The (Re)habilitation needs of the older non-disabled handicapped person: expanding the role of the rehabilitation professional.

The (Re)habilitation Needs of the Older Non-disabled Handicapped Person: Expanding the Role of the Rehabilitation Professional

Introduction

Many older persons of our society may be considered handicapped. Because of the gap in community services to older persons (Benedict & Ganikos, 1981; Blake 1981; Bozarth, 1981; Bahcall & Bervin, 1986), and the attitudinal barriers and misconceptions this population faces (Harris & Associates, 1975; McTavish, 1971), they are susceptible to various stereotypes and negative attitudes that exist towards them which can produce handicapping effects (Benedict & Ganikos, 1981; Salmon, 1981; Thomas, 1981). Therefore, the individual may begin to assume a sick and dependent role, lose previously held coping skills, and label him/herself as deficient (Bengtson, 1973).

At the beginning of this decade, Kleff (1980) examined past policies, programs, and services for persons who are elderly and gave his perception of future needs for older persons in the eighties and beyond. Emphasis was placed on the importance of developing innovative approaches and services to meet the medical, health, and social needs of older persons with the intent of educating society's perceptions of old age, and the perceptions of older persons themselves.

The challenge to develop innovative approaches and services should be embraced by all rehabilitation professionals. Rehabilitation is the facilitative and restorative process which provides individuals with the services necessary to meet their fullest physical, mental, social, vocational and economic usefulness (Wright, 1980). Professionals in rehabilitation are the experts who possess the tools, the philosophy and ability to coordinate and/or assist in the delivery of such services (Barry, 1981). As such, we must seek to modify our current rehabilitative approaches and cultivate new strategies and approaches towards intervention (Barry, 1981; Blake, 1981; Williams, 1981; Bozarth, 1981; Bahcall & Bervin, 1986; Trieschmann, 1987) with the expectation of circumventing both physical and mental disabling conditions (Knight & Walker, 1985; Dowd & Dowd, 1981; Jernigan, 1981). Rehabilitation professionals must also become instrumental in equipping older persons with the tools necessary for dealing with their perceived handicapping conditions (Edinberg, 1985; Kleff, 1980).

For the rehabilitation specialist, nontraditional or innovative rehabilitation programs might include those programs which: address the debilitating effects of ageism through service provision strategies, and are preventive in nature; embrace a total health maintenance orientation or approach (health, fitness, and rehabilitative needs); and offer services outside of traditional health care settings (e.g. hospitals, private office, community mental health center).

Defining the Population

A first step in establishing services for older non-disabled persons is that of defining the population. Many agencies and programs use 65 as their definition of aged (Blake, 1981). While one's chronological age is useful in determining eligibility for services, our greatest concern should be with capabilities or potential rather than with limitations set arbitrarily because of age (Blake, 1981). Therefore, in addition to chronological age, the older person is that individual who first accepts the stereotypes of aging or ageism, and then eventually experiences physical, emotional, and/or psychological breakdown as a result of that acceptance. Thus, losing previously held coping skills. Although necessary, chronological age is not an automatic prerequisite for classification. Rather, the emphasis is on the individual's attitude toward their own aging.

The Need for Innovative Services

For the rehabilitation professional, nontraditional or innovative rehabilitation programs might include those programs which are:

1) Preventative in nature. It would seem both beneficial and cost effective to direct our energy toward preventing, eliminating and/or minimizing the effects of certain disabling conditions. Wright (1980) discusses preventative rehabilitation at three different interventive levels. At the first-level the goal is to reduce the occurrence of handicapping conditions such as ageism. The second-level is directed toward preventing the development of functional limitations often encountered when the individual identifies with the stereotype of aging, i.e. the useless, sick, and dependent role. The third-level takes action to prevent the transition of functional limitations, brought on by a medically diagnosed condition, into a handicap such as ageism.

2) Innovative rehabilitation programs might also seek to embrace a total health maintenance orientation. Health, fitness, and rehabilitation services may be warranted. Fitness services should seek to develop exercises geared to the evaluated capabilities of the older adult (deVries, 1975; Iso-Ahola, 1980; Mobily, 1982; Sager, 1983). Fitness services would be provided at all three levels of prevention. It is possible to develop calisthenics, stretching exercises, aquatic exercises, and other physical activities ranging from passive to active-resistive (deVries, 1979; Piscopo, 1985). Smallegan's (1985) findings indicate that the loss of an older elderly person's strength and agility necessary for walking is a key factor in the decision for nursing home admission.

