3.3 Cognitive Retraining Cognitive capacity can be divided into two broad ability categories; fluid intelligence and crystallized intelligence (Baltes, 1984; Cattell, 1971; Horn & Hofer, 1992). Fluid

Psychosocial Issues and Strategies of Rehabilitation in Old Age intelligence, also called cognitive mechanics, encompasses the most basic cognitive processes and is measured mostly using memory tasks, problem-solving tasks, or perceptual speed tasks. Crystallized intelligence, or cognitive pragmatics, encompasses the experience and knowledge-related parts of cognitive capacity and is measured using knowledge or fluency tasks. Several studies have shown a decline in fluid intelligence already by middle age, while crystallized intelligence shows stability in adulthood and declines markedly only in old age (Salthouse, 1991; Schaie & Willis, 1993; Smith & Baltes, 1996). Such cognitive decline in old age seems characteristic of normal aging; it is not confined to elderly persons with a diagnosis of dementia (Reischies & Lindenberger, 1996), although it is more severe in such cases. Dementia is a syndrome due to brain disease in which there is impairment of multiple higher cortical functions, including memory, thinking, orientation, comprehension, learning capacity, and language (see also Chapter 10, this volume). The prevalence rates for dementia range from 3±7% for the population over 65 years, and increases dramatically with advancing age (Cooper, 1991a). Given cognitive decline in old age, and especially in the case of dementia, it is worth investigating whether (re)training might possibly help with these ageand/or disease-related losses. 7.23.3.3.1 Intelligence training Experimental studies have demonstrated that cognitive interventions in old age are successful (Baltes & Lindenberger, 1988; Baltes,1993). In several studies, it could be shown that the cognitive performance of elderly people is modifiable (Baltes, Sowarka, & Kliegl, 1989; Blieszner, Willis, & Baltes, 1981; Willis, Blieszner, & Baltes, 1981). In these studies, the emphasis of training was on explaining and practicing rules for solving figural relations tasks and inductive reasoning problems. Even with few (5±10) training sessions, elderly participants increased their test scores in postintervention assessments. Despite the gains achieved in cognitive training, it seems necessary to ensure the generalizability of these interventions (e.g., training in inductive reasoning, deductive reasoning, fluency, and memory techniques should help elderly people solve practical, everyday problems). Furthermore, the rehabilitative power of combining cognitive training with other intervention strategies (e.g., psychomotor training components, training in everyday problem solving) deserve consideration (see for instance Butler & Namerow, 1988, and their differentiation between cognitive

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retraining, aimed at improving cognitive ªmicro-processes,º and skill acquisition training as a functional ªmacro-treatmentº with greater rehabilitation impact; e.g., Oswald, Rupprecht, & Gunzelmann, 1998). Elderly persons at risk of dementia or even at low to moderate levels of dementia also can profit from cognitive training, although their training gains are much lower than those of healthy persons (BaÈckman, Josephsson, Herlitz, Stigsdottir, & Viitanen, 1991; Baltes & Sowarka, 1995). Plasticity appears to be greatly reduced in dementia, even at the onset. Therefore, it has been argued that cognitive training might be a useful diagnostic tool for the early detection of dementia processes (e.g., the testing-thelimits approach; Baltes, KuÈhl, Gutzmann, & Sowarka, 1995). 7.23.3.3.2 Memory training Decrease in memory capacity seems to be a marker of aging, at least in the subjective conceptions of elderly people (Abson & Rabbitt, 1988). More equivocal support for memory decline in old age has been reported (Fleischmann, 1989; Kausler, 1991). Nevertheless, memory training with older participants has been tested carefully. A wide variety of memory tasks (recognition, free recall, or pairassociation learning) and memory strategies (including diverse mnemotechniques like verbal categorization, elaboration, visual imagery, and the method of loci; Fleischmann, 1982; Yesavage, Lapp, & Sheikh, 1989) have been examined. In the majority of these experiments, the effects of memory training in elderly people are positive. Interestingly, memory training which combines memory strategies with reattribution training, in order to reduce exaggerated achievement levels and change attribution patterns for success and failure, might help elderly people most (Lachman, Weaver, Bandura, Elliott, & Lewkowicz 1992; Weinert & Knopf, 1990). Memory training can be effective in mildly demented elderly persons as well (Ermini-FuÈnfschilling & Meier,1995). Still, the generalizability of memory training from laboratory settings to everyday memory functioning has yet to be proven (see also Camp, et al., 1993). 7.23.3.3.3 Reality orientation training Persons suffering from dementia can profit greatly from training in time and space orientation (Kaschel, Zeiser-Kaschel, & Mayer, 1992). Dementia not only affects higher order problem solving but, in later stages, it also impedes basic functions like orienting in time

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(year, season, day of the month), space (rooms of apartment or institution), and contacting communication partners (staff members, family). Basic cognitive training encompasses orientation in time and space; also, reinforcement of the mechanics and pragmatics of intelligence may be included depending on the cognitive status of the rehabilitation client (e.g., BaÈckman et al., 1991; Koh et al., 1994; Little, 1991; Rentz, 1991). Speech and communication therapy might also be very helpful in demented patients or patients suffering from stroke (Sarno, 1984; Jordan, Worral, Hickson, & Dodd, 1993). However, persons with dementia do not only profit from cognitive training in the strict sense of the word. A reactivating occupational therapy program can complement functional rehabilitation in long-term geriatric inpatients with slight to moderate dementia (Bach, Bach, BoÈhmer, FruÈhwald, & Grilc, 1995). To summarize, it can be stated that although younger persons profit even more from cognitive interventions, intelligence and memory training are effective in the healthy elderly. Relatively smaller training effects have been demonstrated in the demented elderly, also. Despite the successes reported in such research, cognitive interventions which fit the everyday needs of elderly people are still the exception. Practical problem solving like reading (and understanding) public transportation schedules might be a good example (Schaie & Willis, 1986). It is also unclear whether cognitive interventions have substantial, long-term consequences. Especially in the case of dementia, however, such interventions might support the person and their caregivers in getting along with the ever-increasing complexity of everyday life.

7.23.3.4 Psychotherapeutic Intervention Disability and handicap mean a more or less sudden decrease in the functional capacity of the elderly person; this may severely threaten mental balance and stability. Most threatening for elderly persons is the anticipation that living conditions must be changed dramatically in the near future (such as the relocation to an institutional setting) or that future life will only be possible at the cost of great dependency upon others. The psychological burden of losing one's own independence is compounded by the anticipation of becoming a burden to others, thereby negatively influencing the life course of loved ones. There is also broad evidence in the depression literature that severe physical chronic conditions are correlated significantly

with depressive episodes (e.g., Schulz & Williamson, 1993; see also Gatz, Kasl-Godley, & Karel, 1996); in other words, besides functional impairments, the identity and selfesteem of the handicapped person are also threatened. Geriatric rehabilitation seldom calls upon psychotherapy to play the role it should in addressing the psychological crisis experienced by the disabled elderly. Rehabilitation should, however, rise to meet the challenge of helping the elderly person to cope successfully with their disabilities and handicaps. To restate the argument: psychologists have more than only diagnostic tasks to fulfill in geriatric rehabilitation. Because of the time limitations of normal rehabilitation efforts, individual and group psychotherapy based on a cognitive-behavioral philosophy seem particularly promising to deal with these problems, especially with depressive episodes (Hartke & Horowitz, 1991; Smyer, et al., 1990). However, treatment of depression is only one focus. There are further challenges having to do with the optimization of the rehabilitation success as well as with the maintenance of outcomes, particularly when transitioning from the hospital to the home situation. One task is to enhance motivation in certain clients, particularly in those who have started rehabilitation based on an externally induced motivation (ªMy wife suggested to try it.º). Another approach with special importance for the maintenance of rehabilitation success in the ªreal worldº employs coping skills training (see also Rodin, 1986). This powerful preventive tool serves to develop strategies and train the individual to deal with daily hassles, stress, and possible failure, all of which occur frequently after returning home. Also, counseling with the goal of enhancing feelings of self-efficacy and competence (despite severe disabilities) may be an important task for clinical psychologists in geriatric rehabilitation. In some cases, psychological support with the goal of learning to accept irreversible losses is critical as well. Social competence training may be particularly helpful in those elderly living alone and running the risk of becoming still more isolated after the onset of chronic illnesses and the disabilities and handicaps they entail. Finally, counseling the relatives of the elderly clients (particularly those living with the client) may be crucial for the maintenance of rehabilitation success. If it is true, as research shows, that a dependence-supportive interaction pattern prevails in the private household setting (as well as in institutional settings), then the counseling and education of the persons in the elderly client's social sphere obviously

Psychosocial Issues and Strategies of Rehabilitation in Old Age becomes most important (Baltes & Wahl, 1992; Wahl & Baltes, 1993). A point frequently not taken as seriously as it deserves should be mentioned at the end of this section, namely, rehabilitation with the mentally ill elderly (e.g., HaÈfner, 1986; see also Carstensen, Edelstein, & Dornbrand, 1996). The special rehabilitation needs of the mentally ill (e.g., those suffering from major depressive disorders or psychotic disturbances) are seldom acknowledged, even among professionals. Researchers and professionals in geriatric rehabilitation should be encouraged to give this subgroup of the chronically ill elderly the attention they rightfully deserve.

7.23.3.5 Considering Motivation and Compliance Issues It is a truism to state that the motivation and compliance of the elderly person are necessary conditions for successful rehabilitation (King & Barrowclough, 1989; Ellul, Watkins, Ferguson, & Barer, 1992; Hartke, 1991; Trezona, 1991). The elderly person has to be convinced that participating in a rehabilitation program is worth the effort and cost. Hence, it is necessary to understand the personal attitudes and intentions of the person before starting the rehabilitation process (see, for example Wiesner & Tesch-RoÈmer, 1996). 7.23.3.5.1 Motivation Although the problem of motivating the elderly patient is often mentioned in the rehabilitation literature, rarely are specific measures for increasing motivation described. Quite often, elderly people are convinced that rehabilitation is not worthwhile, that improvement is impossible, that too much effort is required, or that the results of rehabilitation might threaten the current safe (albeit dependent) life situation. Improving motivation can be achieved through communication with the elderly person before and during rehabilitation, giving credence to individual goals, and simplifying steps needed to achieve rehabilitation objectives (Kemp, 1985). Specifically, changing pessimistic self-efficacy beliefs, strengthening self-esteem, increasing optimism, and exploring ªpossible selvesº might be helpful in increasing motivation for rehabilitation (Guthrie & Harvey, 1994). Important aspects of the rehabilitation process that might enhance motivation are information (What should one know about the intervention?), choice (Which options are available?), goalsetting (What are long- and short-term goals?),

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attention to emotional needs (What does the disability/handicap mean to the person?), and dealing with social anxieties (What do other people think/expect?). Finally, it should be noted that lack of motivation could also be due to an endogenous depressive disorder. Similarly, motivational deficits can occur due to reactive depression following loss sustained in the initial illness or even a specific brain disease (like frontal lobe disorder, Vanderpool, 1984). In these cases, specific therapeutic interventions might be necessary. 7.23.3.5.2 Compliance It is not enough that the person is motivated to start rehabilitation, they must also comply with the rehabilitative process, which can take weeks or months. Problems during the intervention process may result from low motivation, psychosocial crises, or cognitive decline (e.g., memory problems). Hence, elderly persons in rehabilitation should be helped to maintain a schedule if necessary. This can be achieved by keeping short-term goals clear and giving simple instructions for rehabilitation procedures. Moreover, motivation should be maintained by regularly encouraging and reinforcing the rehabilitation progress. Examples for the importance of compliance issues can be found in prosthetics use (Cameron & Quine, 1994), implementing safety features at home (El-Faizy & Reinsch, 1994), and continence training (Fonda, 1991). 7.23.3.5.3 Impact of the social network on motivation and compliance The social network of the patient is very important in rehabilitation motivation and compliance. Motivation is not a personal characteristic, but a product of interpersonal interactions. Hence, motivation can be influenced significantly by rehabilitation staff, family members, and community services (Tucker, 1984). An example might be shaping the self-care behavior of elderly nursing home residents via social feedback from staff members (Baltes, Burgess, & Stewart, 1980; Baltes, Kindermann, & Reisenzein, 1986). It should be noted, however, that it is difficult for health professionals in institutional settings to rate rehabilitation motivation; rehabilitation decisions can be facilitated by describing specific behaviors, like mobility, self-care, independence, and socialization (King & Barrowclough, 1989). Before beginning a rehabilitative intervention, it would seem useful to instill a sense of confidence in the elderly client, to persuade

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them that the long road ahead is not so very difficult and well worth the effort. Motivation is a complex product of the interaction between a person's values, the values held by significant others, history, talents and interests, personality, and treatment setting. As a rule of thumb, one should emphasize that if a derogatory, devalued label is applied to the person (either by the person or by the social network), rehabilitative efforts will fail; conversely, if the person is given positive feedback, the individual's motivation for rehabilitation will be enhanced.

7.23.3.6 The Role of Social Support Social relations change with advancing age. The chance of living with a partner, especially for women, decreases, the size of the social network shrinks, and loneliness increases with advancing age (Wagner, SchuÈtze, & Lang, 1996). Elderly people living in institutions are especially vulnerable to accumulated risk factors for social isolation and loneliness. Nevertheless, important aspects of the ªsocial convoyº remain stable even in old age (Antonucci, 1985). Most elderly people have good relations and frequent contact with children and grandchildren, and elderly people at all ages name friends, acquaintances, or neighbors as parts of their social network. Moreover, elderly people are not solely receivers of social support; they also give support to members of their social network. At this point, one should distinguish between emotional and instrumental support. In rehabilitation, one might inquire regarding what role social support plays in the wellbeing of the disabled elderly, and how social support could be mobilized for the purpose of rehabilitation. 7.23.3.6.1 Effects of social support There can be no doubt that social support, whether instrumental or emotional, helps the elderly individual cope with chronic illness and disabilities that remain even after the best rehabilitation efforts (e.g., Antonucci & Jackson, 1987; Silverstone, 1984). Several studies show that social support has positive effects upon a broad range of handicaps and in various rehabilitation settings. Chronic pain patients with supportive families tend to report less pain intensity, less reliance on medication, and greater activity levels than patients with nonsupportive, disharmonic families (Jamison & Virts, 1990). In stroke patients, emotional support and moderate degrees of instrumental

support are related to positive outcomes and recovery (Glass & Maddox, 1992). However, social support might be dysfunctional as well. Too much instrumental support might hinder the recovery of stroke patients. Hence, the positive and potentially negative sides of social support deserve consideration in this context. On the one hand, social partners should be integrated into the rehabilitation process as early as possible, since they are able to contribute significantly to the restoration and maintenance of functional independence of the elderly client. On the other hand, social interactions can also become detrimental to the elderly when social partners tend toward overcare (e.g., Baltes & Wahl, 1996), or care giving situations evoke an overflow of problematic psychodynamic elements (see Pearlin, Aneshensel, Mullan, & Whitlatch, 1996). 7.23.3.6.2 Mobilizing social support Social relations (and the sources of social support) can be divided into informal and formal support givers (Silverstone, 1984). Among the informal support givers are spouses (especially wives), children (especially daughters), friends, and neighbors. The existence of a possible support giver does not necessarily mean that an elderly handicapped person receives help from network members. This is of some importance, because without some type of informal support, a return to the patient's home in the community might be very difficult. The burden (and the support) of the caregivers should also be acknowledged (see Chapter 22, this volume). The support offered by family (and friends) should be supplemented by formal support givers, such as primary health care, rehabilitation services, social workers, homemakers, meals-on-wheels, and so on. It should also be acknowledged that the (possibly short) acute phase of illness is usually followed by a recuperative phase and a (probably long) maintenance phase. Allocation of formal community services should depend on the needs and prospects of the care recipient and amount of resources available. Even in the case of psychiatric disorders, day-care, outpatient care, and community-based care can be implemented (Cooper, 1991b). Hence, whenever possible, the global goal of rehabilitative efforts is to discharge elderly patients into the community, that is, back to their former, everyday living situation. Therefore, the mobilization of social support is important for helping the elderly person to live as independently as possible but with as much help from social partners at home as necessary. Living in the community and in one's own home

Psychosocial Issues and Strategies of Rehabilitation in Old Age means getting permanent and everyday support, even if this support takes the form of ªsmallº gestures and signs from the neighborhood (Wagner, SchuÈtze, & Lang, 1996).

7.23.3.7 Ecological Aspects of Rehabilitation Although a ªgestalt switchº from the elderly person to the environment took place in the 1960s and 1970s (see, for example, Lawton & Nahemow, 1973), gerontology in general and geriatric rehabilitation in particular is still very ªperson centered.º From its inception, environmental gerontology persistently has considered the elderly person's surroundings as protective or risk factors for independent functioning. Of particular relevance here is the Environmental Docility Hypothesis, according to which the elderly suffering from competence losses and chronic conditions are particularly prone to environmental characteristics (e.g., Lawton, 1982; Lawton & Simon, 1968). A few simple statements can be emphasized. Independence in self-care always means independence in a certain bathroom environment (with certain supportive or constraining conditions). Independence in meal preparation always means independent meal preparation in a certain kitchen environment with specific features and equipment. Finally, independence in shopping always means independence within a certain neighborhood or meso-environment with supermarkets of varying proximity.

7.23.3.7.1 Person±environment fit as critical for rehabilitation There is thus good reason to assume that discrepancies between the competence profile of the elderly person and the environment can undermine even the best person-centered rehabilitation effort (e.g., Lawton, 1982; Olbrich & Diegritz, 1995). This is true, for instance, with respect to the eastern part of Germany (the former German Democratic Republic), in which housing conditions are still significantly worse compared to those in the western part. As empirical analyses have revealed, discrepancies on measures of daily competence are at least in part caused by poor living environments within and outside the home (e.g., long distances to supermarkets and pharmacies) that are prevalent in the eastern regions of the country (Olbrich & Diegritz, 1995; Schneekloth & Potthoff, 1993). Thus, rehabilitation should always be aimed at both training the elderly client to cope with

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environmental challenges and changing environmental features to suit their profile of deficits and competencies (e.g., Regnier & Pynoos, 1987; 1992; Parmelee & Lawton, 1990). Rehabilitation may thus be defined as the attempt to reduce all possible discrepancies between personal competence and environmental challenges by focusing on the person and their physical environment.

7.23.3.7.2 Considering objective and subjective environmental aspects within the everyday world One should also note that the physical environments of the elderly are more than mere objective surroundings which vary in the amount of support they offer. Environments may also be viewed as materializations of personal biographies and as extensions of the personal self (Wahl & Oswald, in press); this concept is particularly relevant for the great number of elderly individuals who do not live for decades at the same location. Thus, alterations may indeed be helpful and necessary for the rehabilitation outcome from an objective perspective, but not from the elderly client's point of view. Geriatric practitioners should take these subjective evaluations seriously; the elderly individual's decision to refrain from modifying their home environment must be considered to be a valid choice, even though it might lower independence in daily functioning in the long run. Furthermore, elderly persons should not be seen as mere pawns of their environmental conditions. The creativity with which the elderly (particularly those suffering from chronic conditions) use their potential for compensation is very impressive; they demonstrate consistently a high degree of ªproactivityº in adapting themselves to their living environments and vice versa (Lawton, 1989; see also Wahl & Oswald, in press). The ecological approach to geriatric rehabilitation may be used to illustrate another basic issue. Environmental gerontology and psychology have always stressed the importance of remaining as close as possible to the everyday world of their subjects (see for example the concept of behavior setting proposed by Barker, 1968); likewise, rehabilitation efforts should also demonstrate a good measure of ªecological validityº (Wahl & Baltes, 1993). Rehabilitative work, particularly when it takes place in a hospital setting, should do its utmost remain close to the ªlife worldº of the elderly individual; this is the most promising way to ensure the maintenance of rehabilitation outcomes in the home world.

