By: Brian Garavaglia, Ph.D.
To be old is to be demented, and this statement especially sounds in clarion fashion when dealing with older adults in long-term care settings. Yet, although many take this statement at face value, in reality one must pause with concern about the widespread acceptance of such stereotypes.
The Need to Inject the Social in Addressing Mechanistic Clinical Misconceptions Found in Long-Term Care Environments
To be old is to be demented, and this statement especially sounds in clarion fashion when dealing with older adults in long-term care settings. Yet, although many take this statement at face value, in reality one must pause with concern about the widespread acceptance of such stereotypes. Regardless of how many professionals who deal with the elderly in all phases of health care, including long-term care, consider themselves enlightened and immune toward stereotypic misconceptions, clinical thinking about old age is still filled with misconceptions that often lead to faulty diagnoses. Since the predominant features of long-term care continue to be strongly entrenched in dealing with pathology, often at the exclusion of the social individual, those who are responsible for addressing the social needs of older adults, those involved in “social” work and “social” services need to become vanguards toward making sure misconceptions do not come to minimize the quality of existence of the elderly in long-term care.
Human beings are social individuals, yet as we age or as people enter institutional settings, they often are treated quite mechanically, similar to machines that wear down. In fact, at one time this analogy on the pathophysiological level, called the “wear and tear” theory of aging, was given strong credence toward explaining older adults (Christiansen & Grzybowski, 1999) However, although more recent scientific discoveries have failed to lend credence to this theory, it still comes to hold intuitive appeal toward dealing with aging and issues found in older adults.
Furthermore, long-term care environments such as nursing facilities continue to remain quite institutional. Even with the Edenization movement led by William Thomas, most nursing care facilities continue to be institutional environments that do little to nurture the important social qualities that create the social individual and separate the social person from being a mere biological entity (Thomas, 1996). Nursing care facilities continue to be “total institutions,” which subordinate the older adult’s social existence to the clinical mechanics of palpation and auscultation and allow very little room for older adults to grow and express their unique human qualities as individuals (Goffman, 1961). Moreover, often the paternalistic attitudes found by staff in these institutions further enhance the disempowering self-esteem that older adults come to feel about themselves.
Dementia: Biology versus Social Induction
In the first paragraph, I mentioned that one of the egregious misconceptions about aging is that dementia is inevitable. Although many people, including medical and long-term care professionals, embrace this simplistic and stereotypic thought pattern, it leads to problems that are compounded beyond the mere stereotype (Robb, Chen, & Haley, 2002; Williams, 2000). Most individuals who are older adults do not encounter dementia, and only approximately 25 percent of memory issues can be attributed to aging itself (Garavaglia, 2007). Furthermore, even though individuals in long-term care environments have a greater probability of having an organic brain pathology such as various forms of dementia, patients who are part of long-term care environments are often “assumed” to have various levels of cognitive impairment (Hazen, 1996). Therefore, a norm of cognitive impairment comes to dominate the staff’s perception of how they come to view older adults. In reality, this view is just an extension of the norms in general society that have typically assumed that older adults are slower in their thinking abilities and are likely in the throes of senility. Most of this is based on a poor understanding of the aging process and an inability to distinguish between what I term the senescence versus senility error, with the former indicating normal aging versus pathology indicated by the latter.
If we put together the probability of dementia increasing with age, and add to that most people in nursing care facilities usually have considerable levels of chronic medical conditions, compounded further with stereotypes that assume inevitable and pathological cognitive decline, we now have a labeled population situated in an institutional environment with its own labels that envision any kind of forgetting as a sign of brain pathology. However, although many manifestations of dementia are indeed truly biological pathologies, some are not, and this is where the labels and stereotypes can lead to self-fulfilling prophecies that may influence faulty diagnoses (Becker, 1963; Lemert, 1951; Goffman, 1963; Palmore, 1999; Garavaglia, 2004)
It must be remembered that boredom, lack of sensory and mental stimulation, depression, metabolic instabilities, the increasing number of medications used among this group, and a host of other conditions can lead to memory disturbances and other cognitive symptoms. When these symptoms are found in younger populations, they often lead medical staff to assume some underlying pathology causing the cognitive changes. However, with older adults, it is often assumed that this senile or disease-based symptom is part of normal aging or senescence, or again the senile versus senescence error. When an elderly person experiences these cognitive changes in long-term care facilities, the likelihood of stereotypes and the self-fulfilling prophecy that they carry frequently lead to labels of dementia with very little further investigation into whether it is truly an organic cognitive pathology.