Health services would involve older persons organizing a variety of activities and events in their communities to maintain their desire to continue to be creative, productive, and contributing members of society (Mutran, 1981; Maguire, 1983; Kreitlow & Kreitlow, 1985). Older persons may become involved in participating and/or organizing various physical fitness and educational activities in their communities, i.e. swim meets, walk-a-thons, track meets, elementary school spelling bees, high school and college debates, essay contests etc. The emphasis in health service provision is placed on the preservation and sustenance of the older person's cognitive abilities. The prevention or reduction of confusion has been shown to be very helpful in keeping older elderly persons out of nursing homes (Smallegan, 1985).

Rehabilitation practices would emphasize services in personal and social adjustment. Vocational evaluation would continue to be a service component. Many older persons continue to work well past the age of 55 years of age, and many may make career changes (Deutsch & Sawyer, 1986). Specialists involved in the medical rehabilitation of the individual would be utilized as needed, i.e. physicians, physical and occupational therapists, counselors, audiologists and speech pathologists, etc.

3) The need for services in nontraditional settings is becoming increasingly important. The utilization of noninstitutional services by older persons is low. Edinberg (1985) reports percentages of 2 to 6 percent for patients seen in outpatient settings compared to the estimates of need in the community which is estimated to be 15 percent at a minimum (Redick & Taube, 1980; Vanden Bos, Stapp, & Kilburg, 1981). Many older persons are reluctant to accept formal help (Sargent, 1980). Therefore, services offered in non-traditional outpatient settings which are informal, nonthreatening, and establish a personal relationship and rapport could likely increase this population's use of rehabilitation services when such services are warranted. As we move into the next decade, our services should be delivered in settings that are more informal and nonthreatening.

The above mentioned services are suggested for use at each of the three levels of prevention. Again, it should be emphasized that services are for all persons who have reached or are approaching the Medicare and Medicaid definition of aged (65 years of age), in addition to those who may be considered handicapped by ageism. Or, for those individuals who do in fact suffer from a medically diagnosed condition.

Program Considerations for Proactive

Services

The following program consideration are thought to be necessary in the development of any rehabilitation program for this population.

Social and Environmental Independence

Innovative programs should be structed to meet the individual's total rehabilitative needs in various environmental settings. Social independence may be defined as the extent to which the individual is free to take part in activities relevant to his/her social, emotional, cognitive, and physical fitness needs (SECP). Included in this concept is the individual's freedom of choice to move in and out of the environment most appropriate to meet those needs. Studies have demonstrated (Harel & Noelker, 1982; Bourestom & Pastalan, 1981) that if older persons are free to choose where they will reside, whether it be independent living or in institutions, their life satisfaction and morale tend to be less problematic. Adjustment services designed to reestablish, increase, and maintain older persons' SECP needs may well be the answer to their successful rehabilitation and independence in daily living.

Social independence is obtainable in a number of environments. At home with no special support, at home with observation andconsultation, at home with modifications, institutions such as a state hospital, and state or private nursing home (See Table 1). If an individual's SECP needs are being met, they are considered to be operating at a level of "optimal" social independence. When these needs are ignored, the individual is said to be operating at a level of "reduced" social independence. Individuals operating at reduced levels of social independence may be considered to be "at risk" for illness, pain, physical and/or mental disability. Thus, it is believed that persons operating from any of these reduced levels of social indepence are at greater risk for hospital admissions, nursing home admission, and admission into other long-term care facilities. Because of these risks, service provides are cautioned against making the mistake of thinking that an individual residing at home with no special support (physician, nurse, rehabilitation specialist etc.) is operating at a level of optimal social independence. One may be at home and receiving no special support, but having too few social contacts (close family/friends), and finding it very difficult to exercise their mental capabilities, and needs of physical fitness to maintain their health and agility (See 1a on Table 1).

Although the ideal situation is to keep older persons living independently in their own homes and communities, reality requires that we realize institutionalization often becomes an unavoidable alternative (Smallegan, 1985). Even in this instance, the institutionalized adult can maintain a certain amount of indepence if the change in their environment is congruent with their expectations, and their SECP needs are being provided for.

The rehabilitation specialist may be called upon to pull together the necessary members of the health care team to move the client in and out of the environment most appropriate for them. In addition to such, the counselor and rehabilitation specialist must work to facilitate movement through the counseling relationship. Motivational counseling is likely to be needed, to a greater or lesser degree, at each of these levels.