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7.23.3.7.3 New technologies and their rehabilitation potential Finally the issue of old age and technology should be mentioned briefly, particularly socalled new technologies (e.g., Bouma & Graafmans, 1992; Charness & Bosman, 1990). What is emphasized here, is that there is no reason to assume that elderly persons are unable or unwilling to use new technologies. Instead, these devices could become major parts of the rehabilitative process in a variety of ways. For example, shopping via a home computer may be advantageous to the elderly person with significant impairment in mobility, and contribute greatly to self-efficacy and feelings of control. E-mail services or fax devices can facilitate the maintenance of social networks and social exchange, particularly when social isolation results from disablement. 7.23.4 PSYCHOSOCIAL REHABILITATION ISSUES WITH RESPECT TO PARTICULAR CLIENT GROUPS Rehabilitation must change to suit different kinds of handicaps. With this in mind, four client groups, namely stroke patients, arthritis patients, the sensory impaired elderly, and demented elderly, are discussed in more detail in this subsection. Although it is clear that rehabilitation programs exist for other agerelated handicaps as well (e.g., amputation, Marmann, 1994; falls and hip fracture, Campbell, 1992; Felsenthal & Stein, 1990), there are at least three reasons to concentrate on these four target groups. First, each of these illnesses represents a chronic condition that is highly prevalent in the population at large. Second, arthritis, sensory impairments, dementia, and to a lesser extent, stroke, do not receive the attention within geriatric rehabilitation which they deserve. Third, each patient group poses a significant, yet unique challenge to the rehabilitation professional. 7.23.4.1 Stroke Patients Cerebrovascular diseases belong to the most prevalent diagnoses in old age (SteinhagenThiessen & Borchelt, 1996). Cerebral vascular accident (stroke) constitutes the third leading cause of death in the United States (following heart disease and cancer). About one third of stroke victims will die within the first three months after the stroke. Symptoms of stroke can be partial or complete paralysis, urinary incontinence, difficulties in swallowing, aphasia, and losses in memory and other cognitive functions (Wade, 1992). The functional con-

sequences of stroke are often serious and concern overall physical ability (activities of daily living), walking, dexterity, and communication (Gibson & Caplan, 1984). Very often mood changes occur; many stroke victims develop depressive symptoms which might negatively influence the rehabilitation process (Goldberg, 1984). Early medical treatment of the stroke is extremely important, and it seems that specialized stroke units reduce morbidity and mortality among stroke victims (Langhorne, Williams, Gilchrist, & Howie, 1993). Once the clinical state has settled, one can expect a period of rapid recovery over the first 2±3 weeks, followed by slower but continuing improvement over the next five months (Wade & Langton-Hewer,1987). There is much debate whether functional improvement occurs after that, but some studies show that continued rehabilitative efforts might be helpful (Dam, et al., 1993). More information on pathophysiological changes can be found in geriatric textbooks (Abrams, Berkow, & Fletcher, 1990; Brocklehurst, Tallis, & Fillit, 1992; Evans & Williams, 1992; Pathy, 1991). 7.23.4.1.1 Critical issues of rehabilitation Rehabilitation should start immediately after the onset of stroke. From the beginning, the patient should be mobilized and encouraged to be as independent as possible. Rehabilitation efforts should also be directed toward communication disorders, upper extremity function, and bowel and bladder care. Assessment is also crucial to stroke rehabilitation; detecting disabilities, discovering the relevant impairments, determining prognosis, planning the intervention process, and evaluating rehabilitation progress are the tasks of the interdisciplinary stroke rehabilitation team (Kruse, 1992, 1995; Rustemeyer, 1983). Physicians are responsible for medical diagnosis and treatment, although no effective medical therapy can ensure complete recovery from stroke. Hence, a variety of professions are involved in stroke rehabilitation. Physiotherapeutic exercises, such as those which improve range of motion, muscle strength, and endurance, are necessary for dealing with muscle spasticity and improving functional performance (Lee & Itoh, 1992). The Bobath method of treatment has been very influential in stroke rehabilitation, emphasizing the suppression of abnormal postures and movements before normal motor patterns are practiced (Bobath, 1971). Although physiotherapy should start early, even late physiotherapeutic intervention (12 months after stroke) can improve mobility (Wade, Collen, Robb, & Warlow, 1992). Occupational therapy is

Psychosocial Rehabilitation Issues with Respect to Particular Client Groups directed at training compensatory techniques for performing activities of daily living (Hasselkuss, 1989). Speech therapy is aimed at supporting stroke patients to overcome communication problems (Lehmann, 1992; Sarno, 1984; Vignolo, 1964). Psychologists might carry out several important tasks in stroke rehabilitation. Changes concerning alterations in intellect, personality, and emotional behavior deserve attention in the diagnostic process as well as in psychotherapeutic interventions aimed at the elderly person or their social environment (Kruse, 1984). First, psychological and neuropsychological diagnostics are genuinely psychological tasks and highly relevant for assessing the specific problems of stroke patients (Lawton & Teresi, 1994). Since many patients suffer from depressive symptoms, psychological counseling might help the patient to cope with the losses resulting from the stroke and to recover from depressed mood. Clinical psychologists working with stroke patients need to plan realistic shortterm goals, provide structure for working sessions, and carefully confront the patient with the denial of disability (Goldberg, 1984). Also group therapy with other stroke patients and family therapy, involving spouse and other family members, might be helpful. Ideally, stroke patients should be able to return home after rehabilitation. It is necessary to plan carefully the discharge of the patient, involving family and community-based services as far as possible. If necessary, the patient's home should be altered to accommodate the needs of the stroke patient. For family members, caring for a relative suffering from stroke and its consequences is highly distressing; hence, community services should not only focus attention toward the neuropsychological aspects of stroke patients, but also toward the social functioning of caregivers who support them (Anderson, Linto, & Stewart-Wynne, 1995). 7.23.4.1.2 Effects of rehabilitation and challenges in the future Since the treatment of stroke in older patients is the rule rather than the exception, research has been devoted to demonstrating the effectiveness of rehabilitation over spontaneous recovery. Meta-analyses show that stroke rehabilitation programs may improve the functional performance of stroke patients (Ottenbacher & Jennall, 1993). The extent of improvement appears to be related to the timely initiation of treatment, but not to the duration of intervention. Improvements are also associated with the patient's age, older patients

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taking longer to recover from stroke (Falconer, Naughton, Strasser, & Sinacore, 1994; Kalra, 1994). Regarding the institutional setting of stroke rehabilitation, it seems that early care in specialized stroke units might be most effective (Jùrgensen et al., 1995; Kaste, Palomaki, & Sarna, 1995). In the further rehabilitation process, day hospitals may be more effective (and also economically advantageous) compared to conventional hospital management (Gladman, Forster, & Young, 1995; Hui, Lum, Woo, Or, & Kay, 1995). The 1980s and 1990s have seen the establishment of special stroke units within hospitals. What is needed now are efforts for continuing rehabilitative efforts in the community, cooperation between professions, and better gerontological and geriatric education for professionals working in stroke rehabilitation. In particular, clinical psychologists working in geriatrics commonly report scarce academic preparation and training experiences and relate continuing education to higher satisfaction with geriatric work experiences (Lichtenberg & Rosenthal, 1994). The rehabilitation of a patient who has suffered a stroke is a challenge for the geriatric rehabilitation team and requires diagnostic, management, and counseling resources. Since so many psychomotor functions and psychosocial aspects are affected by a stroke, it can be taken as a general model for rehabilitation in old age. Although the medical treatment of risk factors for stroke (especially hypertension) has proven itself to be an effective prevention, stroke rehabilitation will continue to be an important part of geriatric medicine.

7.23.4.2 Arthritis Patients The most common chronic condition in old age results from arthritis and rheumatism (US Department of Health and Human Services, 1992). Rheumatoid diseases are characterized by chronic inflammation of joints and soft tissues. Degenerative arthritis results from wearing out of joints (e.g., hip, knee) or from degeneration of bones (e.g., osteoporosis). Age at onset has an aggravating effect on disease expression in rheumatoid arthritis (Keitel, 1993). Symptoms of arthritic diseases are pain (like back pain or pain in the affected joints) and decreasing flexibility of the affected joints (e.g., hip, knee, foot, or fingers). Emotional consequences of arthritis can be increased depressive symptoms or dysphoria (Frank et al., 1992). Functional consequences of arthritic conditions are reduced mobility and losses in certain ADL functions (Badley & Tennant, 1993). Treatment of the several forms of rheumatoid and

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degenerative arthritis involves anti-inflammatory and analgesic drugs, although medical and physical treatment modalities are closely interrelated and should always be considered together (Baum, 1984). Hence, physical therapy and exercise programs are also extremely important. Sometimes surgery might be effective (like artificial hip joints). In some cases, dietary restrictions might be helpful (degenerative arthritis: weight loss; gout: restriction of calories and alcohol; osteoporosis: additional supply of calcium). 7.23.4.2.1 Physical therapy In patients with degenerative joint disease, physical exercise programs should be used. Exercises to maintain muscle function are as important as exercises to strengthen specific muscle groups around the affected joint. In contrast, in elderly patients with arthritic conditions, it is necessary to control the underlying inflammatory disease before starting with exercise programs (Baum, 1984). Moreover, morning stiffness and afternoon fatigue make it necessary to schedule active therapy between the end of morning stiffness and the onset of fatigue. Exercise programs have been shown to be effective in increasing mobility, endurance, and functional status (Kovar et al., 1992). Also occupational therapy has positive effects on functional status (Helewa et al., 1991). Moreover, physiotherapy also seems to protect bone mass which may have implications for avoiding bone fractures in the long run (Shawe, Hesp, Gumpel, Sambrook, & Reeve, 1993). 7.23.4.2.2 Psychological interventions Physical exercise programs not only improve physical health but can also improve mood and reduce anxiety and pain (Frobose & Schule, 1992). Hence, it is an important task for gerontopsychologists to strengthen the compliance of elderly arthritic patients with the therapeutic regimen and exercise programs. The perceived benefits of exercise programs can be an important determinant of exercise participation and compliance (Neuberger, Kasal, Smith, Hassanein, & DeViney, 1994). Moreover, certain sociodemographic characteristics (lower income, lower education, and higher chronological age) might lead to underuse of physical or occupational therapy provided by community services (Mayer-Oakes et al., 1992). The particular challenge for geropsychology with respect to arthritic patients lies in the chronic pain which may undermine life quality severely and permanently (Smith, Wallston, & Dwyer, 1995). The stress and coping

literature in general, as well the intervention literature in particular, has not put enough emphasis on the question of what it means to age in the face of chronic and uncontrollable pain. Intervention may thus be aimed at direct alteration of the pain (e.g., by using biofeedback procedures) as well as supportive measures that enable the individual to live better with this chronic stressor (e.g., relaxation techniques, client-centered counseling). Controlled studies show that behavior-oriented interventions might influence knowledge about the disease and pain coping strategies, even if health status deteriorates because of the progressive nature of rheumatoid arthritis (Barry, Purser, Hazleman, McLean, & Hazleman, 1994; Kraaimaat, Brons, Geenen, & Bijlsma, 1995; Matussek, 1992; Simeoni, Bauman, Stenmark, & O'Brien, 1995). Since arthritic diseases affect mobility, the body self-image of an elderly person might be threatened. Clinical psychologists might help arthritic patients to cope with these losses (Jordan & Schmidt, 1988; Lehr, Kruse, & Kruse, 1992). The musculoskeletal diseases account for the most frequent complaints among elderly persons. Since it is rarely possible to provide the patient with complete symptomatic relief, it is necessary to inform them about adequate health habits, concepts of preventive care, the value of physiotherapeutic and occupational exercises, and the gains to be achieved through behavioral and cognitive therapy. 7.23.4.3 Sensory Impaired Elderly Losses in hearing and vision are very common in old age (Tesch-RoÈmer & Wahl, 1996b). Hearing impairment undermines the elderly person's everyday communication, whereas losses in vision impede orientation within the physical environment. Aural rehabilitation with elderly suffering from hearing impairments includes technological devices like hearing aids and behavioral communication strategies (Kaplan, 1989; McCarthy & Sapp, 1993; Wahl & Tesch-RoÈmer, 1996). Rehabilitation with the visually impaired elderly consists in orientation and mobility training, exercises in activities of daily living, and the use of magnifying optical devices (LaGrow & Blasch, 1992; Wahl & Oswald, 1996; Wahl & Tesch-RoÈmer, 1996). 7.23.4.3.1 Hearing impairment Hearing impairment is the second most prevalent chronic condition in old age; about 30% of those over 65 are so severely hearingimpaired that they would benefit from a hearing

Psychosocial Rehabilitation Issues with Respect to Particular Client Groups aid (Davis, 1989; US Department of Health and Human Services, 1992). Presbycusis (or hearing loss in old age) is a high-frequency symmetric hearing loss in old age beginning gradually around the fifth decade and leading progressively and irreversibly to moderate and severe losses of hearing capacity in higher ages (Corso, 1981; Fozard, 1990; Kline & Scialfa, 1996; Willott, 1991; Olsho, Harkins, & Lenhardt, 1985). Age effects for auditory and speech processing independent from hearing sensitivity have also been documented (Humes & Christopherson, 1991). Hearing loss in old age can have negative consequences in the areas of communication, social integration, well-being, and cognitive capacity (Marsiske, Delius, Lindenberger, Scherer, & Tesch-RoÈmer, 1996; Rott, Wahl, & Tesch-RoÈmer, 1996; Weinstein & Ventry, 1983). There is no medical cure for presbycusis. The only way to help elderly hearing-impaired adults is through rehabilitation with hearing aids (Glass, 1986; Stephens & Goldstein, 1983). Hearing aids are small technical devices which amplify environmental sounds. Although there have been advances in hearing aid technology, hearing aids are problematic devices. Four problem areas in the use of hearing aids have been identified. Elderly hearing aid users complain of poor amplification, stigmatization, financial costs, and handling problems (e.g., inserting the hearing aid in the earmold or manipulating small levers; Franks & Beckmann, 1985; May, Upfold, & Battaglia, 1990). Nevertheless, the use of hearing aids reduces the subjective communication problems of elderly persons with hearing impairment (Tesch-RoÈmer, 1997). Elderly hearing-impaired patients should be supported in several ways (Tesch-RoÈmer & Wahl, 1996a). Patients should be informed carefully about the functioning and handling of technical aids (in addition to hearing aids, a variety of listening devices exists; Kaplan, 1987). Since hearing with hearing aids is a new experience for the impaired person, they should adapt systematically to the hearing aid (e.g., use the hearing aid first in one-to-one communication and only later in group situations with background noise). Moreover, it could be useful to train the hearing impaired elderly in communication strategies and ªhearing tactics,º such as asking for well-articulated repetitions, occupying acoustically favorable positions, and lip reading (Vognsen, 1976). 7.23.4.3.2 Visual impairment As is the case with respect to the elderly with hearing impairments, age-related low vision and

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its rehabilitation has only received due acknowledgment in the 1990s. The empirical work (Wahl, 1997; see also Wahl & Oswald, in press) has shown clearly that visual impairment has negative emotional and behavioral consequences. For example, significantly higher rates of clinically relevant depression and lower subjective well-being have been reported repeatedly (for overview, see Wahl, 1997; see also Horowitz, 1995). It should be mentioned here, however, that the negative impact on emotional adaptation does not substantially correlate with the objective loss in visual capacity. Regarding behavior, there can be no doubt that the visual loss has profound negative consequences with respect to daily living competence and independent functioning. Moreover, the visually impaired elderly are challenged by the fact that at least some of their preferred leisure activities (reading activities in particular) may become very difficult or even impossible without a good rehabilitation program. Finally, visual impairment is a prototypical environment-relevant loss in competence (Wahl, 1994). Thus, agerelated loss in vision may be seen as a prototypical case for an ecological approach to geriatric rehabilitation. The negative impact of significant (and irreversible) vision loss (e.g., caused by macular degeneration or diabetic retinopathia) makes a multidimensional rehabilitation approach necessary. The main goal of rehabilitation is the restoration of reading capability by the appropriate use of technical devices. A whole range of technical tools, from magnifying glasses to computer-based reading devices, exists (see, for example, Tesch-RoÈmer & Wahl, 1996a). The challenge here is not the device itself but the implementation of these devices in the everyday world of the visually impaired elderly. Moreover, good training with a high degree of ªecological validityº is also needed. A second rehabilitation issue is training in orientation and mobility. The challenge with respect to these rehabilitation techniques lies in the fact that elderly persons often have concomitant impairments of a chronic nature, for example, coexisting hearing, motor, or cognitive impairments. A third issue is training in the domain of daily living tasks. In all of these rehabilitation efforts, training must take place within the elderly person's everyday world. Interventions in the environment of visually impaired elderly are frequently supportive and helpful. With respect to the social environment, it is very important to educate social partners to take the disabilities of their relatives and friends seriously while resisting the temptation to be overprotective. With respect to the physical environment, a whole range of alterations has

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been suggested (e.g., Hiatt, 1987) such as the enhancement of light conditions (without producing too much glare), the use of contrast and color, and the employment of technical innovations such as special telephones or talking appliances for the kitchen. To conclude this section, the rehabilitative needs of sensory impaired persons have only been articulated in the 1990s. The aim of this section was thus not only to elaborate on the special needs of these groups of elderly (those with impairments in vision and hearing), but also to emphasize that the rehabilitation of these elderly must consist of more than the mere adoption of technical devices. Truly adequate interventions must implement the devices properly and facilitate the elderly person's adaptation to the new technology. And of course, rehabilitation must enable the individual to better cope with the psychosocial losses caused by the sensory impairment (e.g., Tesch-RoÈmer & Nowak, 1995; Wahl & Oswald, 1996).

cognitive training intervention (e.g., Oswald et al., 1988). Family members and other caregivers should be part of rehabilitative efforts, too (Pearlin et al., 1996; see also Chapter 22, this volume). Thus, the comprehensive care of the caregivers, as suggested in the literature on caregiver burden, may also be regarded as a very important part of the geriatric rehabilitation system. In a sense, it also serves important preventive purposes. As is known, being a caregiver for a demented individual heightens the risk of suffering from chronic physical or mental conditions in the long run. Finally, the treatment of dementia provides a prototypical example of how, given unchangeable person characteristics, the possibility of altering the physical environment always remains. This is particularly true in institutional settings, but also relevant in private home living. Some persuasive and empirically proven solutions for modifying and adjusting the environment have been suggested in the literature (e.g., Regnier & Pynoos, 1992).

7.23.4.4 Demented elderly

7.23.5 PRACTICAL ISSUES, RESEARCH QUESTIONS, AND ETHICAL PROBLEMS

Dementia is a very serious problem in the elderly, especially in the very old (see Chapter 10, this volume). In the most common form of dementia, Alzheimer's disease, aphasia, agnosia, and apraxia are present in various combinations as well as emotional and personality changes, memory disorders, slowness in rate of information processing, and the incapacity to fulfill daily living activities. It would therefore be reasonable to question the merit of rehabilitation efforts with the demented elderly. However, professionals as well as society as a whole, cannot neglect the burden and challenge of the tremendous and fast growing number of elderly suffering from dementia. Custodial care is obviously not the right answer. The responsibility for this problem should be shared by all and should address the challenge with those rehabilitative tools which promise at least some measure of success. In this context, it may not be wise to talk about ªdementiaº in general. There are different degrees of severity, and each patient exhibits a unique profiles of competencies; both of these factors crucially affect rehabilitation outcome. Rehabilitation efforts undoubtedly should include reality orientation programs and training to cope, at least in part, with daily living challenges. Data suggest that rehabilitative work of this kind may be particularly promising when it starts in the early stages of the cognitive decline process. Intervention studies hint that further deterioration can be delayed by early

The last section of this chapter is concerned with some practical, research-oriented, and ethical problems associated with rehabilitation in old age. Practical problems concern the institutional organization of geriatric rehabilitation, the qualification of staff, and the assurance of rehabilitation quality. Research questions concern the effectiveness of interventions and the development and evaluation of innovative rehabilitation concepts. Finally, ethical problems deal for instance with the distribution of scarce resources within the health care system. 7.23.5.1 Practical Issues Regarding the institutional organization of geriatric rehabilitation, it has been shown that specialized geriatric units or geriatric hospitals are more effective and more cost efficient than general medical wards (GoÈrres, 1992b). An important problem for elderly patients after rehabilitation is returning home and maintaining independent living in the community. It could be helpful to view this problem from the perspective that individuals with disabilities are handicapped more by barriers in the environments than by their specific impairments (DeJong, Batavia, & McKnew, 1992) and that rehabilitative interventions should be realized in conjunction with community-based long-

Practical Issues, Research Questions, and Ethical Problems term care (Miller, 1991; see also Chapter 20, this volume). Another important practical problem is quality assurance (GoÈrres, 1994; Meier-Baumgartner et al., 1992). Conceptions of rehabilitation programs might be very different from their practical implementation. Hence, it is necessary to control the quality of rehabilitative interventions. Three aspects of quality in medical care and rehabilitation can be distinguished (Donabedian, 1966): quality of structure, process quality, and outcome quality. Quality of structure concerns characteristics of the institution, the educational profile of staff, and quality of technical equipment. Process quality concerns characteristics of the rehabilitation process (diagnostics, development of rehabilitation goals, implementation of therapy and interventions, documentation of changes, and team communication). Outcome quality concerns the evaluation of changes stemming from rehabilitative efforts (reduced morbidity and mortality, increased functional independence, ability and motivation for independent living, patient satisfaction). Quality of rehabilitation structure and process are necessary conditions for outcome quality; but outcome quality certainly is what counts in evaluating rehabilitation services (GoÈrres, 1992b).

