My most important is to improve the quality of life and a major feature of quality living is psychological well-being. There are two sets of factors that must work hand-in-hand to produce psychological well-being. One is the quality of care provided. These are the processes of care that are the focus of most quality programs. Another set of factors, however, too often ignored are the quality-of-life factors that take into account what the patients actually bring to the equation. For example, coping patterns help patients preserve their individuality and spite of declining health. We apply a developmental theory called selective optimization and compensation to refine quality of care strategies. Research in Positive Psychology suggests at least 16 specific factors that seem to influence a resident’s is subjective sense of well-being.
Quality Care and Quality of Life
In many cases quality care patterns have a direct impact on resident quality of living. A safe and timely pattern of care with can lead to a sense of security. Technically proficient healthcare can lead to optimal health and increased levels of functioning. Personal attention and individualized care programs that engage the individual in their own care lead to a sense of autonomy and self-determination. Patterns of care which are respectful of individual needs and values into affirm personhood and reinforce the continuity of the self concept. A higher-quality life comes from recognition by caregivers of individuality as does respect by caregivers to the right to privacy. Even for dementia patients there needs to be continuity with the past and respect for the continuation of social roles important to the individual earlier in life. People are not constituted in a way that allows them to lie in bed hour after hour, day after day, week after week, month after month as the months turn into years. An environment must provide opportunities for activities appropriate to age and skills no matter what the disability.
Preservation of the Self
Sheldon Tobin in his book Preservation of the Self in the Oldest Years points out that those who design and long-term care must take into account the way older people, particularly those over the age of 85, strive to cope with the stress of changes that threaten their sense of self. He divides the coping methods into two classes: rational coping techniques in less than rational coping techniques. The preservation of the sense of self is served by ensuring patients are involved in affirming meaningful activities. They need to have at least a measure of control over daily activities and over social interactions. In too many nursing homes neither of these is the case. He points out that successful coping with the challenges of advanced age involves a contraction of one’s personal space, sense of time and the numbers of people with whom one has significant relationships. However contraction cannot mean elimination and providers of care in LTC must realize this. For example, a couple may have traveled widely and sailed all along the East Coast in earlier years but now must confine their travel to radius 60 miles from their assisted living facility. But travel they can. At the age of 30 that are decades of future ahead at the age of 85 the future is a matter of years at best. In earlier years a person may associate with hundreds or even thousands of people but in the older years associations may be restricted to family and only the closest of friends. Such constrictions are appropriate ways to cope. However, Tobin also points out that are less rational coping techniques. The older person may deny reality completely. Is as an example they may continue to believe in their driving ability well beyond the point at which they should recognize this limitation. Under stress the older person may become more aggressive because this gives them the illusion of continued control. When that is the case punishment of the aggression only leads to more aggression. The older person may blame others for things other than admit to themselves that they are vulnerable. There’s no better example of this in the dementia patient who blames thievery by staff for items they have misplaced or lost. In short older people will go to great lengths to protect their sense of self.
Psychological Well-being
Psychological well-being is a subjective point of view defined as person’s cognitive and affective evaluation of life. The dimensions of well-being include a balance between positive and negative affect. Affect is a psychological term for emotions. Negative affect involves such emotions as anger, fear and depression. On the other hand positive emotions include such things as joy and happiness. How much time in any given day we spend feeling depressed needs to be balanced with time feeling happy. If more of our day is filled with positive emotions than with negative we have a sense of subjective well-being. Well-being is also dependent on how well we meet our fundamental human needs. That includes basic needs like food, shelter and safety. There can be no sense of positive well-being if we feel hungry or fear for our safety. However, given that those needs are met higher level needs like autonomy and self-esteem become important to our sense of well-being. It also seems very important to our sense of well-being that we have a purpose. For the oldest among us it is just as important to have goals even though it may be necessary to limit those goals as we age. Careers are behind and there is increasing limitation on the pursuit of wealth. However, those with a sense of positive well-being continue to set goals and pursue those goals. Activities also seem very important as dimensions of psychological well-being. There may be some constriction in the options available; however, activities within the framework of current skills can make a great difference. For example, one patient of mine in a nursing home and only the use of his upper body. However, to help of his family he arranged an entire world all within the reach of his own arms. Finally, optimism and hope are essential elements for a positive sense of well-being.