Humans as primates have social skills that are more complex and advanced, ultimately separating humans from all other primates. Throughout life, our socialization, or the learning to be social beings, is continuously reinforced by our social interaction and stimulation with our surrounding environment. However, individuals in long-term care environments, or other settings in which individuals experience profound isolation, eventually come to be desocialized, where they lose social skills and not only regress socially, but physically as well. In environments that lack optimal levels of social stimulation, desocialization can become a major issue that leads to decline. In addition, often this is noticed very quickly when many individuals enter long-term care facilities and end up declining both cognitively and physically quite precipitously, leading many family members and staff to think that they brought mom or dad in just in time.
In addition, the social psychological concept of resocialization has to also be mentioned. This happens when individuals have to adapt to an extremely different situation in which normal social behaviors fail to work. Individuals have to adapt autoplastically, through their internally self-based mechanism, to fit into the extreme environment. Nursing care facilities are often total institutions that govern all aspects of a person’s life. This institutional totalization is a marked stressor, both physiologically and mentally, which for even a normal older adult can lead to confusion and, at times, disorientation. An abrupt change to a nursing care environment, coupled with the mechanistic clinical treatment that they are often provided, fails to nurture their social existence. Again, when abrupt changes in mentation occur with the concomitant placement in an environment that is filled with the expectations for cognitive decline, there is often an ineluctable push for diagnoses to fit the accustomed stereotypes that fit with this age group found in this type of institution.
The Need For a Social Advocate
Where does this lead us to this point in this analysis? For one, it is evident that older adults still face a considerable level of discrimination and subsequent stereotypes and labels or what Butler (1969) came to refer to as “ageism” that creates a false understanding of this population. Furthermore, it has been explained how these stereotypes are accentuated in long-term care facilities, which further can lead to faulty clinical diagnoses and cognitive profiles. Finally, when individuals are placed in a mechanistically clinical environment that fails to nurture their social needs, regression of their holistic existence, including their cognitive abilities, can decline quite precipitously.
Therefore, it is at this point evident that there need to be individuals in a long-term care environment who can understand the implications for nurturing the social and not just the physical being. It is here that the “social” worker (I use this term loosely, meaning that it can be not just a degreed social worker, but all clinicians who focus their needs on the social aspects of the individual) needs to be more than a clinician involved in taking psychosocial histories. Those involved in the social services and social work area of long-term care have to understand the problems that are faced by older adults in these types of environments. They need to play a key role in making sure that older adults are not pigeonholed into neat and convenient diagnostic classifications without assisting and advocating for a greater holistic understanding and investigation into the older adult’s condition. It is at this point that social services personnel responsible for social intervention, which does not necessarily have to be relegated to just the social worker, becomes the priest of the social soul of the older adult. With so much emphasis on the mechanistically and often depersonalizing elements of clinical medicine, there have to be individuals who remain focused on nurturing, maintaining, and enhancing the social being.
However, there are institutional impediments that they need to be aware of, and that often lead to formidable challenges. Regardless of the new social movements that have been found in nursing care facilities, these facilities continue to be dominated by the physical concerns of the individuals they serve. Therefore, even though there have been recent movements toward introducing greater social factors in these environments, it is far from what Thomas Kuhn would equate with a paradigm shift (Kuhn, 1963). Social factors within long-term care have continued to be subordinated to the physical care that is rendered.