7.23.5.2 Research Questions For policy planning and program development, it seems necessary to gather epidemiological data on chronic diseases in old age. The lack of adequate epidemiological data might lead to underestimating the need for rehabilitation efforts. A second major research problem concerns the effectiveness of rehabilitation programs (GoÈrres, Tschubar, & Meier-Baumgartner, 1991). Rehabilitation programs should be tested empirically regarding their effectiveness and efficiency by considering a psychosocial view of life quality as well as a cost-benefit ratio. Although it may be ethically questionable to evaluate rehabilitation programs involving experimental and control groups in pre/posttreatment designs, nevertheless controlled studies should be the standard procedure in rehabilitation research (Wottawa & Thierau, 1990). Finally, the development and evaluation of innovative rehabilitation programs is an important research task. It should be emphasized again that not only dramatic diseases (like stroke) should be the focus of future gerontological rehabilitation research. There are a variety of age-related diseases which urgently require rehabilitation (e.g., arthritis, vision problems and blindness, hearing loss).

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7.23.5.3 Ethical Problems There are several ethical issues concerning rehabilitation in old age (e.g., Spicker, Ingman, & Lawson, 1987). Thinking about rehabilitation implies reference to norms (What is the goal of rehabilitation?), making a decision between rehabilitation and care (When does rehabilitation promise progress in the individual?), and weighing individual and social benefits and costs (What are the gains of rehabilitation compared to the costs?). Considering rehabilitation goals, normative standards (e.g., independent living) could come in conflict with individual values (e.g., security and social contact). Hence, in developing rehabilitation goals, individual values should be considered carefully. Second, before an individual rehabilitation process is initiated, a decision has to be made regarding the rehabilitation potential of the particular individual; sometimes this decision concerns the alternatives rehabilitation vs. care. But even in geriatric, long-term care facilities, nursing does not necessarily have to fulfill a primarily custodial function; rather, it could also be performed according to a therapeutic model of rehabilitation (Burgio & Burgio, 1990). However, sometimes the general goal of rehabilitation has to be given up, and a decision to commit to long-term care be made. This decision might also involve considerations of costs and benefits (Brody, 1987; Hausman, 1987). There are individual costs connected with rehabilitation (e.g., time and effort), but these costs might be outweighed by the potential benefits of rehabilitation outcomes. Additionally, there are also material costs (e.g., financial support for rehabilitation programs). It should be emphasized, though, that rehabilitation is based on humanistic values. This basic ethical orientation stresses that the disabled elderly deserve, as much as anyone else, the opportunity to participate in all aspects of life (Kemp, 1985). Beyond humanistic arguments, however, one might add that current economic conditions make rehabilitation more efficient in the long run than long-term care. Rehabilitation in old age is a promising field. Empirical research demonstrates the effectiveness of psychosocial interventions in a variety of chronic diseases. Moreover, rehabilitation in old age should not necessarily be dominated by the medical profession. Instead, clinical psychology should demonstrate its rich reservoir of intervention and therapeutic strategies, and clinical psychologists might more often lay hold of the leadership in interdisciplinary rehabilitation teams. Despite unsolved practical issues, open research questions, and difficult

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ethical problems, rehabilitation in old age is a gratifying field of expertise for clinical psychologists. 7.23.6 SUMMARY In this chapter, general principles and geropsychological essentials of rehabilitation in old age are reviewed from a geropsychological perspective. Rehabilitation aims at reducing the disability and handicap experienced as a result of disease and impairment. Since aging is associated with increased chronic illness, the goal of rehabilitation in old age is not necessarily complete cure of disease but improving functional capability and maximizing wellness. An overview concerning psychosocial issues and strategies of rehabilitation in old is given, including comprehensive geriatric and psychosocial assessment, restoration of functional independence, cognitive and reality orientation training, therapeutic intervention, motivational and compliance problems, the role of social support, and the ecology of aging. Since different geriatric client groups have different rehabilitation needs, four highly prevalent and serious chronic conditions in old age are treated specifically, that is, stroke, arthritis, sensory impairment, and dementia. The chapter closes with perspectives for psychologists working in rehabilitative settings discussing practical issues, research questions, and ethical considerations. 7.23.7 REFERENCES Abrams, W. B., Berkow, R., & Fletcher, A. J. (Eds.) (1990). The Merck Manual of Geriatrics. Rahway, NJ: Merck, Sharp, & Dohme Research Laboratories. Abson, V., & Rabbitt, P. M. (1988). What do self-rating questionnaires tell us about changes in competence in old age? In M. M. Gruneberg, P. E. Morris, & R. N. Sykes (Eds.), Practical aspects of memory: Current research and issues (pp. 188±191). Chichester, UK: Wiley. Anderson, C. S., Linto, J., & Stewart-Wynne, E. G. (1995). A population-based assessment of the impact and burden of caregiving for long-term stroke survivors. Stroke, 26, 843±849. Andrews, K. (1987). Rehabilitation of the older adult. London: Edward Arnold. Andrews, K. (1991). Rehabilitation of the elderly. In M. S. J. Pathy (Ed.), Principles and practice of geriatric medicine (pp. 1341±1365). Chichester, UK: Wiley. Antonucci, T. C. (1985). Personal characteristics, social support, and social behavior. In R. H. Binstock & E. Shanas (Eds.), Handbook of aging and the social sciences (2nd ed., pp. 94±128). New York: Van Nostrand Reinhold. Antonucci, T. C., & Jackson, J. S. (1987). Social support, interpersonal efficacy, and health: A life course perspective. In L. L. Carstensen & B. A. Edelstein (Eds.), Handbook of clinical gerontology (pp. 291±311). New York: Pergamon. Bach, D., Bach, M., BoÈhmer, F., FruÈhwald, T., & Grilc, B. (1995). Reactivating occupational therapy: a method to

improve cognitive performance in geriatric patients. Age and Ageing, 24, 222±226. BaÈckman, L., Josephsson, S., Herlitz, A., Stigsdotter, A., & Viitanen, M. (1991). The generalizability of training gains in dementia: Effects of an imagery-based mnemonic on face-name retention duration. Psychology and Aging, 6, 489±492. Badley, E. M., & Tennant, A. (1993). Disablement associated with rheumatic disorders in a British population: problems with activities of daily living and level of support. British Journal of Rheumatology, 32, 601±608. Baltes, M. M. (1996). The many faces of dependency in old age. Cambridge, UK: Cambridge University Press. Baltes, M. M., Burgess, R. L., & Stewart, R. B. (1980). Independence and dependence in self-care behaviors in nursing home residents: An operant-observational study. International Journal of Behavioral Development, 3, 489±500. Baltes, M. M., Kindermann, T., & Reisenzein, R. (1986). Die Beobachtung von unselbstaÈndigem und selbstaÈndigem Verhalten in einem deutschen Altenheim: Die soziale Umwelt als EinfluûgroÈûe [The observation of dependent and independent behavior in a German old age home: the social environment as an influencing factor]. Zeitschrift fuÈr Gerontologie, 19, 14±21. Baltes, M. M., KuÈhl, K. P., Gutzmann, H., & Sowarka, D. (1995). Potential of cognitive plasticity as a diagnostic instrument: a cross-validation and extension. Psychology and Aging, 10, 167±172. Baltes, M. M., Maas, I., Wilms, H.-U., & Borchelt, M. (1996). Alltagskompetenz im Alter: Theoretische UÈberlegungen und empirische Befunde [Everyday competence in old age: Theoretical issues and empirical findings]. In K. U. Mayer & P. B. Baltes (Eds.), Die Berliner Altersstudie [The Berlin Aging Study] (pp. 525±542). Berlin, Germany: Akademie Verlag. Baltes, M. M., & Sowarka, D. (1995). Kognitive Intervention im Alter [Cognitive intervention in old age]. In R. Oerter & L. Montada (Eds.), Entwicklungspsychologie [Developmental psychology] (pp. 1116±1126). Weinheim, Germany: Psychologie Verlags Union Baltes, M. M., & Wahl, H.-W. (1992). The dependencysupport script in institutions: Generalization to community settings. Psychology and Aging, 7, 409±418. Baltes, M. M., & Wahl, H.-W. (1996). Patterns of communication in old age: The Dependency-Support and Independence-Ignore Script. Health Communication, 8, 217±231. Baltes, M. M., Wahl, H.-W., & Reichert, M. (1991). Successful aging in long-term care institutions. Annual Review of Gerontology and Geriatrics, 11, 311±338. Baltes, P. B. (1984). Intelligenz im Alter [Intelligence in old age]. Spektrum der Wissenschaft, Mai 1984, 46±60. Baltes, P. B. (1987). Theoretical propositions of life-span developmental psychology: On the dynamics between growth and decline. Developmental Psychology, 23, 611±626. Baltes, P. B. (1993). The aging mind: Potential and limits. The Gerontologist, 33, 580±594. Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives on successful aging: the model of selective optimization with compensation. In P. B. Baltes & M. M. Baltes (Eds.), Successful aging. Perspectives from the behavioral sciences (pp. 1±34). Cambridge, UK: Cambridge University Press. Baltes, P. B. & Lindenberger, U. (1988). On the range of cognitive plasticity in old age as a function of experience: 15 years of intervention research. Behavior Therapy, 19, 283±300. Baltes, P. B., Sowarka, D., & Kliegl, R. (1989). Cognitive training research on fluid intelligence in old age: What can older adults achieve by themselves? Psychology and Aging, 4, 217±221.

References Barker, R. G. (1968). Ecological psychology. Stanford, CA: Stanford University Press. Barry, M. A., Purser, J., Hazleman, R., McLean, A., & Hazleman, B. L. (1994). Effect of energy conservation and joint protection education in rheumatoid arthritis. British Journal of Rheumatology, 33, 1171±1174. Baum, J. (1984). Rehabilitation aspects of arthritis in the elderly. In T. F. Williams (Ed.), Rehabilitation in the aging (pp. 177±197). New York: Raven Press. Blieszner, R., Willis, S. L., & Baltes, P. B. (1981). Training research in aging on the fluid ability of inductive reasoning. Journal of Applied Developmental Psychology, 2, 247±265. Bobath, B. (1971). Adult hemiplegia: evaluation and treatment. London: Heinemann. Bouma, H., & Graafmans, J. A. M. (Eds.) (1992). Gerontechnology. Amsterdam: IOS Press. Brocklehurst, J. C., Tallis, R. C., & Fillit, H. M. (Eds.). (1992). Textbook of geriatric medicine and gerontology (4th ed.). Edinburgh, UK: Churchill Livingstone. Brody, B. (1987). Wholehearted and halfhearted care: national policies vs. individual choice. S. F. Spicker, S. R. Ingman, & I. R. Lawson (Eds.), Ethical dimensions of geriatric care (pp. 79±93). Dordrecht, The Netherlands: Reidel. Burgio, L. D., & Burgio, K. L. (1990). Institutional staff training and management: A review of the literature and a model for geriatric, long-term-care facilities. International Journal of Aging and Human Development, 30, 287±302. Butler, R. W., & Namerow, N. S. (1988). Cognitive retraining in brain-injury rehabilitation: A critical review. Journal of Neurologic Rehabilitation, 2, 97±101. Cameron, I. D., & Quine, S. (1994). External hip protectors: Likely non-compliance among high risk elderly people living in the community. Archives of Gerontology and Geriatrics, 19, 273±281. Camp, C. J., Foss, J. W., Stevens, A. B., Reichard, C. C., McKitrick, L. A., & O'Hanlon, A. M. (1993). Memory training in normal and demented elderly populations: the E-I-E-I-O model. Experimental Aging Research, 19, 277±290. Campbell, A. J. (1992). Role of rehabilitation in fall recovery and prevention. Reviews in Clinical Gerontology, 2, 53±65. Carstensen, L. L., Edelstein, B. A. , & Dornbrand, L. (Eds.) (1996). The practical handbook of clinical gerontology. Thousand Oaks, CA: Sage. Cattell, R. B. (1971). Abilities: Their structure, growth, and action. Boston: Houghton Mifflin. Charness, N., & Bosman, E. A. (1990). Human factors and design for older adults. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (3rd ed., pp. 446±463). San Diego, CA: Academic Press. Cooper, B. (1991a). The epidemiology of dementia. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (pp. 574±585). Oxford, UK: Oxford University Press. Cooper, B. (1991b). Principles of service provision in old age psychiatry. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (pp. 274±300). Oxford, UK: Oxford University Press. Corso, J. F. (1981). Aging sensory systems and perception. New York: Praeger. Crimmins, E. M., Hayward, M. D., & Saito, Y (1996). Differentials in active life expectancy in the older population of the United States. Journal of Gerontology: Social Sciences, 51B, S111±S120. Dam, M., Tonin, P., Casson, S., Ermani, M., Pizzolato, G., Iaia, V., & Battistin, L. (1993). The effects of long-term rehabilitation therapy on poststroke hemiplegic patients. Stroke, 24, 1186±1191.

545

Davis, A. C. (1989). The prevalence of hearing impairment and reported hearing disability among adults in Great Britain. International Journal of Epidemiology, 18, 911±917. DeJong, G., Batavia, A. I., & McKnew, L. B. (1992). The independent living model of personal assistance in national long-term-care policy. Generations, 16, 89±95. Dixon, R. A., & BaÈckman, L. (Eds.) (1995).Compensating for psychological deficits and declines. Managing losses and promoting gains. Mahwah, NJ: Erlbaum. Donabedian, A. (1966). Evaluating the quality of medical care. Millbank Memorial Fund Quarterly, 44, 166±206. Ebrahim, S. (1992). Rehabilitation. In J. C. Brocklehurst, R. C. Tallis, & H. M. Fillit (Eds.), Textbook of geriatric medicine and gerontology (4th ed., pp. 1038±1054). Edinburgh, UK: Churchill Livingstone. El-Faizy, M., & Reinsch, S. (1994). Home safety intervention for the prevention of falls. Physical and Occupational Therapy in Geriatrics, 12, 33±49. Ellul, J., Watkins, C., Ferguson, N., & Barer, D. (1993). Increasing patient engagement in rehabilitation activities. Clinical Rehabilitation, 7, 297±302. Ermini-FuÈnfschilling, D., & Meier, D. (1995). GedaÈchtnistraining: Wichtiger Bestandteil der Milieutherapie bei seniler Demenz [Memory training: An important constituent of milieu therapy in senile dementia]. Zeitschrift fuÈr Gerontologie und Geriatrie, 28, 190±194. Evans, J. G., & Williams, T. F. (Eds.). (1992). Oxford textbook of geriatric medicine. Oxford, UK: Oxford University Press. Falconer, J. A., Naughton, B. J., Strasser, D. C., & Sinacore, J. M. (1994). Stroke inpatient rehabilitation: A comparison across age groups. Journal of the American Geriatrics Society, 42, 3±44. Felsenthal, G., & Stein, B. D. (1990). Rehabilitation of dysmobility in the elderly: A case study of the patient with a hip fracture. In S. J. Brody & L. G. Pawlson (Eds.), Aging and rehabilitation II: the state of the practice (pp. 110±129). New York: Springer. Fleischmann, U. M. (1982). GedaÈchtnistraining im hoÈheren LebensalterÐAnsatzpunkte und MoÈglichkeiten [Memory training in old ageÐFoci and possibilities]. Zeitschrift fr Gerontologie, 15, 53±62. Fleischmann, U. M. (1989). GedaÈchtnis und Alter. Multivariate Analysen zum GedaÈchtnis alter Menschen [Memory and old age. Multivariate analyses of the memory of the elderly]. Bern, Switzerland: Huber. Fonda, D. (1991). Management of the incontinent disabled patient. Clinical Rehabilitation, 5, 331±336. Fozard, J. L. (1990). Vision and hearing in aging. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (3rd ed., pp. 150±170). San Diego, CA: Academic Press. Frank, R. G., Chaney, J. M., Clay, D. L., Shutty, M. S., Beck, N. C., Kay, D. R., Elliott, T. R., & Grambling, S. (1992). Dysphoria: a major symptom factor in persons with disability or chronic illness. Psychiatry Research, 43, 231±241. Franks, J. R., & Beckmann, N. J. (1985). Rejection of hearing aids: Attitudes of a geriatric sample. Ear and Hearing, 6, 161±166. Franzen, M. D. & Martin, R. C. (1996). Screening for neuropsychological impairment. In L. L. Carstensen, B. A. Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology (pp. 188±216). Thousand Oaks, CA: Sage. Fries, J. F. (1990). Medical perspectives upon successful aging. In P. B. Baltes & M. M. Baltes (Eds.), Successful aging. Perspectives from the behavioral sciences (pp. 3549). Cambridge, UK: Cambridge University Press. Frobose, I., & Schule, K. (1992). Befindlichkeits- und EinstellungsaÈnderungen beim Sport mit Rheumatikern [Mood and attitude change as a consequence of sports