Selective Optimization and Compensation
Paul Baltes of the Max Plank Institute for Human Development in Berlin and his wife Margaret Baltes of the Free University of Berlin have conducted extensive research on what they characterize as ‘Successful Aging’ and they have proposed that success is in part dependent on the selection process in which strengths are optimize in older people learn to compensate for losses in appropriate ways. For example, they become more discriminating in the choice of activities while which to spend their time and energy. Interactions with family become increasingly important in that may restrict themselves to a few real friends other than a large number of acquaintances. Optimization involves building resources needed to cope through self-education and continued learning. For example memory skills training can help in compensating for some of the losses that are associated with aging. Compensation involves doing whatever is needed to mitigate limitations and losses. Visually impaired older people use reading machines which magnify the written word. If they cannot read that can begin to listen to audio books. To avoid falls they can learn to use a walker, a wheelchair or a cane. To the extent that quality care processes facilitate selective optimization and compensation patients in long term care are more likely to experience a positive sense of well-being in spite of losses.
Psychological Well-being Factors
There are sixteen factors that contribute significantly to a resident’s sense of subjective well being in Long Term Care settings:
- Control
- Mindfulness/Flow
- Calming
- Wisdom
- Modulation
- Communication
- Optimism
- Joy
- Humor
- Music
- Movement/Exercise
- Connectedness
- Time Perspective
- Remembrance
- Spirituality
- Purpose
We will briefly discuss each.
Support Optimized Control
People need optimal autonomy they need to believe they exert some control over their world. As patients move from independent living into the different levels of long-term care they lose some of the kind of control over even daily routine and has been a part of their life. As we age we shift from primary control in which we actually can act to change our environment and solve problems directly into secondary control in which we are increasingly required to change our reaction in emotional response in order to maintain an emotional even keel. To maintain a sense of well-being in long term care patients must learn to balance control with acceptance. As dependency increases due to chronic and acute illnesses and patients exert less and less control. Thus it is important that those who control quality of the care giving processes finally used to optimize control where it is possible and help the patient’s compensate by shifting to secondary control and acceptance when conditions cannot be changed. While there is an understandable inclination to take over all aspects of care and at times for purposes of safety that may be required it is important to keep the patient making choices and feeling as autonomous as is possible. As in other areas the number of choices becomes more constricted and the patient has fewer options from which to choose to caregivers need to allow patients to select from that narrower range. Even for dementia patients we can give them several clothing options from which to choose rather than deciding it for them. We can provide them with a calendar of activities and allow them to make choices from the list. We can engage them in selection from food options. A positive sense of well-being and the quality of life that attends that sense is facilitated we realize the importance of a sense of autonomy and control to every person.
Optimize opportunities for humor
We have all heard that laughter is the best medicine and research on psychological well-being has tended to support the notion. We are learning more and more about home after has its impact. We know that laughing increases the oxygen levels to the brain is in this intern can improve our perception and awareness. Laughter releases endorphins which are the feel-good hormones in the brain that increase our sense of well-being for a while. There is also increasing evidence that laughing improves immune system functioning. As this evidence has accumulated we understand better and better the experience of Norman Cousins who decided to take his health and his own hands when given a poor prognosis for chronic illness by bringing his favorite comedy movies into his hospital room. He recovered completely and later was given an appointment at the UCLA School of Medicine for his work on what was called the laughing cure. To promote a sense of well being in long term care the sounds of disease must be balanced as often as possible by the sounds of laughter. One of my standard questions now is about my patient’s favorite comedy shows on television. I make a note of when they come on the cable system and do what I can to make sure that we turn CNN off and turn on comedy shows. It would be useful in long term care organizations with stock up on DVDs that can be played for patients individually or in groups.