Social service professionals have to continue to remain sensitized to their insensitivity of focusing on social factors. Psychologizing and becoming part of the mainstream mechanistic medical environment in which they work will often lead them to focus on pathology and come to view the social needs of the individual as secondary to their physical ailments. However, it is here where social service professionals working in long-term care situations have to become the vanguard for influencing the paradigmatic shift that is needed in long-term care. The social services worker, being a “social” professional, has to imbue the culture with the need to view individuals as more than just physical entities with pathologies that need to be treated and fixed, but social beings who fail to exist as “human” or “humane” beings without their nurtured social dispositions. In addition to the older adults’ physical ailments, their emotions, thoughts, anticipations, beliefs, values, attitudes, and general understanding of self, all of which fail to be fixed by IV infusions or other pharmacological remedies, need to be addressed for residents in long-term care.
It must also be stated that because medical facilities, including long-term care facilities, emphasize the biological over the social, it subsumes our most important features for health, human existence, and our sense of self to our underlying biological building blocks. However, the essence of our human existence and the development of a healthy sense of self along with healthy cognitive ability is tied intimately and inextricably to nurturing our social relationship and our social self (Erber, 2005; Pruchno & Rosenbaum, 2003; Rowe & Kahn, 1997). This is where the long-term care social services professional needs to exert skill, for biological and social health are dialectical, with both needing to exist in proper proportion to produce a more humane environment in long-term care settings.
The intent of this article was to demonstrate the important impact that the social services personnel can have in long-term care settings. However, more than a delegation of services given to a particular professional, the underlying assumption is for movement toward a greater social paradigm for nursing home care. This means that this social paradigm should encompass all long-term care professionals, including physicians and nurses. As a result of their unique training and understanding of the social factors of human existence, social service professionals who have expertise in this area need to become important leaders for humanizing the long-term care setting and making sure that others obtain the necessary training to sensitize others toward this very important vantage point. Therefore now is the time for the social paradigm with its “social practitioners” in the long-term care settings to become increasingly involved in the medical environment as social medicine specialists.
Becker, H. S. (1963). Outsiders: Studies in the sociology of deviance. New York: The Free Press.
Butler, R (1969). Ageism: Another form of Bigotry. The Gerontologist, 9, 243-246.
Christiansen, J. L., & Grzybowski, J. M. (1999). Biology of aging. New York: McGraw-Hill.
Erber, J. T. (2005). Aging and older adulthood. Belmont, CA: Wadsworth.
Garavaglia, B. (2004, May/June). Misdiagnosed. ADVANCE for Providers of Post-Acute Care, 8 (3).
Garavaglia, B. (2007, July/August). The pitfalls of diagnosing dementia: Looking beyond patient age. Long-term Care Interface, 8 (4), 46-48.
Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. New York: Doubleday Anchor.
Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.
Hazan, H. (1996) From first principles: An experiment in aging. Westport, CT: Bergin & Garvey.
Kuhn, T. (1963). The structure of scientific revolutions. Chicago: University of Chicago Press.
Lemert, E. M. (1951). Social pathology. New York: McGraw-Hill.
Palmore, E.B. (1999). Ageism: Negative and positive. New York: Springer Publishing.
Pruchno, R., & Rosenbaum, J. (2003). Social relationships in adulthood and old age. In B. Weiner (Ed.), Handbook of psychology. New York: Wiley.
Robb, C., Chen, H., & Haley, W. E. (2002). Ageism in mental health care: A critical review. Journal of Clinical Geropsychology, 8 (1): 1-12.
Rowe, J. W., & Kahn, R. L. (1997). Successful aging. New York: Pantheon Books.
Thomas, W. (1996). Life worth living. Acton, MA: Vander Wyk & Burnham.
Williams, B. O. (2000). Ageism helps to ration medical treatment. Health Bulletin, 58 (3): 198-2002.
Brian Garavaglia, Ph.D., is a gerontologist in Michigan with interests in dementia, delirium, and depression, especially within long-term care. He has worked as a long-term care administrator and ethicist, and teaches at colleges in the Detroit metropolitan area.