546

Rehabilitation in Old Age: Psychosocial Issues

with rheumatic patients]. Die Rehabilitation, 31, 198±201. Gatz, M., Kasl-Godley, J. E., & Karel, M. J. (1996). Aging and mental disorders. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (4th ed., pp. 365±382). San Diego, CA: Academic Press Gibson, C. J. & Caplan, B. M. (1984). Rehabilitation of the patient with stroke. In T. F. Williams (Ed.), Rehabilitation in the aging (pp. 145±159). New York: Raven Press. Gladman, J., Forster, A., & Young, J. (1995). Hospitaland home-based rehabilitation after discharge from hospital for stroke patients: analysis of two trials. Age and Ageing, 24, 49±53. Glass, L. E. (1986). Rehabilitation for deaf and hearingimpaired elderly. In S. J. Brody & G. E. Ruff (Eds.), Aging and rehabilitation (pp. 218±237). New York: Springer. Glass, T. A., & Maddox, G. L. (1992). The quality and quantity of social support: Stroke recovery as psychosocial transition. Social Science and Medicine, 34, 1249±1261. Goldberg, R. (1984). Psychosocial aspects of stroke. In D. W. Krueger (Ed.), Rehabilitation psychology (pp. 293±300). Rockville, MD: Aspen. GoÈrres, S. (1992a). StationaÈre Rehabilitation und Nachsorge aÈlterer Menschen [Hospital rehabilitation and post-hospital care of the elderly]. In A. MuÈhlum & H. Oppl (Eds.). Handbuch der Rehabilitation [Handbook of rehabilitation] (pp. 401-423). Neuwied, Germany: Luchterhand. GoÈrres, S. (1992b). QualitaÈtssicherung in der Geriatrie [Quality assurance in geriatrics]. Archiv fuÈr Wissenschaft und Praxis der Sozialen Arbeit, 23, 90±111. GoÈrres, S. (1994). QualitaÈtssicherung in der Rehabilitation aÈlterer Menschen [Quality assurance in the rehabilitation of the elderly]. Die Rehabilitation, 33, 64±68. GoÈrres, S., Tschubar, H., & Meier-Baumgartner, H.-P. (1991). Zur Bedeutung klinikinterner Erfolgskriterien in der geriatrischen Rehabilitation. Ergebnisse eines Nachsorgeprojekts zum Problem der QualitaÈtssicherung [On the importance of outcome criteria in geriatric rehabilitation: Findings from a post-hospital care project on the problem of quality assurance]. Die Rehabilitation, 30, 63±68. Guthrie, S., & Harvey, A. (1994). Motivation and its influence on outcome in rehabilitation. Reviews in Clinical Gerontology, 4, 235±243. Harris, R. E., O'Hara, P. A., & Harper, D. W. (1995). Functional status of geriatric rehabilitation patients: A one-year follow-up study. Journal of the American Geriatrics Society, 43, 51±55. Hartke, R. J. (1991). The older adult's adjustment to the rehabilitation setting. In R. J. Hartke (Ed.), Psychological aspects of geriatric rehabilitation (pp. 73-96). Gaithersburg, MD: Aspen. Hartke, R. J., & Horowitz, M. (1991). Psychotherapy with the older rehabilitation patient. In R. J. Hartke (Ed.). Psychological aspects of geriatric rehabilitation (pp. 229±248). Gaithersburg, MD: Aspen. Hasselkus, B. R. (1989). Occupational and physical therapy in geriatric rehabilitation. Physical and Occupational Therapy in Geriatrics, 7, 3±20. Hausman, D. M. (1987). Health care: efficiency and equity. In S. F. Spicker, S.R. Ingman, & I.R. Lawson (Eds.), Ethical dimensions of geriatric care (pp. 67±78). Dordrecht The Netherlands: Reidel. HaÈfner, H. (1986). Psychische Gesundheit im Alter [Mental health in old age]. Stuttgart, Germany: Fischer. Helewa, A., Goldsmith, C. H., Lee, P., Bombardier, C., Hanes, B., Smythe, H. A., & Tugwell, P. (1991). Effects of occupational therapy home service on patients with rheumatoid arthritis. Lancet, 337, 1453±1456. Hiatt, L. G. (1987). Designing for the vision and hearing impairments of the elderly. In V. Regnier & J. Pynoos

(Eds.), Housing the aged (pp. 341±371). New York: Elsevier. Horgas, A., Wahl, H.-W., & Baltes, M. M. (1996). Dependency in late life. In L. L. Carstensen, B. A. Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology. Newbury Park, NJ: Sage. Horn, J. L., & Hofer, S. M. (1992). Major abilities and development in the adult period. In R. J. Sternberg & C. A. Berg (Eds.), Intellectual development (pp. 44±99). New York: Cambridge University Press. Hui, E., Lum, C. M., Woo, J., Or, K. H., & Kay, R. L. (1995). Outcomes of elderly stroke patients. Day hospital versus conventional medical management. Stroke, 26, 1616±1619. Humes, L. E., & Christopherson, L. (1991). Speech identification difficulties of hearing-impaired elderly persons: The contributions of auditory processing deficits. Journal of Speech and Hearing Research, 34, 686±693. Hussian, R. A. & Davis, R. L. (1985). Responsive care. Champain, IL: Research Press. Jamison, R. N., & Virts, K. L. (1990). The influence of family support on chronic pain. Behaviour Research and Therapy, 28, 283-287. Jette, A. M. (1996). Disability trends and transitions. In R. H. Binstock & L. K. George (Eds.), Handbook of aging and the social sciences (4th ed., pp. 94±116). San Diego, CA: Academic Press. Jordan, F. M., Worral, L.E., Hickson, L. M., & Dodd, B. J. (1993). The evaluation of intervention programmes for communicatively impaired elderly people. European Journal of Communication Disorders, 28, 63±85. Jordan, J., & Schmidt, M. (1988). Rehabilitationspsychologische Aspekte bei Erkrankungen des rheumatischen Formenkreises [Psychological aspects of rheumatic diseases relevant for rehabilitation]. In U. Koch, G. LuciusKoene, & R. Stegie (Eds.), Handbuch der Rehabilitationspsychologie [Handbook of rehabilitation psychology] (pp. 455±478). Berlin, Germany: Springer. Jùrgensen, H. S., Nakayama, H., Raaschou, H. O., Larsen, K., Hubbe, P., & Olsen, T. S. (1995). The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. A community-based study. Stroke, 26, 1178±1182. Kalra, L. (1994). The influence of stroke unit rehabilitation on functional recovery from stroke. Stroke, 25, 821±825. Kaplan, H. (1987). Assistive communication devices. In H. G. Mueller & V. C. Geoffrey (Eds.), Communication disorders in aging: Assessment and management (pp. 464±496). Washington, DC: Gallaudet University Press. Kaplan, H. (1989). Communication problems of the hearing-impaired elderly: What can be done? Pride Institute Journal of Long Term Health Care, 7, 10±22. Kaschel, R., Zaiser-Kaschel, H., & Mayer, K. (1992). RealitaÈts-Orientierungs-Training: LiteraturuÈberblick und Implikationen fuÈr die neuropsychologische GedaÈchtnisrehabilitation [Reality orientation training: Literature review and implications for neuropsychological memory rehabilitation]. Zeitschrift fuÈr Gerontopsychologie und -psychiatrie, 5, 223±235. Kaste, M., Palomaki, H., & Sarna, S. (1995). Where and how should elderly stroke patients be treated? A randomized trial. Stroke, 26, 249±253. Kausler, D. H. (1991). Experimental psychology, cognition, and human aging (2nd ed.). New York: Springer. Keitel, W. (1993). Verlauf der Rheumatoid-Arthritis bei Beginn im hheren Lebensalter [The course of rheumatoid arthritis beginning in advanced age]. Zeitschrift fuÈr Rheumatologie, 52, 138±141. Kemp, B. (1985). Rehabilitation and the older adult. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (2nd ed., pp. 647±663). New York: Van Nostrand Reinhold.

References Kemp, B. (1996). Rehabilitation. In J. E. Birren (Ed.), Encyclopedia of Gerontology (Vol 2, pp. 381±386). San Diego, CA: Academic Press. King, P., & Barrowclough, C. (1989). Rating the motivation of elderly patients on a rehabilitation ward. Clinical Rehabilitation, 3, 289±291. Kline, D. W., & Scialfa, C. T. (1996). Visual and auditory aging. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (4th ed., pp. 181±203). San Diego, CA: Academic Press. Koh, K., Ray, R., Lee, J., Nair, A., Ho, T., & Ang, P.C. (1994). Dementia in elderly patients: can the 3R mental stimulation programme improve mental status? Age and Ageing, 23, 195±199. Kovar, P. A., Allegrante, J. P., MacKenzie, C. R., Peterson, M. G., Gutin, B., & Charlson, M. E. (1992). Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial. Annals of Internal Medicine, 116, 529±534. Kraaimaat, F. W., Brons, M. R. Geenen, R., & Bijlsma, J. W. (1995). The effect of cognitive behavior therapy in patients with rheumatoid arthritis. Behavior Research and Therapy, 33, 487±495. Kruse, A. (1984). Der Schlaganfallpatient und seine Familie [The stroke patient and her/his family]. Zeitschrift fuÈr Gerontologie, 17, 359±366. Kruse, A. (1987). Kompetenz bei chronischer Krankheit im Alter [Competence in chronic disease in the aged]. Zeitschrift fuÈr Gerontologie, 20, 355±366. Kruse, A. (1992). Rehabilitation in der Gerontologie theoretische Gundlagen und empirische Forschungsergebnisse [Rehabilitation in gerontology - theoretical base and empirical findings]. In A. MuÈhlum & H. Oppl (Eds.). Handbuch der Rehabilitation [Handbook of rehabilitation] (pp. 333±355). Neuwied, Germany: Luchterhand. Kruse, A. (1995). Ergebnisse aus einer LaÈngsschnittstudie zu Effekten der ambulanten Rehabilitation [Findings of a longitudinal study aimed at the outcome of homebased rehabilitation]. Zeitschrift fuÈr Gerontologie und Geriatrie, 28, 104±112. Lachman, M. E., Weaver, S. L., Bandura, M., Elliott, E., & Lewkowicz., C. J. (1992). Improving memory and control beliefs through cognitive restructuring and selfgenerated strategies. Journals of Gerontology: Psychological Sciences, 47, P293±P299. LaGrow, S. J., & Blasch, B. B. (1992). Orientation and mobility services for older persons. In A. Orr (Ed.), Vision and aging: Crossroads for service delivery (pp. 255±288). New York: American Foundation for the Blind. Langhorne, P., Williams, B. O., Gilchrist, W., & Howie, K. (1993). Do stroke units save lives? Lancet, 342, 395±398. Lawton, M. P. (1982). Competence, environmental press, and the adaption of older people. In M. P. Lawton, P. G. Windley, & T. O. Byerts (Eds.), Aging and the environment. Theoretical approaches (pp. 33±59). New York: Springer. Lawton, M. P. (1989). Behavior-relevant ecological factors. In K.W. Schaie & C. Schooler (Eds.), Social structure and aging: Psychological processes (pp. 57±78). Hillsdale, NJ: Erlbaum. Lawton, M. P. & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9, 179±186. Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer & M. P. Lawton (Eds.), Psychology of adult development and aging (pp. 619±674). Washington, DC: American Psychological Association. Lawton, M. P., & Simon, B. (1968). The ecology of social relationships in housing for the elderly. The Gerontologist, 8, 108±115. Lawton, M. P., & Teresi, J. A. (Eds.). (1994). Annual

547

Review of Gerontology and Geriatrics. Focus on assessment techniques. New York: Springer. Lee, M. H. M., & Itoh, M. (1990). Rehabilitation. In W. B. Abrams, R. Berkow, & A. J. Fletcher (Eds.), The Merck Manual of Geriatrics (pp. 249±273). Rahway, NJ: Merck, Sharp, & Dohme Research Laboratories. Lehmann, W. (1992). Diagnose und Therapie von geriatrischen Aphasiepatienten nach einem zerebrovaskulaÈren Insult [Diagnosis and therapy of geriatric aphasic patients following cerobro-vascular stroke]. Zeitschrift fuÈr Gerontologie, 25, 271±277. Lehr, U. (1993). Erkenntnisse psychologischer Grundlagenforschung fuÈr PraÈvention und Rehabilitation im Alter [Results of psychological basic research relevant for prevention and rehabilitation in old age]. In A. Niederfranke (Ed.), Fragen geriatrischer Rehabilitation [Questions of geriatric rehabilitation]. (pp. 39±46). Stuttgart, Germany: Kohlhammer. Lehr, U. (1996). Psychologie des Alterns [Psychology of aging] (8th ed.). Heidelberg, Germany: Quelle & Meyer. Lehr, U., Kruse, A., & Kruse, M. (1992). Rheumatische Erkrankungen im hoÈheren Lebensalter - Psychologische Aspekte [Rheumatic diseases in advanced age - psychological aspects]. Zeitschrift fuÈr Rheumatologie, 51, 290±294. Lichtenberg, P. A., & Rosenthal, M. (1994). Characteristics of geriatric rehabilitation programs: A survey of practitioners. Rehabilitation Psychology, 39, 277±281. Little, A. (1991). Psychological treatments. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (pp. 400±415). Oxford, UK: Oxford University Press. Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland Medical Journal, 14, 61±65. Marmann, C. (1994). Der geriatrisch Amputierte nach Entlassung aus erfolgreicher Rehabilitation [The geriatric amputee after discharge from successful rehabilitation]. Die Rehabilitation, 33, 69±75. Marsiske, M., Delius, J., Lindenberger, U., Scherer, H., & Tesch-RoÈmer, C. (1996). Sensorische Systeme im Alter [Sensory systems in old age]. In K. U. Mayer & P. B. Baltes (Eds.). Die Berliner Altersstudie [The Berlin Aging Study] (pp. 379±403). Berlin, Germany: Akademie Verlag. Mattussek, S. (1992). Die ªcP-Schule Hannoverº: Entwicklung eines Curriculums und DurchfuÈhrung einer kontrollierten Studie zur Schulung von Patienten mit einer chronischen Polyarthritis [The ªHannover Chronic Polyarthritis Schoolº: Development of a curriculum and conductance of a controlled study of education of patients with chronic arthritis]. Zeitschrift fuÈr Rheumatologie, 51, Suppl. 1: 41±50. May, A. E., Upfold, L. J., & Battaglia, J. A. (1990). The advantages and disadvantages of ITC, ITE and BTE hearing aids: Diary and interview reports from elderly users. British Journal of Audiology, 24, 301±309. Mayer-Oakes, S. A., Hoenig, H., Atchison, K. A., Lubben, J.E., De-Jong, F., & Schweitzer, S. O. (1992). Patientrelated predictors of rehabilitation use for communitydwelling older Americans. Journal of the American Geriatrics Society, 40, 336±342. McCarthy, P. A., & Sapp, J. V. (1993). Rehabilitative considerations with the geriatric population. In J. G. Alpiner & P. A. McCarthy (Eds.), Rehabilitative audiology: Children and adults (2nd ed., pp. 331±373). Baltimore: Williams & Wilkins. Meier-Baumgartner, H.-P., Nerenheim-Duscha, I., & GoÈrres, S. (1992). Die EffektivitaÈt von Rehabilitation bei aÈlteren Menschen unter besonderer Bercksichtigung psychosozialer Komponenten bei ambulanter, teilstationaÈrer und stationaÈrer Betreuung [Outcome of rehabilitation with the elderly]. Stuttgart, Germany: Kohlhammer. Miller, J. A. (1991). Community-based long-term care:

548

Rehabilitation in Old Age: Psychosocial Issues

Innovative models. Newbury Park, NJ: Sage. Mosqueda, L. (1996). Geriatric rehabilitation. In L. L. Carstensen, B. A. Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology (pp. 468±480). Thousand Oaks, CA: Sage. Nelson, E. A., & Dannefer, D. (1992). Aged heterogeneity: Fact or fiction? the fate of diversity in gerontological research. The Gerontologist, 32, 17±23. Neuberger, G. B., Kasal, S., Smith, K. V., Hassanein, R., & DeViney, S. (1994). Determinants of exercise and aerobic fitness in outpatients with arthritis. Nursing Research, 43, 11±17. Olbrich, E., & Diegritz, U. (1995). Das Zusammenwirken von Person- und Umweltfaktoren im Alltag: Eine kritische Diskussion von AktivitaÈten des taÈglichen Lebens und instrumentellen AktivitaÈten des taÈglichen Lebens [On the interaction of person and environment in everyday life: A critical discussion of activities of daily living and instrumental activities of daily living]. Zeitschrift fuÈr Gerontopsychologie und -psychiatrie, 8, 199±212. Olsho, L. W., Harkins, S. W., & Lenhardt, M. L. (1985). Aging and the auditory system. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (2nd ed., pp. 332±377). New York: Van Nostrand Reinhold. Oswald, W. D., Rupprecht, R., & Gunzelmann, T. (1998). Effekte eines einjaÈhrigen GedaÈchtnis-, Kompetenz- und psychomotorischen Trainings auf die LeistungsfaÈhigkeit im hoÈheren Lebensalter [Effects of a one-year memory, competence and psychomotor training on performance in old age]. In A. Kruse (Ed.), Jahrbuch der Medizinischen Psychologie. Psychosoziale Gerontologie, Band II: Intervention [Yearbook of Medical Psychology. Psychosocial gerontology, Vol II: Intervention] (pp. 94±107). GoÈttingen, Germany: Hogrefe. Ottenbacher, K. J., & Jannell, S. (1993). The results of clinical trials in stroke rehabilitation research. Archives of Neurology, 50, 37±44. Parmelee, P. A., & Lawton, M. P. (1990). The design of special environments for the aged. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (3rd ed., pp. 464±488). San Diego, CA: Academic Press. Pathy, M. S. J. (Ed.). (1991). Principles and practice of geriatric medicine (2nd ed.). Chichester, UK: Wiley. Pearlin, L. I., Aneshensel, C. S., Mullan, J. T., & Whitlatch, C. J. (1996). Caregiving and its social support. In R. H. Binstock & L. K. George (Eds.), Handbook of aging and the social sciences (4th ed., pp. 283±302). San Diego, CA: Academic Press. Regnier, V., & Pynoos, J. (Eds.) (1987). Housing the aged: Design directives and policy considerations. New York: Elsevier. Regnier, V., & Pynoos, J. (1992). Environmental intervention for cognitively impaired older persons. In J. E. Birren, R. B. Sloane, & G. D. Cohen (Eds.), Handbook of mental health and aging (2nd ed., pp. 763±792). San Diego, CA: Academic Press. Reischies, F. M., & Lindenberger, U. (1996). Grenzen und Potentiale kognitiver LeistungsfaÈhigkeit im Alter [Limits and potentials of cognitive performance in old age]. In K. U. Mayer & P. B. Baltes (Eds.), Die Berliner Altersstudie [The Berlin Aging Study] (pp. 351±377). Berlin, Germany: Akademie Verlag. Rentz, D. M. (1991). The assessment of rehabilitation potential: Cognitive factors. In R. J. Hartke (Ed.), Psychological aspects of geriatric rehabilitation (pp. 97±114). Gaithersburg, MD: Aspen. Rodin, J. (1986). Aging and health: Effects of the sense of control. Science, 233, 1271±1276. Rott, C., Wahl, H.-W., & Tesch-RoÈmer, C. (1996). Zur Bedeutung von Seh- und HoÈrveraÈnderungen fuÈr den Alternsprozess [On the meaning of visual and hearing

impairment or the aging process]. In C. Tesch-RoÈmer & H.-W. Wahl (Eds.), Seh- und HoÈreinbussen aÈlterer Menschen: Herausforderungen in Medizin, Psychologie und Rehabilitation [Visual and hearing impairment in old age: Challenges within medicine, psychology, and rehabilitation] (pp. 89±106). Darmstadt, Germany: Steinkopff. Rubenstein, L. Z., Josephson, K. R., Wieland, D., English, P. A., Sayre, J. A., & Kane, R. L. (1984). Effectiveness of a geriatric evaluation unit. New UK Journal of Medicine, 311, 1664±1670. Rustemeyer, J. (1983). Rehabilitative Massnahmen [Rehabilitation strategies]. In D. Platt (Ed.), Handbuch der Gerontologie. Band 1: Innere Medizin [Handbook of gerontology, Vol. 1, Internal Medicine] (pp. 13±32). Stuttgart, Germany: Fischer. Salthouse, T. A. (1991). Theoretical perspectives on cognitive aging. Hillsdale, NJ: Erlbaum. Saltz, C. C. (1995). Rehabilitation. In G. L. Maddox (Ed.), The encyclopedia of aging (2nd ed., pp. 798±799). New York: Springer. Sarno, M. T. (1984). Communication disorders in the elderly. In T.F. Williams (Ed.), Rehabilitation in the aging (pp. 161±176). New York: Raven Press. Saudan, Y. (1990). Prinzipien der funktionellen Rehabilitation im Alter [Principles of functional rehabilitation in old age]. In F. Martin & J.-P. Junod (Eds.), Lehrbuch der Geriatrie [Textbook of geriatrics] (pp. 696±707). Bern, Switzerland: Huber. Saup, W. (1993). Alter und Umwelt. Eine EinfuÈhrung in die OÈkologische Gerontologie. [Aging and environment. An introduction to environmental gerontology]. Stuttgart, Germany: Kohlhammer. Schaie, K. W., & Willis, S. L. (1986). Can decline in adult intellectual functioning be reversed? Developmental Psychology, 22, 223±232. Schaie, K. W., & Willis, S. L. (1993). Age difference patterns of psychometric intelligence in adulthood: Generalizability within and across ability domains. Psychology and Aging, 8, 44±55. Schneekloth, U., & MuÈller, U. (1995). Hilfe- und PflegebeduÈrftige in Heimen. Endbericht zur RepraÈsentativerhebung im Rahmen des Forschungsprojekts ªMoÈglichkeiten und Grenzen selbstaÈndiger LebensfuÈhrung in Einrichtungen.º [Persons with basic care needs in institutions. Research report]. MuÈnchen, Germany: Infratest Sozialforschung und Infratest Epidemiologie und Gesundheitsforschung. Schneekloth, U., & Potthoff, P. (1993). Hilfe- und PflegebeduÈrftige in privaten Haushalten. Bericht zur RepraÈsentativerhebung im Forschungsprojekt ªMoÈglichkeiten und Grenzen selbstaÈndiger LebensfuÈhrung.º [Persons with basic care needs in private households. Research Report]. MuÈnchen, Germany: Infratest Sozialforschung und Infratest Epidemiologie und Gesundheitsforschung. Schulz, R., & Williamson, G. M. (1993). Psychosocial and behavioral dimensions of physical frailty. The Journals of Gerontology, 48 (Special Issue), 39±43. SchuÈtz, R. M. (1993). Geriatrische RehabilitationÐeine Standortbestimmung [Geriatric rehabilitationÐA point of view]. In A. Niederfranke (Ed.), Fragen geriatrischer Rehabilitation [Questions of geriatric rehabilitation] (pp. 16±20). Stuttgart, Germany: Kohlhammer. Shawe, D., Hesp, R., Gumpel, J. M., Sambrook, P. N., & Reeve, J. (1993). Physical activity as a determinant of bone conservation in the radial diaphysis in rheumatoid arthritis. Annals of Rheumatic Diseases, 52, 579±581. Silverstone, B. (1984). Social aspects of rehabilitation. In T. F. Williams (Ed.), Rehabilitation in the aging (pp. 59±79). New York: Raven Press. Simeoni, E., Bauman, A., Stenmark, J., & O'Brien, J. (1995). Evaluation of a community arthritis program in