Optimize opportunities for mindfulness and flow experiences
We all spend at least part of our time being mindful which means focusing on exactly what’s happening now in our lives. However we also spent a good part of our mental life regretting the past and anticipating the future with some anxiety. Older people who have been through acute illnesses, surgery and other health-related trauma can spend too much time reliving those from and ruminating about a future that remains ambiguous at best. Psychologists have discovered a state of mind which is come to be called flow when we are fully connected with what we’re doing not thinking about the past or worrying about the future. Each of us and those involved in long term care need those kinds of restorative experiences each day. I am one patient who gets into that state of mind by watching and listening to the birds in an aviary. Another gets into that state of mind by rolling her wheelchair up to the window and watching what goes on outside in nature. There is an active way to attain that state of mind and there is a more passive way through what is called meditation. Those are two pathways to the same restorative experiences. Many creative activities such as painting can lead the mindful/flow experience. We can tell when we been in flow of effectively lose track of time and totally concentrate on what we do. Games, including checkers, chess or card games can lead to the same kind of experience. The key seems to be that whenever we’re doing must be within our skill range but we need to stretch a bit to attaining a goal. Rhythmic activity like walking can also lead the mindful experience if one focuses on a card experience related to walking like breathing or changes in muscle activity with each step. Any activity requiring concentration can be a door to the flow and mindful attentiveness. There are also many activities that would be considered pure play that can lead to the same kind of experience. Many of the repetitive motion activities of dementia patients are seeking the same kind of attention. Plus many dementia units provide Montessori types of activities that are simple and repetitive.
Optimize availability of music and rhythmic movement
Music, they say, has the power to soothe the savage breast. In the era of brain imaging studies we are increasingly able to identify the impact of music on different areas of the brain and we are learning that can be of major value in enhancing emotional self-regulation. We know that high pitched musical sounds tend to make us happy and we can actually see that happen with brain imagery as the areas of the brain associated with positive emotions light up. We know that low pitched sounds can do make us sad. We know that music with a faster beat heightens alertness and arousal levels. And we now know that slow music has a buffering effect on our stress response system. Studies of blood chemistry have shown that listening to music as a direct impact in reducing stress hormones. Amazingly the human heart seems designed for music. Researchers have found that the human heartbeat tends to synchronize with music experienced by the individual while heart rate is being monitored. Other researchers have found changes in electrical rhythms in the brain when music is being played. Care managers and long term care settings should arrange for music each and every day both in groups gathered in common areas and individually in their rooms or to assure privacy for others with the use of headphones. With every new residence we should evaluate their musical preferences. Studies have shown that even those who say they do not care for music and would not arrange it on their own still show significant physiological changes in appropriate music is played. Dementia patients continue to show physiological responses to music strongly suggestive of that aspect of memory continues to work long after linguistic patterns have declined. Finally we should arrange for rhythmic movement a tuned to the sound of music since that tends to rivet attention to the sound. Patients regularly exposed to music report much higher levels of positive well-being.
Optimize calm and deep relaxation each day
Anxiety may very well be a much more common symptom in long term care than depression although depression is much easier to detect. A variety of fears associated with higher risk and medical procedures as well as disability and death are common. While they may not rise to the level of the diagnosable and thus treatable mental health problem may nonetheless have significant impact on overall health and a sense of well-being. Thus those providing care in long term care settings should assist patients in learning and employing methods of relaxation. The most common in the easiest method to learn is deep abdominal breathing. When we are anxious we tend to breathe rapidly high and our chest area. Anyone can learn to breathe more deeply involved the abdominal region by simply placing their hand above their navel and making sure the hand rises and falls with each breath. And the simplest form of meditation can be achieved by most anyone by just attending to their breathing and simply returning to the sensations associated with the breathing as thoughts intrude. The exception to this of course is COPD patients who may need professional help to develop relaxation alternatives. Another very simple method of deep relaxation is to use the minds ability to visualize. Anyone can help a resident identifies a scene likely to produce feelings of calm. Perhaps it’s lying on the beach listening to the sounds of the surf. Perhaps it’s lying by a fast-moving creek listening to the sound of birds singing in the feelings of breeze on their face. Research has shown that the more sensory detail we build into such visualization experiences the better. There are a number of other methods including body scan in progressive relaxation that may require professional help.