References Australia: Dissemination of a developed program. Arthritis Care Research, 8, 102±107. Smith, C. A., Wallston, K. A., & Dwyer, K. A. (1995). On babies and bathwater: disease impact and negative affectivity in the self-reports of persons with rheumatoid arthritis. Health Psychology, 14, 64±73. Smith, J., & Baltes, P. B. (1996). Altern aus psychologischer Perspektive: Trends und Profile im hohen Alter [Aging from a psychological point of view: Trends and profile in the oldest old]. In K.U. Mayer & P.B. Baltes (Eds.), Die Berliner Altersstudie [The Berlin Aging Study] (pp. 221±250). Berlin, Germany: Akademie Verlag. Smyer, M. A., Zarit, S. H. & Qualls, S. H. (1990). Psychological intervention with the aging individual. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (3rd ed., pp. 375±403). San Diego, CA: Academic Press. Spicker, S. F., Ingman, S.R., & Lawson, I.R. (Eds.) (1987). Ethical dimensions of geriatric care; Value conflicts for the 21st century. Dordrecht, The Netherlands: Reidel. Steinhagen-Thiessen, E., & Borchelt, M. (1996). MorbiditaÈt, Medikation und FunktionalitaÈt im Alter [Morbidity, medication, and functionality in old age]. In K. U. Mayer & P. B. Baltes (Eds.), Die Berliner Altersstudie [The Berlin Aging Study] (pp. 151±183). Berlin, Germany: Akademie Verlag. Stephens, S. D. G., & Goldstein, D. P. (1983). Auditory rehabilitation for the elderly. In R. Hinchcliffe (Ed.), Hearing and balance in the elderly (pp.174±200). Edinburgh, UK: Churchill Livingstone. Stuck, A. E., Siu, A. L., Wieland, G. D., Adams, J., & Rubenstein, L. Z. (1993). Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet, 342, 1032±1036. Suzman, R. M., Willis, D. P., & Manton, K. G. (Eds.) (1992). The oldest old. New York: Oxford University Press. Svanborg, A. (1988). The health of the elderly population: Results from longitudinal studies with age-cohort comparisons. In D. Evered & J. Whelan (Eds.), Research and the ageing population (pp. 3±16). Chichester, UK: Wiley. Tallis, R. (1992). Rehabilitation of the elderly in the 21st century. The F. E. Williams Lecture 1992. Journal of the Royal College of Physicians of London, 26, 413±422. Tesch-RoÈmer, C. (1997). Psychological effects of hearing aid use in older adults. Journal of Gerontology. Psychological Sciences, 52B, P127±P138. Tesch-RoÈmer, C., & Nowak, M. (1995). BewaÈltigung von HoÈr- und VerstaÈndnisproblemen bei SchwerhoÈrigkeit [Coping with hearing and communication problems in aural impairment]. Zeitschrift fuÈr Klinische Psychologie, 24, 35±45. Tesch-RoÈmer, C., & Wahl, H.-W. (Eds.) (1996a). Seh- und HoÈreinbussen aÈlterer Menschen: Herausforderungen in Medizin, Psychologie und Rehabilitation [Visual and hearing impairment in old age: Challenges within medicine, psychology, and rehabilitation]. Darmstadt, Germany: Steinkopff. Tesch-RoÈmer, C., & Wahl, H.-W. (1996b). Was es bedeutet, (nicht) hoÈren und sehen zu koÈnnen [What it means (not) to be able to hear or see]. In C. TeschRoÈmer & H.-W. Wahl (Eds.), Seh- und HoÈreinbussen aÈlterer Menschen: Herausforderungen in Medizin, Psychologie und Rehabilitation [Visual and hearing impairment in old age: Challenges within medicine, psychology, and rehabilitation] (pp. 1±12). Darmstadt, Germany: Steinkopff. Thomae, H. (1979). The concept of development and life span developmental psychology. In P. B. Baltes & O. G. Brim (Eds.), Life span developmental psychology (Vol. 2, S282±S312). New York: Academic Press. Thomae, H. (1996). Das Individuum und seine Welt: Eine

549

PersoÈnlichkeitstheorie [The individual and her/his world] (2nd ed.). GoÈttingen, Germany: Hogrefe Verlag. Trezona, R.R., Jr. (1991). The assessment of rehabilitation potential: Emotional factors. In R. J. Hartke (Ed.), Psychological aspects of geriatric rehabilitation (pp. 115±134). Gaithersburg, MD: Aspen Publishers. Tucker, S.J. (1984). Patient staff interaction with the spinal cord patient. In D.W. Krueger (Ed.), Rehabilitation psychology (pp. 257±266). Rockvill, MD: Aspen. US Department of Health and Human Services (1992). Vital and health statistics: Current estimates from the National Health Interview, 1991. Series 10: Data from the National Health Survey, No. 184. Hyattsville, MD: National Center for Health Statistics. Vanderpool, J. P. (1984). Stressful patient relationships and the difficult patient. In D. W. Krueger (Ed.), Rehabilitation psychology (pp. 167±181). Rockvill, MD: Aspen. Vignolo, L. A. (1964). Evolution of aphasia and language rehabilitation. Cortex, 1, 344±367. Vognsen, S. (Ed.) (1976). Hearing tactics: How hearing impaired persons may solve their hearing problems in their daily life. Copenhagen, Denmark: State Hearing Centre. Wade, D. T. (1992). Stroke rehabilitation. In J. G. Evans & T. F. Williams (Eds.), Oxford textbook of geriatric medicine (pp. 321±328). Oxford, UK: Oxford University Press. Wade, D. T., Collen, F. M., Robb, G. F., & Warlow, C. P. (1992). Physiotherapy intervention late after stroke and mobility. British Medical Journal, 304, 609±613. Wade, D. T., & Langton-Hewer, R. (1987). Functional abilities after stroke: measurement, natural history, and prognosis. Journal of Neurology, Neurosurgery, and Psychiatry, 50, 177±182. Wagner, M., SchuÈtze, Y., & Lang, F. (1996). Soziale Beziehungen alter Menschen [Social relations of the elderly]. In K. U. Mayer & P.B. Baltes (Eds.), Die Berliner Altersstudie [The Berlin Aging Study] (pp. 301±319). Berlin, Germany: Akademie Verlag. Wahl, H.-W. (1992). OÈkologische Perspektiven in der Gerontopsychologie: Ein Blick in die vergangenen drei Jahrzehnte und in die Zukunft [Ecological perspectives in geropsychology: Viewing three decades backwards and into the future]. Psychologische Rundschau, 43, 232±248. Wahl, H.-W. (1994). Visual impairment in later life: A challenge for environmental gerontology. Aging and Vision News, 6, 1±2. Wahl, H.-W. (1997). AÈltere Menschen mit SehbeeintraÈchtigung: Eine empirische Untersuchung zur Person-UmweltTransaktion. [Age-related visual impairment: An empirical study of person-environment transaction]. Frankfurt, Germany: Peter Lang. Wahl, H.-W., & Baltes, M. M. (1993). OÈkopsychologische Aspekte geriatrischer Rehabilitation [Ecological aspects of geriatric rehabilitation]. In A. Niederfranke (Ed.), Fragen geriatrischer Rehabilitation [Questions of geriatric rehabilitation]. (pp. 63±69). Stuttgart, Germany: Kohlhammer. Wahl, H.-W., & Oswald, F. (1996). Schwere Seheinbussen im Alter aus psychologischer Sicht: Belastung und BewaÈltigungsmoÈglichkeiten [Severe visual impairment in old age from a psychological point of view: Stress and coping potential].. In C. Tesch-RoÈmer & H.-W. Wahl (Eds.), Seh- und HoÈreinbussen aÈlterer Menschen: Herausforderungen in Medizin, Psychologie und Rehabilitation [Visual and hearing impairment in old age: Challenges within medicine, psychology, and rehabilitation] (pp. 127±148). Darmstadt, Germany: Steinkopff. Wahl, H.-W., & Oswald, F. (in press). The person/ environment perspective of visual impairment. In B. Silverstone, M. A. Lang, B. Rosenthal, & E. Faye (Eds.), The Lighthouse handbook on vision and rehabilitation. New York: Oxford University Press.

550

Rehabilitation in Old Age: Psychosocial Issues

Wahl, H.-W., & Tesch-RoÈmer, C. (1996). UÈber die Technik hinaus - Psychosoziale Aspekte der Rehabilitation bei HoÈr- und Seheinbussen im Alter [Beyond technique Psychosocial aspects of rehabilitation of hearing and vision loss in old age]. In C. Tesch-RoÈmer & H.-W. Wahl (Eds.), Seh- und HoÈreinbussen aÈlterer Menschen: Herausforderungen in Medizin, Psychologie und Rehabilitation [Visual and hearing impairment in old age: Challenges within medicine, psychology, and rehabilitation] (pp. 203±231). Darmstadt, Germany: Steinkopff. Weinert, F. E., & Knopf, M. (1990). GedaÈchtnistraining im hoÈheren Erwachsenenalter - Lassen sich GedaÈchtnisleistungen verbessern, waÈhrend sich das GedaÈchtnis verschlechtert? [Memory training in old age - Improvement of memory performance and memory impairment at the same time?] In R. Schmitz-Scherzer, A. Kruse, & E. Olbrich (Eds.), Altern - Ein lebenslanger Prozess der sozialen Interaktion [Aging - A lifespan process of social interaction] (pp. 91±102). Darmstadt, Germany: Steinkopff. Weinstein, B. E., & Ventry, I. M. (1983). Audiometric correlates of the Hearing Handicap Inventory for the Elderly. Journal of Speech and Hearing Disorders, 48, 379±384. Wiesner, M., & Tesch-RoÈmer, C. (1996). HoÈrgeraÈtebenutzung im Alter: Der Zusammenhang zwischen Intention und Verhalten [Use of an hearing aid in old ageÐThe link between intention and behavior]. Zeitschrift fuÈr Gerontologie, 26, 273±279. Williams, T. F. (Ed.) (1984a). Rehabilitation in the aging. New York: Raven Press. Williams, T. F. (1994). Rehabilitation in old age. In R.P.

Abeles, H.C. Gift, & M.G. Ory (Eds.), Aging and quality of life (pp. 121±132). New York: Springer. Willis, S. (1991). Cognition and everyday competence. Annual Review of Gerontology and Geriatrics, 11, 80±109. Willis, S. L. (1996). Everyday problem solving. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (4th ed., pp. 287±307). San Diego, CA: Academic Press. Willis, S. L., Blieszner, R., & Baltes, P. B. (1981). Intellectual training research in aging: Modification of performance on the fluid ability of figural relations. Journal of Educational Psychology, 73, 41±50. Willott, J.F. (1991). Aging and the auditory system: Anatomy, physiology, and psychophysics. San Diego, CA: Singular Publishers. Wisocki, P. A. (Ed.) (1991). Handbook of clinical behavior therapy with the elderly client. New York: Plenum. World Health Organisation. (1980). International classification of impairments, disabilities and handicaps. Geneva, Switzerland: World Health Organization. Wottawa, H., & Thierau, H. (1990). Lehrbuch Evaluation [Textbook evaluation]. Bern, Switzerland: Huber. Yesavage, J. A., Lapp, D., & Sheikh, J. L. (1989). Mnemonics as modified for use by the elderly. In L.W. Poon, D.C. Rubin, & B.A. Wilson (Eds.), Everyday cognition in adulthood and late life (pp. 598±611). Cambridge, UK: Cambridge University Press. Zeiss, A. M., & Steffen, A. M. (1996). Interdisciplinary health care teams: The basic unit of geriatric care. In L. L. Carstensen, B. A. Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology (pp. 423±450). Thousand Oaks, CA: Sage.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

7.24 Interdisciplinary Health Care Teams in Geriatrics: An International Model ANTONETTE M. ZEISS, VA Palo Alto Health Care System, CA, USA and ANN M. STEFFEN University of Missouri at St. Louis, MO, USA 7.24.1 INTRODUCTION

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7.24.2 WHY TEAMS?

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7.24.3 INTERDISCIPLINARY TEAM THEORY 7.24.3.1 Types of Teams 7.24.3.2 Advantages of Interdisciplinary Teams 7.24.3.3 Disadvantages of Interdisciplinary Teams (and Ways to Deal With Them) 7.24.4 NATURAL HISTORY OF TEAM DEVELOPMENT 7.24.4.1 Processes of Team Development 7.24.4.1.1 Forming 7.24.4.1.2 Storming 7.24.4.1.3 Norming 7.24.4.1.4 Performing 7.24.4.1.5 Team evolution 7.24.4.2 Dilemmas of Team Work 7.24.5 DEVELOPMENT OF INTERDISCIPLINARY TEAM SKILLS 7.24.5.1 Formal Educational Settings 7.24.5.2 On-the-job Training 7.24.5.3 Role Definition on Interdisciplinary Teams 7.24.6 INTERDISCIPLINARY TEAM TREATMENT PLANNING

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7.24.7 INTERDISCIPLINARY TEAM CONCEPTS IN ACTION: TEAM RESPONSE TO A GERIATRIC PATIENT WITH MULTIPLE MEDICAL PROBLEMS AND DEPRESSION (SAM P.)

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7.24.8 RESOURCES AND TRAINING MATERIALS 7.24.8.1 Outcomes and Descriptions of Interdisciplinary Teams 7.24.8.2 Team Training Guides 7.24.8.3 Communication Training 7.24.8.4 Factors that Influence Team Functioning 7.24.9 HELPING WITH INTERDISCIPLINARY TEAM DEVELOPMENT

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7.24.10 SUMMARY

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7.24.11 REFERENCES

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7.24.1 INTRODUCTION As a mental health practitioner, you often receive referrals for the evaluation and treatment of patients who attend a variety of specialty clinics at your medical center. Your most recent referral is to assess and treat Sam P., a 76 year-old man exhibiting symptoms of depression. The Medical Resident treating Sam's cardiovascular disease and arthritis in the hospital's Geriatric clinic had become alarmed and made the referral after Sam began to cry and then refused to answer questions during his most recent medical appointment.

Your clinical decisions regarding the assessment and treatment of Sam P. will be influenced by your model of depression and how it is treated in older adults. Sam's response to treatment, however, will also depend upon your ability to work effectively with professionals from a variety of disciplines who are involved in his care. What difference in your work would there be if you were an official member of the interdisciplinary geriatric clinic team, as opposed to operating separately as a referral service? Few of us have received formal training in the advantages and tasks involved in working in interdisciplinary team settings. This chapter is designed to introduce both the conceptual and practical issues that are a part of interdisciplinary team work.

7.24.2 WHY TEAMS? Geriatric patients are characterized by two pervasive qualities: their problems are complex and chronic (Binstock & George, 1990; Birren & Schaie, 1990; Dornbrand, Hoole, & Pickard, 1992; Schneider & Rowe, 1990). Problem complexity has many dimensions, including the following: patients may have multiple problems, each exacerbating the others; problems may present differently in geriatric patients than in younger patients; geriatric patients are likely to present inconsistent information about their health concerns; current problems are influenced in complex ways by a lengthy history of medical and/or psychosocial problems; and patients bring complex attitudes towards health care based on their past involvement with other health care providers (Hickey & Rakowski, 1981). Chronic health problems, such as cardiovascular complaints, arthritis, or pulmonary decline, are more typical of older individuals than younger ones (Federal Council on Aging, 1981). While

older patients can, of course, also present with acute problems, the typical health care visit is more likely to be prompted by chronic concerns among elders (Woolf, Kamerow, Lawrence, Medalie, & Estes, 1990; Zawadski & Eng, 1988). Older patients are also more heterogeneous than younger patients. While age typically brings decline, as measured by average capacity, on many biological functions (e.g., visual acuity, cardiac efficiency, speed of male erection, lung capacity), age is also typically characterized by increased variability (Fries & Crapo, 1981). Looking within a group of older adults, the range of capacities will be highly variable for any function, with some individuals displaying better function than the average younger person, whereas others display severe decline. There is also variability within individuals, with some functions remaining at high levels and others showing decline of varying degrees. Because of these issues, the model of patient care which is the best fit for the management of such patients (i.e., those with chronic, complex problems which present in diverse ways and where stereotyped expectations about patients are inappropriate) is the interdisciplinary team model. This chapter will review basic aspects of interdisciplinary team theory, the natural history of team development, skills necessary for interdisciplinary teamwork, strategies for interdisciplinary team treatment planning, and models of effective interdisciplinary teams. There has been a growing international awareness of the role of interdisciplinary care in a variety of settings. In Europe, concerns about the care of cancer patients led the Council of Europe in 1987 to create a Select Committee of experts to consider coordination of care for patients. The Committee recommended ªthe provision of joint professional education as a means of improving teamwork in cancer care . . .º (Jones, 1992). The European Health Committee has funded a review of interdisciplinary training of health care staff in member states, and the World Health Organization has supported the development of a network for interprofessional education, based in Linkoping, Sweden (Goble, 1994). In the USA, a network of geriatric education centers (GECs) has been created to provide didactic and clinical training to a wide range of health professionals. These GECs are sponsored by the Bureau of Health Professions of the US Health Resources and Services Administration. Also in the US, the Interdisciplinary Team Training Program (ITTP) is funded by the Division of Veterans Affairs in 12 medical centers to promote direct service and training in a variety of inpatient and outpatient settings.

Interdisciplinary Team Theory 7.24.3 INTERDISCIPLINARY TEAM THEORY To say that a group of health care providers is a ªteamº says very little, as there are many different kinds of teams, organized in different ways to perform different functions. A group that is a team shares a common workplace and set of patients, but teams differ among themselves in their membership composition, commitment to common goals, degree of collaboration in accomplishing team-related tasks, handling of leadership, and the kind of attention paid to team processes. While these factors theoretically could be combined in a large number of ways, in practice the five kinds of teams shown in Table 1 are commonly identified (Takamura; 1985; Takamura, Bermost, & Stringfellow, 1979). Interdisciplinary teams will be described in some detail, along with briefer descriptions of the other kinds of health care team organization. 7.24.3.1 Types of Teams Unidisciplinary teams (from the Latin ªuni,º or one) are made up of many providers from a single background, such as a group of public health nurses providing home care. All team members share the same professional skills and training, speak a common language of health care, and function in the same role within the group. Intradisciplinary teams (from the Latin ªintra,º or within) are also composed of professionals from one discipline, but include team members from different levels of training and skills within the discipline. For example, a geriatric mental health outpatient clinic team might be composed of a Licensed Psychologist, a postintern, prelicensing psychological

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assistant, a psychological technician, and two psychology practicum students. The term Multidisciplinary team is often used as if it were synonymous with interdisciplinary team, but the two are actually different in very important ways. A multidisciplinary team (from the Latin ªmulti,º or many) is composed of members from more than one discipline, so that the team can offer a greater breadth of services to patients. However, in a multidisciplinary team, each discipline does its own assessment, generates its own treatment plan, implements the plan, evaluates progress, and refines the plan based on their own evaluation (see Figure 1). Team members share information with each other, typically at meetings attended by all team members. There is no attempt to generate or implement a common plan, although members may choose to utilize information obtained in the meeting to revise their own goals or intervention strategies. Multidisciplinary teams are hierarchically organized, that is, there is a designated program ªChief,º who is usually the highest ranking professional (commonly an MD). The designated leader is responsible for overseeing the program, leading meetings, resolving conflicts, allocating case load, and so on. Other team members feel responsible only for the clinical work of their discipline, and need not share a sense of responsibility for program function and team effectiveness. Interdisciplinary teams (from the Latin ªinter,º or among) also are composed of members from more than one discipline, making a breadth of resources available to patients. Interdisciplinary teams work much more collaboratively, however, as shown in Figure 2. Individual team members do their own assessment, but generally have worked out overall assessment strategies so that patients are not asked redundant questions or submitted to

Table 1 Types of health care teams. Type of team

Defining characteristics

Unidisciplinary team

Members from a single discipline; all members have the same role

Intradisciplinary team

Members from a single discipline, but at different levels of training; roles and responsibilities assigned by training level

Multidisciplinary team

Members from different disciplines; team members have independent roles and meet to share information

Interdisciplinary team

Members from different disciplines; team members have interdependent, collaborative roles and meet to plan treatment and evaluate response

Transdisciplinary team

Members from different disciplines, but team members largely have similar roles and responsibilities

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Discipline #1

Discipline #2

Discipline #3

Assessment

Assessment

Assessment

Treatment plan

Treatment plan

Treatment plan

Implementation

Implementation

Implementation

Evaluation

Evaluation

Evaluation

Treatment plan revision or Patient discharge from discipline’s services

Treatment plan revision or Patient discharge from discipline’s services

Treatment plan revision or Patient discharge from discipline’s services

Structure Meetings held regularly Information shared Figure 1

Organization of multidisciplinary team care.

repeated tests. Assessment information is shared with the team as a whole to generate an overall conceptualization of the relationships among biological, psychological, and social aspects of the case (the ªbiopsychosocialº model). This model is used to generate shared team goals for overall outcomes and to delineate how different disciplines will work together to create desired outcomes. Team members then can implement interventions, either individually or collaboratively as necessary, and evaluate progress. Those evaluations become new assessment data, which are brought back to the team to revise the team's goals and/or strategies for reaching them. This process is repeated as often as necessary until goals are achieved and the patient can either be discharged or a maintenance plan can be put in place. In an interdisciplinary team, the group as a whole takes responsibility for program effectiveness and team function. Leadership functions are shared among members, with the expectation that everyone must be equally committed to both the clinical content of the program and the process in which team members work together. All team members

are assumed to be colleagues, and there is no hierarchical team organization. One member may be designated team ªcoordinator,º but this is understood to be an administrative role and does not imply that the team member has higher status, a stronger say in resolving conflict, or the ability to make unilateral decisions. Because interdisciplinary teamwork requires so much collaboration and consensus decision-making, team members must have a high degree of interpersonal skill. The team must make a commitment to spending time developing effective working strategies and to attending consistently to the process of working together as well as to the quality of the outcomes of their work. Communication skills, role development, leadership skills, conflict resolution skills, and skills for comprehensive conceptualization of cases are necessary for all team members. This approach has also been labeled ªinterprofessional care,º especially in Europe. A new journal which is rapidly becoming a primary source of articles on interdisciplinary care is titled the Journal of Interprofessional Care. Interdisciplinary and interprofessional seem to be interchangeable terms; there do not seem to

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Interdisciplinary Team Theory

Structure Meetings held regularly

Assessment

Information shared Joint collaboration on treatment plans

Implementation

Unsuccessful or incomplete outcome

Evaluation

Successful outcome

Interdisciplinary discharge planning

Figure 2 Organization of interdisciplinary team care.

be important conceptual distinctions between them. In transdisciplinary teams (from the Latin ªtrans,º or beyond), disciplinary lines are blurred, and team members share role functions to a high degree. For example, nurses, psychologists, social workers, and occupational therapists in an adult day health care program might all drive the van to bring in patients, run groups, see individual cases for supportive counseling, supervise lunchtime interactions, work with patients on increasing physical and cognitive activity, and so on. This model does not have wide application in geriatric settings, since patients generally need the special skills of each discipline, obtained through extensive specialized training, not just generic skills that many disciplines might share. 7.24.3.2 Advantages of Interdisciplinary Teams The major reason to adopt a particular model of health care is that it provides the most costeffective results. In cost-effectiveness analyses, effectiveness should be considered first: for example, does the approach reduce symptoms, increase quality of life, promote health, and

prevent future illness? If more than one approach is effective, then it is meaningful to ask what the relative costs of each approach are and to select the program that provides the greatest effectiveness for the least cost. Wellfunctioning interdisciplinary teams provide cost-effective care by increasing the effectiveness of outcomes, thereby decreasing costs for continued treatment (e.g., Hendriksen, Lund, & Stromgard, 1984). There are four usual ways in which this occurs. First, interdisciplinary teams reduce duplication of services, compared to multidisciplinary teams, because team members plan carefully how to allocate resources and to cover necessary tasks. This may involve the collaboration of more than one discipline but precludes duplication. For example, on a multidisciplinary team both the social worker and the psychologist might begin individual psychotherapy for depression with a patient; this would not happen on an interdisciplinary team. Second, a related cost-saving impact is that problems do not fall through the cracks when care is organized by an interdisciplinary team. It is not uncommon on units staffed by multidisciplinary teams for discharge to be planned and then delayed repeatedly as the staff

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discover that not all the necessary work has been done; for example, the home care coverage is arranged before the physical therapist has become aware of the need to see the patient, and then home care plans have to be rearranged. A third advantage is that interdisciplinary teams can generate more creative interventions, since the ideas and knowledge of a group can be brought to bear and team members can stimulate each other's ideas. Finally, interdisciplinary teams can reduce institutional costs, because they increase staff morale and reduce staff turnover (Lichtenberg, Strzepek, & Zeiss, 1990; Sbordone & Sherman, 1983). As a result, more continuous care can be provided and the cost of recruiting and training replacement staff is reduced. While there is a need for more research to examine each of the elements of this argument in favor of the cost-effectiveness of teams, the evidence available does support the interdisciplinary team approach. For example, Zeiss & Okarma (1985) compared interdisciplinary team approaches to multidisciplinary care in an outpatient rheumatology clinic setting. Interdisciplinary team approaches were shown to improve patient outcomes on measures of quality of life (such as life satisfaction, self-rated pain, and depression) and measures of health care utilization (e.g., inpatient stays, the most costly care delivery modality). Another study in Sweden compared the outcomes of two groups of female outpatients with rheumatoid arthritis; one group had interdisciplinary care and the other standard care by a rheumatologist. While there were no significant differences in joint function or disease activity, overall health improved significantly over one year only in the interdisciplinary group (Ahlmen, Sullivan, & Bjelle, 1988). Other research showing the effectiveness and/or cost-effectiveness of interdisciplinary teams is reviewed in Lichtenberg (1994) and West and Poulton (1997). Concern is sometimes expressed that interdisciplinary teams may be too costly, because of the number of disciplines involved. However, interdisciplinary teams have no specific complement of personnel; it is not necessary that every team have a physician, nurse, psychologist, social worker, pharmacist, occupational therapist, and so on. Teams need to include members of those professions who are essential to provide effective care for the identified patient population. Thus, a well-designed interdisciplinary team involves no more personnel than would normally staff a clinic or inpatient unit for that population. The staff are simply organized differently than they would be if the unit had some other type of team (or no team framework at all).

7.24.3.3 Disadvantages of Interdisciplinary Teams (and Ways to Deal With Them) Even though interdisciplinary teams can be effective, they are not necessarily the treatment of choice in all care settings. Settings where patients have simple, routine problems would probably benefit more from some other form of care, since in-depth discussion of each case is unnecessary if everyone is going to receive essentially the same straightforward intervention. A clinic offering acute care to generally healthy adults, for example, is best staffed by nurses working with physicians; adding staff and meetings for the majority of the presenting concerns would serve no useful purpose. If a 40year-old woman comes down with bronchitis, adding collaborative care from a social worker, pharmacist, psychologist, and other disciplines to a routine medical visit is unlikely to be costeffective or satisfying to either the patient or the providers. It is rare, however, that elderly individuals have straightforward problems or benefit from routinized care. If an 80-year-old woman comes down with bronchitis, it may be essential to know that she is caregiver for a demented husband, what other medications she is taking, what her immune status is, and other issues pertinent to her physical and emotional well-being. Social work, pharmacy, psychology, psychiatry, and/or other team members may be essential in planning not only acute treatment for her bronchitis but also backup care for her demented husband. The other potential drawback of interdisciplinary teams is that they are not organized to provide rapid response in crisis situations; they are organized to provide care for chronic, complex problems. If a patient calls with an acute problem on Tuesday morning, and the next team meeting is not scheduled until the following Monday afternoon, there must be a way for individual team members, or a smaller set of team members, to make emergency decisions. Interdisciplinary teams can handle this by allocating such authority to team members, with the understanding that the issues will be raised at the next team meeting so that the implications of the crisis can be factored into the team's overall plan and the treatment responsibilities of other team members. 7.24.4 NATURAL HISTORY OF TEAM DEVELOPMENT Groups do not immediately become wellfunctioning interdisciplinary teams by deciding to make a commitment to that model of care. Much learning and development within the team must occur, over a period of time which

Natural History of Team Development lasts at least several months and sometimes longer. The term ªteam buildingº is sometimes used to describe activities during this period, but it is a particularly inappropriate term, because of the implications of the word ªbuilding,º which could imply that a solid structure, impervious to change, is being built. In fact, good teams learn to change continually and to respond fluidly to new demands, new patients, new staff, new health care policies, and so on, through a coordinated, collaborative process. Thus, the term ªteam developmentº is preferable, since it implies an ongoing, fluid process. 7.24.4.1 Processes of Team Development The sequence of experiences that groups go through in the process of developing cohesion and a high level of function has been described by many authors (e.g., Center for Interdisciplinary Education in Allied Health, 1980; Gersick, 1989; Scholtes, 1988), but most influentially by Tuckman (1965). He identified four processes which usually occur in sequence in the process of team development. He labeled these four processes Forming, Storming, Norming, and Performing; they will be described in more detail. It is important to note that these are processes, not stages. If these four processes are seen as four stages that all teams must go through, the opportunity to understand each team's unique pattern can be obscured. In addition, since these are fluid processes, it is not helpful to think of the team as being in only one stage at any given time. For example, a team may be still Storming with regard to some issues while it has already progressed to Performing in other areas. Furthermore, teams can change by leaping forward or falling back in response to personnel changes, the development of new treatment options, stresses or positive events in team members' lives, or a variety of other events. Nonetheless, these processes can be examined to help in conceptualizing the changes and skills necessary for effective team functioning without falling into a rigid stage theory framework. 7.24.4.1.1 Forming Teams may be formed when programs develop, expand, or are consolidated. A new team must deal with a number of issues, including which staff are part of the team; which patients will be served; what resources are available, such as hospital beds or outpatient visit rooms; how the team treatment planning process will be organized; and so on. Early in the life of the team, these decisions about content matters take priority, and little attention is paid

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to the process of working together. Team members typically feel a bit awkward with each other, and are willing to develop team relationships but unsure of what that involves. Team members may have concerns about trust, wondering whether it is all right, for example, to express disagreement or concern about how the group is working together. 7.24.4.1.2 Storming As the team continues to work together, process issues become unavoidable. It becomes clear that team members do not always agree about content issues, for example, how the team treatment planning should be set up. Differences in personal style may need to be faced: one person may handle concerns directly in ways that others see as too brusque, or a team member may try so hard to be tactful that no one can tell what he or she is saying. Team members may make different assumptions about basic working structure, for example, some may assume that starting the meeting at 10 a.m. means 10 on the dot, whereas others assume it means any time before 10.15 a.m. More substantive issues may arise, for example, different beliefs about whether the first-level intervention for depression should be antidepressant medication or psychotherapy. The group will have to learn to voice disagreement in a way that communicates a desire to stay engaged and work out the issues fairly in a collaborative process. If it cannot, the group will likely disband or fall back to multidisciplinary functioning, where individuals can make autonomous decisions without the need for collaboration and consensus. 7.24.4.1.3 Norming If the group can work on areas of disagreement constructively, a working strategy will evolve. This strategy can be thought of as ªground rulesº or norms which describe the way the group will work together and resolve conflict. Norms can be very specific (e.g., ªstarting at 10 a.m. means any time before 10.05 a.m.º) or more general (e.g., ªWhen team members disagree we will engage in a complex process to show our respect and trust for each other and remind each other that good people can disagree; then we will start to work on the substance of the issueº). If the norms developed are reasonable and effective, the group will set aside time to check on its progress (often referred to as ªprocess timeº) and to continue clarifying its norms. In addition, content decisions will be made and acted on, and the group will begin to feel cohesive.

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If the norms are ineffective, the group will feel stuck and rising frustration will throw the group back into Storming. For example, if the team develops a norm that polite agreement will be voiced on most occasions when disagreement occurs, team meetings may seem peaceful at first, but team members who disagree privately are likely to implement their own ideas rather than the ideas ostensibly agreed on in the meeting. This leads to hard feelings and the belief that meetings waste time; the group will have to learn to express disagreement openly and honestly before effective norms can be established that really resolve issues from the Storming process. 7.24.4.1.4 Performing Over time, the group will develop a high level of effectiveness, called ªperforming,º in which the team becomes expert at using its process to make decisions and get work done. Ground rules will rarely need to be explicitly stated; the group might seem to be on automatic pilot, especially to outsiders who see a seamless performance with deceptively little effort being needed to make complex decisions. The group will feel cohesive and morale will be high. 7.24.4.1.5 Team evolution Unfortunately, maintaining function in Performing mode consistently over time is unlikely and not a realistic team goal. Key staff members leave; a needed new discipline is added to the team; the program is moved to a different building; or trainees rotate through at fourmonth intervals. The group must be able to change accordingly, and it is likely that the team must go back through the four processes of team development before settling into Performing mode again. The new team and its resources and responsibilities must be examined in a Forming phase. Old norms may no longer work (e.g., if the team member whose role it was to draw out quieter team members has left), so there will be a Storming process as the implications of change

for the day-to-day life of the team become clear. The team will develop new norms, which maintain as much of what worked before as possible, but which also enthusiastically embrace the different skills and personal style of any new team members. If continual change is a reality, for example, if new trainees appear at frequent intervals, the team will develop metanorms for how to allow trainees to have some impact on the group, without constantly having to redefine the group from scratch. 7.24.4.2 Dilemmas of Team Work One helpful way to think about the processes groups need to go through to become performing teams is summarized in Table 2. Groups must learn to deal effectively with three inevitable challenges: interdependence, complexity, and disagreement. The first issue the team faces is interdependence; by definition, an interdisciplinary team seeks to share responsibility for patients by working collaboratively. Early in the life of the team, this usually leads to turf battles, as each team member realizes that his or her skills overlap, often substantially, with the skills of other team members. In well-functioning teams, this will be a source of camaraderie and confidence, but early in the team's development, members can fight over who ªshouldº be doing various activities. For example, teams might argue about whether social work or psychology ªshouldº do family therapy, or whether pharmacy or nursing ªshouldº do home visits to check patients' medicine cabinets and prevent mistakes in the home drug regimen. In the Storming process, these issues will be highlighted in order to develop team-specific agreements (norms) about how such tasks will be distributed and/or shared. The section on team role maps below (7.24.5.3) gives more detail on this process. The second issue is complexity. By definition, interdisciplinary teams are established to deal with complexity, and case discussions, to be useful, must increase the complexity of the

Table 2 Dilemmas of teamwork. Theme

Problem

Opportunity

Work to be done

Interdependence

Turf battles

Collaboration

Knowledge of and respect for diversity and shared abilities

Complexity

Endless assessment

Comprehensive care

Conceptualization, key issues, language of function

Disagreement

Destructive conflict

Integration of multiple perspectives

Communication skills

Development of Interdisciplinary Team Skills whole group's understanding of the interrelationships of each patient's biological, functional, social, and psychological problems. On a well-functioning team, this leads to a breadth of understanding that allows effective comprehensive care. Early in the life of the team, it can lead to information overload and frustration that cases are discussed seemingly without end. In the Storming process, the team must develop strategies for integrating information and capturing the team's complex understanding of the patient in a written format that facilitates treatment planning and implementation. Section 7.24.6 provides some examples of formats teams can use for developing treatment plans that capture complexity and promote collaborative intervention. The third issue is disagreement. Interdisciplinary teams rely on healthy conflict, in which the different perspectives and knowledge of team members can be presented. It is illusory to believe that these different perspectives will always be complementary; sometimes they are in direct contradiction. For example, the patient may have told one team member that he is sleeping better since starting a behavioral sleep hygiene program, but told another team member that his sleep problems are unchanged. Teams that are having problems are likely to treat these differences as issues in which one team member is right and the other is wrong, leading to conflict destructive to team cohesion and effective patient care. However, in a functioning team, the team members will recognize that there is direct conflict and see it as an opportunity to learn something more about the patient and themselves. The patient may be trying to manipulate one team member to obtain pain medications. Or the patient may be more demented than the team realized and generating unreliable answers to questions. It is also possible that different team members have different interview styles that elicit different information from the patient, or team members may attend selectively to different kinds of information patients present. The important point to remember is that the ability to consider multiple possibilities and integrate multiple perspectives in handling conflict is the hallmark of a highly functioning team. A detailed analysis of strategies for learning to handle conflict effectively are beyond the scope of this chapter, but important sources giving such analysis are presented in Section 7.24.8. Thus, interdisciplinary teams must develop the capacity not only to deal with the patient issues that the program was originally designed to treat, but also to deal with the interpersonal world of collaborative care. Skills that are necessary for all team members include

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knowledge and respect for other team members' abilities, the capacity to conceptualize cases holistically, the expertise to develop written team treatment plans which capture the clinical conceptualization, communication skills, leadership skills, conflict resolution skills, and the capability to anticipate and respond to change. 7.24.5 DEVELOPMENT OF INTERDISCIPLINARY TEAM SKILLS 7.24.5.1 Formal Educational Settings Since the mid-1980s there has been an increase in university-based gerontology programs. However, these programs may not result in the development of skills needed for working in interdisciplinary environments. Clark (1993) argues that the basic departmental structure of universities can create problems for maintaining a truly interdisciplinary perspective. Interdisciplinary principles and practice cannot be taught in a classroom with didactic methods over a short period of time. Instead, interdisciplinary experiences must be integrated into the program at a variety of points, so that students can master the conceptual frameworks and acknowledge the differing value orientations of different disciplines. In discussing interdisciplinary education embedded in specific university departments, Mitchell (1993) states that exposure to clinical settings is essential for beginning health care students if they are to change their traditional orientation and embrace an interdisciplinary perspective of patient care. For example, only 9% of first-year physiotherapy students acknowledged the importance of being able to communicate with other health professionals (Mitchell, 1993); it appears that these students had already developed specific beliefs about therapeutic practice. Clark's (1993) guidelines for interdisciplinary education involved the following recommendations for educators who need to: (i) clarify the educational objectives of interdisciplinary programs, (ii) attend to team process issues by including a substantial experiential component, (iii) develop educational methods and materials for communicating across disciplines, (iv) focus on obtaining high-level institutional support for interdisciplinary programs, and (v) recognize that interdisciplinary education represents a true educational revolution. 7.24.5.2 On-the-job Training The majority of professionals are exposed to interdisciplinary team concepts for the first time when at work. Most interdisciplinary health

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Interdisciplinary Health Care Teams in Geriatrics: An International Model

care teams are not formed with the intent to be time limited, and teams have the additional challenge of continuously changing group membership. Because of these factors, team skills need to be taught on an ongoing basis to individuals with very different beginning skill levels. Drinka (1994) points out that it is often the task of ongoing members to teach new members how to collaborate and assume leadership within the team. This process may be difficult at times, since developing a collaborative set involves integrative problemsolving skills in professionals who may be used to working independently. All team members must feel empowered to participate in conflict resolution. While individual members will have varying degrees of formal power, informal power is also important, particularly for new team members. Informal power can be gained through organizational skills, developing increased knowledge about the other disciplines, demonstrating commitment to the team's mission, and increased tenure (Drinka, 1994). Teams can facilitate this process through inservices and retreats that foster both an increased knowledge of other disciplines and a sense of ownership of the team's mission. Individual members may also protect the rights of new members by drawing them into discussions, for example, by asking their opinion before soliciting the view of established team members. Team members also need to feel comfortable enough with the team to disagree in order to avoid poor decision-making (Heinemann, Farrell, & Schmitt, 1994). In addition to team retreats that provide opportunities for informal social activities, team members can practice brain-storming exercises and rotate the role of ªdevil's advocate,º thus formalizing the importance of alternative views (Heinemann et al., 1994).