Optimizing body movement and exercise
Our bodies are meant to be more than a pedestal for our heads. Human beings are meant to move until it is a longer possible. Recent research has demonstrated that older people including those in long term care can reap the same health benefits from exercise as younger people. There is no better place to consider the value of selective optimization and compensation then in this area. Because of illness or even major events like a stroke the movement options and range of motion may be limited and successful movement such as walking may require compensation, however, we should continue to encourage movement each and every day. All the different kinds of exercises can be made available to older people than with some creativity on the part of the care providers patients can reap significant benefits. The value of exercise is nowhere more evident than in maintaining balance in reducing the risk of falls. Older people can benefit from strength and resistance training although the amount of weight used in the training must be significantly reduced. Aerobic exercises can build cardiorespiratory fitness by elevating than sustaining cardiac activity. The best form of exercise continues to be the most basic. And that is walking. Walking without a walker can be of value but also walking behind their wheelchair or with a walker can also be of benefit. Even when the lower body may not be able to be exercised their number of options and simply use the upper body. No exercise program should ever be started without the approval of the primary care physician. For cardiac patients a stress test is absolutely essential. One big barrier to an exercise program is motivation by professionals can be of help in that arena.
Optimize recognition of wisdom
Wisdom is not about passing multiple-choice tests or is it equivalent to a high IQ. Wisdom involves knowledge when both the cognitive and the emotional are in complete harmony. An auto mechanic can be very wise while a college professor can be perfectly stupid. Psychologists John Mayer of the University of New Hampshire and Peter Salovey of Yale coined the term emotional intelligence in 1990. In brief, emotional intelligence is the intelligent use of emotions and the use of emotions to make us more intelligent. An emotionally intelligent individual intentionally makes emotions work for them to guide thinking and behavior. Wisdom is emotional intelligence applied to our own lives. Baltes argues persuasively that the artful application of selective optimization and compensation is a form of profound wisdom. Wisdom involves knowledge of the pragmatics of living day to day and involves appropriate adjustment to the changes that come with aging. Adjustment to change requires flexibility and rigidity in the face of change is more stupid than wise. Having a positive outlook can be said to be wise while having a negative outlook is not. Having concern for others is a form of wisdom while total self-absorption is not. Living in constant regret about the past is not wise while being willing to move on and let go of the past is reflective of wisdom. Living in constant worry about the future is not wise while converting worries into problem-solving is a form of wisdom. It could be argued that one of the tasks of being older is to develop a philosophy of life and then to share that philosophy with younger people. We should encourage them to do so.
Optimize Social Connectivity
Over the last 20 years researchers in areas like recovery from cancer have learned an important lesson and that is that social support can help make us healthier. Victims of breast cancer were found to have fewer recurrences and longer periods of being cancer free when they were provided with social support groups. However one of the most robust characteristics of individual personality is introversion an extraversion. While we should encourage social exchanges in long term care you need to keep in mind that some people like a balance of activities that includes a certain amount of solitude. One of the most important elements in social connectivity is social assertiveness. Some patients may actually need social skills training in order to improve their ability to connect with others. This may include such things as good listening skills and learning how to express empathy for others. Care providers should make an effort to set up interest groups and opportunities for social exchanges rather than leave it up to the patient to make those connections. Such groups can be as simple as scheduling and time to watch a television program together and then discuss what they saw was one another. Board games can offer a structure within which significant social interaction can take place. Having specific times when visiting one another in rooms is encouraged is another way to promote social interaction and social connectivity.
Optimize modulation of negative affect
Persistent patterns of negative affect such as depression and anger can do exacerbate physical illnesses. We know now for example that heart patients who are depressed are at greater risk of another heart attack and have significantly more problems in recovery. The relationship between hostility and heart attacks has been reasonably well established. This is important that care providers help modulate or reduce the intensity and frequency of bouts of depression and help patients regulate their anger. Generally the best way to address negative emotions is to replace them with positive emotions and to seek a balance between the two. There are times when medications are required in order to chemically modulate persistent patterns of depression. This is one area that is important enough that care providers need to have available to them mental health professionals who can work with the patient using such methods as Cognitive Behavior Therapy (CBT). However, one of the best ways to address depression patterns in long term care is with positively reinforcing activities. In keeping patient’s active serve to modulate depression and can prevent recurrence of bouts of depression. Thus the activity therapists in long term care pla7 much more important role than those steeped in the medical model realize. Finally, professional intervention in the form of anger management may be necessary and should be available to LTC staff.