7.24.5.3 Role Definition on Interdisciplinary Teams One of the activities which helps a team progress is the development of a shared understanding of the roles of each team member. An example of such a role map is shown in Figure 3; this role map is adapted from one generated for a hospital-based home care team (HBHC). This Department of Veterans Affairs program serves home-bound older patients and their caregivers; all team members drive to each patient's home to assess needs and provide services. Team members shown in the figure are a physician, four nurse practitioners, a social worker, an occupational therapist, a pharmacist, and a psychologist. Each discipline is

represented by an oval, and each oval overlaps with others. Within each discipline's oval are listed the components of their role. In the part of the oval that does not overlap with other ovals appear clinical responsibilities assumed only by that discipline. In areas where two circles overlap, clinical responsibilities appear which either discipline might perform or which the two team members might perform as co-therapists. For example, either psychology or medicine might do cognitive screening. There are also areas where three, or even more, ovals overlap. In those intersections appear tasks which several team members might perform, for example, nursing, medicine, or pharmacy might all educate patients about the effects and side effects of medications. Figure 3 has been simplified for clarity and does not include all the roles of any of the disciplines, but a more complex version could be generated that did demonstrate the complete range of tasks performed. Generating and/or examining such a diagram provides several kinds of information. First, it can delineate all the clinical services which patients could receive from this team. Second, it clarifies for each discipline what they offer to the team and what the team will expect them to provide. Third, it clarifies areas which, on a well-functioning team, will be opportunities for conjoint efforts or, in a poorly-functioning team, will be sources of conflict that can be termed ªturf battles.º If pharmacy and nursing each want to hold the unique right in this setting to educate the patient about medications, for example, the two disciplines are likely to be in conflict about this issue. If each sees the other as a collaborative resource instead, team work (and patient care) will be enhanced. Fourth, Figure 3 suggests which disciplines may have the most difficulty speaking each other's language. The roles of pharmacy and psychology, for example, overlap very little in this setting. In a well-functioning team, members will see these as complementary functions and take pride in being able to provide a range of services well beyond the purview of any discipline. In a poorly functioning team, members will complain about the time taken to discuss issues outside their own scope of practice and compete for time to discuss the issues most closely connected to their own role. To generate a role map which captures the realities of a specific program and the disciplines on its team takes some time, but is usually well worth the effort. Each team member needs to specify his/her role and present it for team discussion; often this results in adding tasks to the list which the team member did not specify but recognized when mentioned by other team

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Interdisciplinary Team Treatment Planning

Social Work: Facilitate use of community resources; facilitate family meetings for decision making

ly mi ing Fa nsel u Co

Psychology: Personality and behavioral assessment, psychotherapy, behavioral medicine interventions

Cognitive Assessment

Coordinate placement for DC planning

Planning and counseling during chronic Nursing: or terminal Screen for psychosocial illness and functional problems, refer to case management

Medicine: Serve as Primary Care M.D.; Monitor diagnosis and treatment

Med. Education

Physical assessment; and treatment planning, coordinate care with other providers

Decide on equipment needs

Occupational Therapy: Assess and increase ADL and activity function; energy conservation advise re: home hazards

Monitor Medication Regimen

Pharmacy: Medication review Facilitate pharmacy dispensing

Figure 3 Geriatric interdisciplinary team role map.

members. This also begins to highlight the areas of overlap, as team members recognize some of their own tasks on colleagues' lists. After all disciplines have presented their roles, someone on the team, or a small group, needs to organize the lists to capture graphically areas of overlap and areas of unique function. This document can then become a tool to help in shaping norms and to help in the process of socializing new team members and reaching or returning to the Performing level of team process.

7.24.6 INTERDISCIPLINARY TEAM TREATMENT PLANNING Interdisciplinary teams generate treatment plans through two interlocking processes. First,

the team must be able to conceptualize patients broadly, incorporating all the relevant information and the relationships between different problems. Thus, the team must go beyond simply listing patient concerns on a problem list, to look at the relationships among problems. For example, a patient's depression may be triggered by loss of independence in activities of daily living (ADL) and the depression may be the primary reason (because of the patient's apathy and hopelessness) for medication nonadherence. Psychology or psychiatry could list depression on the problem list; occupational therapy could list difficulties with ADL; pharmacy could list medication nonadherence. But the efforts of each discipline to deal with these problems will be enriched if the linkages among problems are understood.

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Interdisciplinary Health Care Teams in Geriatrics: An International Model

This type of conceptualization will be demonstrated in more detail in the case study in Section 7.24.7. Second, the team must have a structured format for guiding and capturing on paper the treatment planning process. That structure should, at minimum, specify which problems will be treated, what the goals of treatment are, what treatment strategies will be used, and which team members will be involved. It is helpful to indicate which team members will be involved by name as well as discipline, to emphasize accountability. The plan may indicate time frames, specifying which interventions should begin immediately, which will be implemented after progress is made on initial problems, and the expected time frame to accomplish the goals. The plan could also include space to update status of progress generally, such as noting if the treatment goals are accomplished The plan should be available to all team members to guide their activities in implementing their own roles, and it should be available at team meetings to guide discussion. To ensure continuous availability, teams can circulate copies to all members or keep charts in an easily accessible place. To guide team discussions, plans can be shown using overhead transparencies, or circulated at the meeting, or a team member can review highlights of the plan before case discussion. 7.24.7 INTERDISCIPLINARY TEAM CONCEPTS IN ACTION: TEAM RESPONSE TO A GERIATRIC PATIENT WITH MULTIPLE MEDICAL PROBLEMS AND DEPRESSION (SAM P.) In order to further clarify the use of the team treatment planning process, we return now to the case which opened the chapter, Sam P., a man referred to a mental health practitioner for the assessment and treatment of depression. Let's look at this case in more detail to see how an interdisciplinary perspective influences his treatment. This case also offers the opportunity to contrast how an interdisciplinary team would approach the planning and treatment processes differently from a multidisciplinary team. Sam P. is a man in his mid-70s of Italian-American background. He has been married to his wife, Pauline, for 40 years: they have been in the same two-storey home for their entire marriage and enjoy gardening, visiting with family and friends, and participating in some church activities. For the last 15 years, Sam has had progressively greater trouble with day-to-day function as a result of his

medical problems. His arthritis results in joint pain, especially in his hands, knees, and hips. This joint pain also negatively affects his sexual function. Sam's cardiovascular disease results in impaired blood flow, especially to his legs, to the extent that he gets cramping pain in his legs after walking as little as half a block. Impaired blood flow also has impaired Sam's ability to get and keep an erection. Taken together, these problems have affected almost every aspect of Sam's life. He has trouble getting up and downstairs in his home, he cannot do the gardening he enjoys, he has trouble joining family and friends on outings, and he and his wife have stopped any form of physical intimacy because of his frustration with his sexual function problems. Sam is taking various medications for his medical problems and comes to the geriatric clinic every three months on average. At the clinic, the medical residents rotate every four months; Sam feels frustrated when he has to retell information to a new doctor. He sometimes gets disgusted and angry with clinic staff, and forgets the questions he has about his medications. On several occasions, Sam has lost track of his medication schedule, became overmedicated, and developed severe nausea, diarrhea, and cognitive confusion. At other times, he has failed to take medication for days at a time, resulting in increased pain and decreased energy. Sam says that he sometimes feels depressed and useless. He and his wife used to baby-sit their infant granddaughter, but Sam can no longer keep up with a toddler and gets rattled by too much noise and activity. Sam used to enjoy activities in his neighborhood, such as pot-lucks and reading groups, but has stopped going because of his physical problems. His major independent forms of recreation before his decline were driving his friends on outings and attending Elks Club meetings; he has also stopped trying to do these things. He reports that he is often ªblueº and tearful, and describes a poor appetite and waking early, about 4 a.m., several days a week. During the 40 years of their marriage, Sam and Pauline enjoyed physical intimacy and Sam describes feeling sad and frustrated that he ªcan't perform.º Besides problems with erections, Sam often feels tired and is afraid that having intercourse would put too much physical stress on his joints. Sam also admits to feeling self-conscious about the way he looks and has a hard time believing that his wife still finds him sexually attractive.

You can see from this case description that a competent professional in any one discipline cannot address the many issues involved in Sam's physical and mental health. Like many older adults, his treatment should involve the cooperation of a number of disciplines, including nursing, social work, medicine, psychiatry, pharmacy, occupational therapy, and psychology. The psychologist involved in the case

Interdisciplinary Team Concepts in Action would probably conduct a careful mood assessment, then contact the psychiatry consult service to determine if Sam's medication regimen is commonly associated with depression. Several key issues likely to be related to Sam's negative mood would be examined: decreased participation in activities that are both meaningful and pleasurable for him; beliefs that he is no longer useful to others; and disruption of his marital intimacy, both physically and emotionally, as a result of his sexual dysfunction. The psychologist may consider some neuropsychological assessment to evaluate Sam's short-term memory, given that he has forgotten to take some doses of medication in the past and taken too much medicine at other times. There are additional areas that could be targeted for change, such as his frustration and communication difficulties with clinic staff. Psychiatry and psychology may discuss together the usefulness of prescribing antidepressant medications. The other disciplines involved in his care would have their own concerns and areas of interest. The geriatric medical resident assigned to Sam would continue to evaluate choice of medications with the goals of reducing pain and minimizing joint damage, and maximizing cardiac function and circulation. The nursing staff may want to further educate Sam and his family about his medical diagnoses and the reasons for daily fluctuations in pain and function. Occupational therapy might work with Sam on selecting assistive devices to aid him in difficult tasks (e.g., buttons, zippers, jar lids), create hand splints to protect his hands from further arthritic damage, and plan ways for him to continue important daily activities (e.g., design a table-top garden for which he does not have to kneel). The social worker involved in the case would be aware that Sam and Pauline's two-storey house is a problem because of Sam's swollen knees and peripheral neuropathy, and would discuss housing and long-term plans with them. Sam's episodes of overdosing on medications would be concerning to the pharmacist, who may consider ways to reduce the likelihood of this re-occurring. So far, it may appear that each professional could execute her or his own treatment plans without the input of the other disciplines (i.e., as a multidisciplinary team). Upon closer inspection, the evaluation and treatment goals in each area overlap in a way that creates the potential for conflict as well as cooperation. For example, the psychologist's suggestions for increasing pleasant activities may appear to directly contradict what Sam has been told by the occupational therapist and the geriatric medical resident. In addition, the psychologist and

563

social worker might be convinced that his medication overdose and seeming confusion during appointments are related to complex issues such as anxiety about his illness, some recent decline in short-term memory that should be monitored, his response to the staffing patterns of the clinic, and a lack of support from his family. This may contradict the pharmacist's approach that the main issue is regulating medication regimens and providing more education about the purpose of each medication. From a different perspective, the medical resident may believe that too much time is spent in team meetings discussing Sam's emotional and psychosocial reactions to his illness. After all, the severity of his symptoms would decline significantly if he would just carefully follow his medication regimen and not engage in strenuous physical activity. These conflicts might be traced to several aspects of the team setting: poor patterns of communication during and outside of team meetings, a decision-making process that minimizes opportunities for discussion or dissent, and a lack of understanding and respect for each discipline's norms and perspectives for patient care. In contrast to how a multidisciplinary team would approach the patient, the interdisciplinary team in this case would spend more time and attention coordinating Sam's evaluation and care. Through regularly scheduled opportunities for education during team meetings, the interdisciplinary team members would develop a greater understanding of the competencies and perspectives of the other disciplines. This would result in the team's enhanced ability to identify shared treatment goals and the specific needs for collaboration necessitated by each patient. What team response could be expected in Sam's case? The following section describes an interdisciplinary effort focused on several interwoven goals and strategies. From the information provided in the case description plus some additional assessments, a treatment plan was developed. An important issue that became clear during interdisciplinary discussion was that Sam's care had been fragmented and spread across several specialty clinics, rather than being consolidated in a primary care setting and coordinated. Sam's loss of mobility was a particular focus. He had been seen by orthopedics, who planned hip replacement surgery with the expectation that he would be able to return to most of his prior activities after surgery. However, when seen by cardiology, he was told that hip replacement surgery was unnecessary and that he would be more mobile if his cramping pain (known as claudication) was treated with a medication to

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improve cardiovascular performance. Sam tried that medication, but stopped using it because of side effects, especially headaches. When he stopped using it, he did not go back to cardiology to try another medication, nor did he go back to orthopedics, because of his pain, difficulty getting to the doctor for appointments, and his general discouragement and depression. Thus, his treatment plan was based on the idea that his care needed to be coordinated, not fragmented, and that regaining mobility would be key to resolving many of the other issues that Sam presented. The three interwoven issues that were targeted as initial goals thus became: (i) decrease depression; (ii) reduce joint pain; and (iii) improve cardiovascular performance. It was expected that improvements in these three areas would result in improved function across a variety of activities, including increased mobility, return to valued social and recreational activities, and improved sexual function with his wife. These functional changes were also considered important aspects of the treatment plan, and are woven into it. The frst two elements of the treatment plan are shown in more detail in Table 3. This also shows how the goals for the first two problems are related to specific intervention strategies, the disciplines working together to provide services, and the time frame for completing each intervention. The reader will also notice from Table 3 that the suggested interventions were linked closely to a jointly developed conceptualization of each problem. After targeting Sam's main problems and agreeing on etiological models for each, the team identified goals that could be linked to time-specific interventions facilitated by team members. The first, central issue was addressing Sam's discouragement about treatment and alienation from health care providers. A plan was developed to provide Sam with more personalized and consistent care by establishing a stable staff person on the interdisciplinary team as his primary contact person. This staff member (the social worker in this case) could help him use his medical appointments more effectively and efficiently and provide support and encouragement to pursue more vigorous treatment of his medical problems. This intervention also improved the team's overall knowledge of Sam's medical and psychosocial status. The team believed that improving Sam's involvement with care and motivation to participate fully in care were crucial in meeting the second goal of reducing joint pain in his hips by rescheduling hip replacement surgery. In turn, reducing that joint pain was essential to work on increasing mobility.

The team viewed Sam's depression as heavily influenced by his progressively decreasing involvement in pleasurable activities due to chronic pain and decreased mobility. The team encouraged Sam to participate in brief psychotherapy with the team psychologist, with the further expectation that the psychologist and Sam would work with the occupational therapist on selecting activities and environments that would match his interests and degree of physical disability. As his physical situation improved, with surgery and medication, the level of activity could increase, but they could also develop strategies for increased pleasure, satisfaction, and sense of competence even before the surgery. This could help combat his discouragement and passive withdrawal from treatment, just as the closer relationship with the team did. Antidepressant medications were not recommended by the psychiatrist because of the strong situational components tied to his recent depression (i.e., decreased involvement in pleasant activities, chronic pain) and Sam's difficulty in managing his other medications. Sam was initially surprised at the team's feedback that his feelings of depression were important and could be treated. He had expected someone in the clinic to tell him to ªnot be so emotional and just deal with it.º After talking to the psychologist about the team's view of his depression, Sam attended four individual sessions with the psychologist and learned to identify the activities that were most closely linked with feelings of happiness and satisfaction. Sam and the therapists carefully planned ways to retain the daily activities most meaningful to him and to adapt activities, like gardening, that he had believed must be given up. He reported that, while still feeling sad at times, he was less tearful and more energetic. In addition, his appetite and sleep schedule returned to a more normal basis. The team also arranged an appointment for Sam and his wife to meet with the geriatric medical resident and the psychologist. During this visit, Sam and Pauline were able to discuss their concerns about the impact of Sam's pain and physical functioning on sexual activity. They agreed to try different body positions and touching that resulted in less pressure on his affected joints. Sam also began to use a warm bath and pain medication just prior to making love and reported that this was helpful. After Sam's hip replacement surgery and improved function with cardiovascular treatment, the therapists helped Sam and his wife work out additional positions and timing for sexual activity and to continue communicating clearly

Table 3 Treatment plan for Sam P. Problem area (1) Depression (linked to discouragement about treatment, reduced pleasant activities, and loss of marital and sexual intimacy)

Treatment goal

Timeframe

(1) Offer following therapies:

(1)

(i) Understanding of and confidence in treatment providers and potential treatment outcomes

(i) Consolidate care in geriatrics clinic; appoint a long-term staff member to meet with client every visit to assist in clarifying issues and questions for the medical resident; preclinic discussion of case with resident to ensure knowledge of treatment plan and consistent follow-up (ii) Brief psychotherapy using OT as consultant on adapting activities (iii) Joint appointments with patient and wife for problem-solving re. sexual activity

(i) Social worker as long term staff contact; entire team involved

(i) Ongoing

(ii) Psychology and

(ii) 4 months

2(i) Decrease pain

(ii) Prevent further problems (iii) Reduce stress on joints in day to day life

OT, occupational therapy.

Disciplines involved

(1) Increase

(ii) Pleasant activities (iii) Level of physical intimacy (2) Joint pain, particularly in hips, knees, and hands (believed by the team to be primarily a result of osteoarthritis, exacerbated by lack of joint protection activities)

Intervention

(iii) Medicine and psychology

2(i)(a) Reschedule hip surgery, with close communication between geriatrics clinic and orthopedics

2(i)(a) Medicine

(i)(b) Increase consistent use of pain medication through education and increasing motivation (i)(c) Use hand splints to reduce pain and prevent deformity (ii) Patient and family education about arthritis self-management (iii) Assist patient and wife make long range plans about housing if still needed after hip surgery; adapt gardening and daily tasks using joint protection techniques and assistive devices

(i)(b) Pharmacy and psychology (i)(c) OT (ii) Nursing and psychology (iii) Social work and OT

(1)

(iii) 6 months

2(i)(a) 1 month

(i)(b) 2 months (i)(c) 2 months (ii) 3 months (iii) 6 months, if needed

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Interdisciplinary Health Care Teams in Geriatrics: An International Model

about their expectations and occasional problems. Sam was able to keep better track of his medications through the suggestions and encouragement of the pharmacist and the nurse, especially after his depression began to resolve with treatment. They helped him understand the differences between different medications in his regimen and set up a procedure for organizing his weekly medication regimen. There were no further instances of taking too much medication, and Sam was better able to report to the geriatric resident on whether different medications were having their intended impact. Ultimately, Sam did have hip replacement surgery, which resulted in a significant improvement in his pain and mobility. During his postsurgery recovery, the work on depression and maintaining a strong team relationship continued, resulting in a rapid recovery and reestablishment of a wide spectrum of activities, including a return to more social contact. After the surgery, Sam was able to stay in his twostorey house, so the social work intervention which was considered was not, in the end, necessary.

7.24.8 RESOURCES AND TRAINING MATERIALS While the case of Sam P. demonstrated an interdisciplinary team at work in a hospital setting, this type of case formulation and treatment is important when working with older adults in a variety of mental and physical health care settings. This chapter has introduced the concepts and practice of interdisciplinary teamwork, with the expectation that more resources and experience will be needed for those wanting to apply this information to their own work groups. This section discusses additional written materials and training guides that may be useful. The disciplines of industrial/organizational psychology, social psychology, and business management have traditionally devoted the most attention to studying group behavior, decision-making, and conflict resolution. However, a separate literature on interdisciplinary team functioning in health care settings has also developed. Some basic early work is covered in an annotated bibliography (Czirr & Rappaport, 1984). Early work will be mentioned, but the chapter will emphasize more recent publications and training approaches. While it is beyond the scope of this chapter to review these literatures in depth, the following section outlines several articles and books that provide a context for understanding interdisciplinary team issues.

7.24.8.1 Outcomes and Descriptions of Interdisciplinary Teams The literature on team functioning in geriatrics is dominated by articles describing and evaluating interdisciplinary programs (e.g., Rubenstein et al., 1984; Zimmer, Eggert, & Schiverton, 1990) and discussing barriers to effective team functioning (e.g., Saltz, 1992; Chafetz, West, & Ebbs, 1988). Qualls and Czirr (1988) discuss how models for professional functioning differ across disciplines and influence team participation and collaboration. Goldstein (1989) looks at team functioning from the perspective of physicians and offers practical advice for developing team approaches in geriatric health care settings. Drinka and Streim (1994) provide case examples of teams functioning ineffectively and suggest intervention strategies to help teams escape from ªhealth care purgatory.º In his book A Guide to Psychological Practice in Geriatric Long-term Care, Lichtenberg (1994) does an excellent job advocating for an interdisciplinary approach in long-term care settings. The chapter on creating effective interdisciplinary teams is particularly useful for those needing more information on models for training nursing assistants, organizational interventions in long-term care settings, and specific examples of team-development approaches (including the Department of Veterans Affairs' Interdisciplinary Team Training Program). Lichtenberg also reviews the empirical literature on the relationship between team functioning and patient outcome, noting studies such as the work by Feiger and Schmitt (1979) that demonstrate a relationship between collegiality in interdisciplinary health teams and improved physical, social, and emotional functioning in patients. 7.24.8.2 Team Training Guides There are a variety of ªhands-onº training manuals for those interested in practical advice and examples of team development exercises. Some of these guides target work groups in business, while others are specific to health care settings. Several are particularly helpful. While not specific to health care environments, The Team-Building Sourcebook (Phillips & Elledge, 1989) is a comprehensive resource for practicing team consultants and others who are involved in team development. This guide discusses the steps of the team development process and provides numerous examples and activities to be used in addressing the specific needs of a given team. A strength of this resource text is the inclusion of agendas and workshop suggestions for a variety of tasks, giving specific amounts of

Resources and Training Materials time for team development activities. For example, the implementation section of the source book outlines the possible contents of team development workshops lasting from four hours to two days. Eleven modules are presented with step-by-step instructions for conducting team development sessions, complete with handouts and materials to be used in flip charts. The Team Handbook: How to Use Teams to Improve Quality (Scholtes, 1988) is another excellent team-training guide. Although it was also developed with business consulting in mind, the handbook is relevant for health-care professionals. This work discusses quality improvement concepts, then shows how productive meetings and cooperative work groups are important components of increasing team efficacy. Scholtes addresses common problems in team settings (e.g., dominating or reluctant participants, feuding team members) and makes specific recommendations on how to work through these difficulties. The handbook also includes an entire chapter of team development activities and exercises, from handling introductions to helping team members make observations about group processes. A Guide to Team Development was developed by an interdisciplinary team (Center for Interdisciplinary Education in Allied Health, 1980) at The University of Kentucky's Center for Interdisciplinary Education in Allied Health. This field manual was designed for faculties who train students in team development. It identifies tasks and exercises focused on organizing team meetings, goal setting, decision-making, generating an open and creative environment for team problem-solving, and evaluating the team process. An assessment tool for evaluating interdisciplinary training efforts is The Interdisciplinary Education Perception Scale (IEPS) (Luecht, Madsen, Taugher, & Petterson, 1990). The IEPS is an attitude inventory that assesses perceptions of professionals, and has four factors: beliefs about competence and autonomy; perceived need for cooperation; perceptions of actual cooperation among different disciplines; and understanding others' values. The Centre for the Advancement of Interprofessional Postgraduate Education has identified interprofessional training initiatives throughout the United Kingdom (CAIPE, 1989). The University of Newcastle Health Care Research Unit also developed a report that suggested practical steps for increasing collaboration among health care professionals. More broadly in Europe, an organization, the European Network for Development of Multiprofessional Education in Health Sciences

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(EMPE), has been developed to promote interprofessional education (Goble, 1994). This organization offers expert resources and opportunities for meeting to share educational plans, implementation strategies, and data. Resources for promoting interprofessional collaboration have also been developed in Finland (Lamska, Hietanen, & Lamsa, 1994) and Romania (Stephenson & McCreery, 1994). 7.24.8.3 Communication Training There are occasions when a group has already accomplished many of the tasks needed to function as an interdisciplinary team, yet team members have difficulty resolving conflict or communicating clearly. Two books are recommended that specifically address conflict resolution and communication skills. Gottman, Notarius, Gonso, and Markman's A Couple's Guide to Communication (1976) is a classic in the psychotherapy and counseling literature for very good reasons. Although it targets communication difficulties in married couples, this work provides the rationale and description of exercises that can improve communication in a variety of contexts and settings. The first five chapters in the book, covering skills such as listening, validation, constructively expressing grievances, negotiating agreements, and handling hidden agendas, are especially helpful. A highly recommended book by Fisher, Ury, and Patton (1991), Getting to YES: Negotiating Agreement Without Giving In, is based on work done by the Harvard Negotiation Project. Getting to YES addresses both the conceptual orientation and practical implications of principled negotiation, a method of negotiation that can be used in a wide variety of circumstances. In principled negotiation (also called negotiation on the merits), negotiators are encouraged to separate the people from the problem, focus on interests instead of positions, generate a variety of alternatives before making decisions, and base results on some objective standard. These authors also discuss handling several common dilemmas in negotiations, including negotiating with someone who is more powerful and working with others who continue to rely on positional bargaining or unprincipled tactics. 7.24.8.4 Factors that Influence Team Functioning Interdisciplinary teams are based on nonhierarchical interactions, but team members come from a larger social structure that often emphasizes rank and status. Work has been

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done in areas such as the behavior of lowranking group members, and cultural and gender differences, as they influence the decision-making strategies of groups. Lichtenberg, Strzepek, and Zeiss (1990) discuss factors that limit the participation of psychiatric aides in treatment teams. They use a particular program, the Veterans Administration's Interdisciplinary Team Training in Geriatrics Program (ITTG; now known as the Interdisciplinary Team Training Program or ITTP), as an example of how to bring about change. Mechanic (1962) discussed the attributes of the social structure of an organization that led to greater power and influence by lower ranking group members. When these concepts are applied to team members from traditionally lower-ranked disciplines (i.e., recreational therapists, nursing assistants, clerks), Mechanic's work has implications for team interventions. For example, teams can increase opportunities for these staff to interact and have access to other professionals, which will increase their influence in teams and improve the quality of team decisions. The team can also develop ways to recognize explicitly that individuals from low-ranking disciplines often have important expert knowledge that is not readily available to others in the team. On a related topic, Kirchmeyer and Cohen (1992) discuss the concept of constructive conflict and then demonstrate empirically how specific behaviors in multicultural groups may increase the participation of ethnic minorities. This approach is described in more detail by Tjosvold (1991), who presents some actions that can be taken by designated group leaders to encourage the active involvement of all team members. Kelley and Streeter (1992) review issues and research on gender in organizations, covering such wide topics as trends in work patterns and perceived gender differences in performance and job attitudes.

7.24.9 HELPING WITH INTERDISCIPLINARY TEAM DEVELOPMENT It should be clear that all interdisciplinary teams, no matter how motivated and talented the members, will have difficulty from time to time. The material presented thus far is intended to provide a theoretical background for how teams function, an example of good interdisciplinary team treatment planning, and information on resources where more can be learned about team functioning and essential skills for teamwork. It is also helpful to consider how to try to have a positive impact

as a team member or how to help with program development. First, there is a need to respect a fundamental tenet of interdisciplinary team development: by definition, no single person can make a group become an interdisciplinary team. Even with enthusiasm about interdisciplinary team ideas and a desire to see them put into action, no single person can make this occur, even if he or she has the institutional power to define program goals and organizational structure. Interdisciplinary teams ultimately depend on and are the embodiment of a powerful principle: people support what they help create. A group can only become an interdisciplinary team if the group members decide themselves that they want to take on the responsibilities of shared leadership and interdependent functioning. An individual's role can be one of bringing the concept to the table and trying to generate shared enthusiasm for it, but it cannot be mandated from above. If the group must function in a way mandated by authority, it is, by definition, not an interdisciplinary team. If the group embraces the interdisciplinary concept, an individual can help create experiences that will move the group forward. It is usually essential early in the life of the team to generate a vision statement that articulates team members' understanding of program goals, including what patients are to be served, what resources are available to serve them, and the expected impact of the program. This can help the team negotiate the Storming process by providing a grounding in a commonly held set of values. When the team has a shared sense of purpose, other training experiences largely mirror the organization of this chapter. Team members need to learn about interdisciplinary concepts and to confirm their commitment to shared responsibility for the success of the team. They need to recognize how much there is to know, for example, about each others' professions, about sharing leadership, and about communication skills and conflict resolution. The group optimally will decide together on strategies for appropriate additional training. Team members can train each other, or it may be necessary to bring in a team consultant. It will be especially important to bring in a consultant if the team cannot handle successfully the Storming process, either because the group avoids all conflict or because conflict escalates uncontrollably. There are systems level factors that encourage team members to ignore conflict. For example, factors such as low staff-topatient ratios, lack of proximate office space that would allow informal staff contact, and few direct incentives for team process meetings

References (Drinka, 1994) all point to the benefits of having a consultant assist in the process of team development. In the training process, it is particularly helpful to find a balance between content and process. During process time, team members can share personal reactions to the tensions and pleasures of interdisciplinary work and discuss experiences with communication styles in the group. During content training, it is very helpful to have the group develop its own unique role map. This also provides an opportunity for each discipline to educate the others about its skills, training experiences, licensure status, and model of health care. The group can also look at different approaches to team treatment planning and choose one that best fits the team's mission and style of working. Any team member can suggest such strategies and contribute to implementing the group's decisions. If the group does not develop effectively, or one individual seems to make all the suggestions or guide all the training experiences, bringing in a team consultant would be a good idea. The more one person tries to carry a reluctant team, the less interdisciplinary it will be, and the more that person will become the de facto leader of a multidisciplinary team. In such cases, the most helpful thing to be done is to relinquish power in order to encourage other team members to join in the process of assessing the team's problems and generating solutions.

7.24.10 SUMMARY Interdisciplinary teams are a particularly appropriate way to organize health care for geriatric patients, who typically have complex, chronic problems. The interdisciplinary team provides care in which several disciplines coordinate assessment and treatment, so that problems can be dealt with consistently and comprehensively. Interdisciplinary teams are characterized by a nonhierarchical organization, in which responsibility for the effective functioning of the team is shared by all team members. This requires that team members be excellent representatives of and advocates for their disciplines. It also requires that team members have training in team theory, leadership skills, and communication skills, including conflict resolution skills. Interdisciplinary teams go through a process of development. Newly formed teams work out goals and basic models of function; this process usually highlights areas of disagreement among team members in strategies of care and/or personal interaction styles. As groups work out these

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disagreements, they develop shared norms which define the team's working strategies. With experience, most interdisciplinary teams reach a high level of function and deliver costeffective care while supporting staff morale. Interdisciplinary teams come about through the efforts of health care providers who are committed to the idea that patients will be best served when their care is coordinated and provided by team members who challenge, learn from, and rely on each other. Interdisciplinary teams depend on the wise and creative integration of diverse viewpoints. Sometimes those are complementary, but sometimes they are conflicting. The team must learn to value diversity, remain cohesive when viewpoints conflict, and negotiate agreement to which all team members are committed. 7.24.11 REFERENCES Ahlmen, M., Sullivan, M., & Bjelle, A. (1988). Team versus non-team outpatient care in rheumatoid arthritis. Arthritis and Rheumatism, 31, 471±479. Binstock, R. H., & George, L. K. (1990). Handbook of aging and the social sciences. San Diego, CA: Academic Press. Birren, J. E., & Schaie, K. W. (1990). Handbook of the psychology of aging. San Diego, CA: Academic Press. Center for Interdisciplinary Education in Allied Health (1980). A guide to team development. Lexington, KY: College of Allied Health Professions, University of Kentucky. Centre for the Advancement of Interprofessional Postgraduate Education (CAIPE) (1989). A report of a national survey on interprofessional education in primary health care. Chafetz, P., West, H., Ebbs, E. (1987). Overcoming obstacles to cooperation in interdisciplinary long term care teams. Journal of Gerontological Social Work, 11, 131±140. Clark P. (1993). A typology of interdisciplinary education in gerontology and geriatrics: Are we really doing what we say we are? Journal of Interprofessional Care, 7, 217±227. Czirr, R., & Rappaport, M. (1984). Toolkit for teams: Annotated bibliography on Interdisciplinary Health Teams. Clinical Gerontologist, 2, 47±54. Dornbrand, L., Hoole, A. J., & Pickard, C. G. (1992). Manual of clinical problems in adult ambulatory care. Boston, MA: Little, Brown. Drinka, T. J. K. (1994). Interdisciplinary geriatric teams: Approaches to conflict as indicators of potential to model teamwork. Educational Gerontology, 20, 87±103. Drinka, T. J. K., & Streim, J. E. (1994). Case studies from purgatory: Maladaptive behavior within geriatric health care teams. The Gerontologist, 34, 541±547. Federal Council on Aging, United States Department of Health and Human Services (1981). The need for long term care: Information and issues. DHHS Publication (OHDS) 81-20704. Washington, DC: United States Government Printing Office. Feiger, S. M., & Schmitt, M. H. (1979) Collegiality in interdisciplinary health teams: Its measurement and its effects. Social Science Medicine, 13, 217±229. Fisher, R., Ury, W., & Patton, B. (1991). Getting to YES: Negotiating agreement without giving in. New York: Penguin.

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Fries, J. F., & Crapo, L. M. (1981). Vitality and aging: Implications of the rectangular curve. San Francisco: Freeman. Gersick, C. J. (1989). Marking time: Predictable transitions in task groups. Academyof Management Journal, 32, 274±309. Goble, R. (1994). Multiprofessional education: European Network for Development of Multiprofessional Education in Health Sciences (EMPE). Journal of Interprofessional Care, 8, 85±92. Goldstein, M. (1989). Physicians and teams. In R. J. Ham (Ed.) Geriatric medicine annual (pp. 256±275), Oradell, NJ: Medical Economics Books. Gottman, J., Notarius, C., Gonso, J., & Markman, H. (1976). A couple's guide to communication. Champaign, IL: Research Press. Heinemann, G. D., Farrell, M. P., & Schmitt, M. H. (1994). Groupthink theory and research: Implications for decision making in geriatric health care teams. Educational Gerontology, 20, 71±85. Hendriksen, C., Lund, E., & Stromgard, E. (1984). Consequences of assessment and intervention among elderly people: A three year randomised controlled trial. British Medical Journal, 289, 1522±1524. Hickey, T., & Rakowski, W. (1981). Consistency in patients' health and treatment expectations at a Geriatric Clinic. Journal of the American Geriatrics Society, 29, 278±284. Jones, R. V. H. (1992). Teamwork in primary care: How much do we know about it? Journal of Interprofessional Care, 6, 25±2 9. Kelley, K., & Streeter, D. (1992). The roles of gender in organizations. In K. Kelley (Ed.), Issues, Theory, and Research in Industrial/Organizational Psychology (pp. 285±337). Oxford, UK: Elsevier. Kirchmeyer, C., & Cohen, A. (1992). Multicultural groups: Their performance and reactions with constructive conflict. Group & Organization Management, 17, 153±170. Lamska, A., Hietanen, I., & Lamsa, J. (1994). Education for holistic care: A pilot programme in Finland. Journal of Interprofessional Care, 8, 31±43. Lichtenberg, P. (1994). A guide to psychological practice in geriatric long-term care. New York: Haworth Press. Lichtenberg, P., Strzepek, D., & Zeiss, A. (1990). Bringing psychiatric aides into the treatment team: An application of the Veterans Administration's ITTG model. Gerontology and Geriatrics Education, 10, 63±73. Luecht, R. M., Madsen, M. K., Taugher, M. P., & Petterson, B. J. (1990). Assessing professional perceptions: Design and validation of an interdisciplinary education perception scale. Journal of Allied Health, 19, 181±191. Mechanic, D. (1962). Sources of power of lower participants in complex organizations. Administrative Science Quarterly, 7, 349±364. Mitchell, M. (1993). Models of therapeutic practice amongst first year students: A problem for educators in the health professions? Journal of Interprofessional Care, 7, 247±252. Phillips, S., & Elledge, R. (1989). The Team-Building Sourcebook. San Diego, CA: University Associates.

Qualls, S., & Czirr, R. (1988). Geriatric health teams: Classifying models of professional and team functioning. The Gerontologist, 28, 372±376. Rubenstein, L., Wieland, D., English, P., Josephson, K., Sayre, J., & Abrass, I. (1984). The Sepulveda VA Geriatric Evaluation Unit: Data on four±year outcomes and predictors of improved patient outcomes. Journal of the American Geriatrics Society, 32, 503±512. Saltz, C. (1992). The interdisciplinary team in geriatric rehabilitation. Special Issue: Geriatric Social Work Education. Journal of Gerontological Social Work, 18, 133±142. Sbordone, R. J., & Sherman, L. T. (1983). The Psychologist as a consultant in a nursing home: Effect on staff morale and turnover. Professional Psychology: Research and Practice, 14, 240±250. Schneider, E. L., & Rowe, J. W. (1990). Handbook of the biology of aging. San Diego, CA: Academic Press. Scholtes, P. R. (1988). The Team Handbook: How to Use Teams to Improve Quality. Madison, WI: Joiner Associates. Stephenson, P., & McCreery, R. (1994). Two heads are better than one: Interprofessional collaboration for capacity building in health systems research in Romania. Journal of Interprofessional Care, 8, 57±61. Takamura, J. (1985). IntroductionÐHealth teams. In L. J. Campbell & S. Vivell (Eds.), Interdisciplinaryteam training for primary care in geriatrics: An educational model forprogram development and evaluation (pp. II.64ÐII.67). Washington, DC: United States Government Printing Office. Takamura, J., Bermost, L., & Stringfellow, L. (1979). Health team development team. University of Hawaii, HI: John A. Burns School of Medicine. Tjosvold, D. (1991). The conflict-positive organization: Stimulate diversity and create unity. Reading, MA: Addison-Wesley. Tuckman, B. W. (1965). Developmental sequence in small groups. Psychological Bulletin, 64, 384±399. West, M. A. & Poulton, B. C. (1997). A failure of function: Teamwork in primary health care. Journal of Interprofessional Care, 11, 205±216. Woolf, S. H., Kamerow, D. B., Lawrence, R. S., Medalie, J. H., & Estes, E. H. (1990). The periodic health examination of older adults: The recommendations of the US Preventive Services Task Force. Journal of the American Geriatrics Society, 38, 817±823. Zawadski, R. T., & Eng, C. (1988). Case management in capitated long-term care. Health Care Financing Review, Annual Suppl., 75±81. Zeiss, A. M., & Okarma, T. (1985). Effects of interdisciplinary health care teams on elderly arthritic patients: A randomized prospective trial of alternative team models. Proceedings of the Sixth Annual Conferenceon Interdisciplinary Health Team Care. (pp. 21±35). Hartford, CN: University of Connecticut School of Allied Health Professions, Nursing, Pharmacy, & Medicine. Zimmer, J., Eggert, G., & Schiverton, P. (1990). Individual versus team case management in optimizing community care for chronically ill patients with dementia. Journal of Aging and Health, 2, 357±372.