Important Resources of Our Communities

Rehabilitation programs designed for older persons should utilize the skills, talents, and knowledge of older persons themselves. Individuals who have successfully adjusted to aging should be involved in the coordination, provision and/or supervision of all programs and services. For exampel, many of these individuals have experienced life as successful professionals, and programs would be wise to utilize these individuals as career counselors. They, better than anyone, are capable of offering knowledge, guidance, experience, and suggestions to high school students stuggling with carerr choices.

The nontraditional rehabilitation program offering medical services (physical therapy, occupational therapy, counseling, speech-language therapy, audiological services etc.) should utilize retired medical professionals to assist in the provision of such services.

Counseling: An Integral Service

Counseling is designed to be a helping relationship, rather than creating a dependent relationship (Sargent, 1980). As a counselor for older individuals, the goal should be to assist them in dealing effectively with present and future difficulties. With the proper tools, older persons are capable of solving their own problems (Keller et al, 1975; Ellis & Abrahms, 1978; Bradley & Edinberg, 1982; Edinberg, 1985). Because of the negative attitudes and misconceptions cited earlier with regards to aging, and the underutilization of noninstitutional health services, counseling to aid in the social and emotional adjustments of aging, as well as the handicapping effects of ageism, are becoming increasingly important. Innovative rehabilitation programs for older persons handicapped by ageism might also consider providing psychological support groups. Well adjusted members from this population can serve as role models or informal leaders in the counseling relationship. Spreitzer (1976) has shown that informal leaders, in some respects, can function as "lay therapists" among their peer groups.

Concepts in Adjustment

According to Baker (1972), "The general purpose of all adjustment services should be to bring about changes in client behavior including all behaviors that interefere with the client's attempt to become a functional, independent member of his community" (p. 29). The adjustment specialist is the individual who is responsible for the training and behavior change of the individual with regards to his personal, social, and work adjustment. Many older persons continue to work well past the age of 65 years of age (Deutsch & Sawyer, 1987). Many will go through career or job changes. An adjustment specialist may be needed to assess how this job change may effect the individuals view of themselves in relation to their changing environment.

Often, it is not the goal of the rehabilitation professional to return the individual to work. Adjustment services may be needed for the individual who has recently retired. The older adult may guilty of tying the acceptance of self with situational-confidence, confidence associated of self with situations such as the work environment. There is nothing wrong with work-confidence. Certainly it is important, however, the acceptance of our being and our person should not be tied to our achievements or accomplishments at work. If one should lose the ability to work well, or is no longer able to work, does it mean that one is a worthless individual and of no real value? Certainly not!

Another example of confusing situational-confidence with self-acceptance is placing the value or acceptance of self on mobility functions. This may be termed mobility-confidence. Mobility-confidence exists when people tell themselves they have always been able to go anywhere, and always at anytime--and will continue to do so. The time may come, however, especially for the older elderly adult, when they will no longer be able to drive their automobiles. The older person may also have to accept the fact that there may be the possibility of decline in the physical activities in which they were once able to take part. If the acceptance of self is based on the condition of mobility, an individual may irrationally believe that if they lose the ability to drive and move around on their own, they fall back to being a useless and worthless individual. It is at this point that older adults become most vulnerable to the stereotypes of ageism.

One cannot achieve a "true" sense of self-acceptance by achieving anything. It is a thing of choice and cannot be tied to a set of situations or conditions. (Ellis & Abrahms, 1978). The adjustment specialist had the responsibility of helping the older adult determine new choices, goals, activities, and capabilities. Assistance must also be given to help them realize that many of their past activities and skills are still attainable.

Conclusions

The role of the rehabilitation professional must be expanded to meet the needs of older persons. Older persons constitute an increasing proportion of our total population. Inevitably, the caseload of the rehabilitation professional must expand to reflect the demographic changes of our society if we are to effect positive change in this area.

As professionals in rehabilitation, awareness and recognition of the debilitating effects of ageism must be realized. Society's misconception and fear of aging serves to limit the performance, opportunities and services potentially available to individuals who constitute this population. As such, modification of current approaches in rehabilitation should be cultivated to meet the total rehabilitative needs of older persons.

References

Bachall, D.S., & Berven, N. L. (1986). Service to older adults in rehabilitation facilities. Vocational Evaluation and Work-Adjustment Bulletin, 19, 9-14.

Baker, B. (1972). Determining the goals and techniques of adjustment services. Rehabilitation Counseling Bulleting, 16, 29-40.

Barry, J. R. (1981). Challenges of the Future. Journal of Rehabilitation, 47, 94-95.

Bearden, L.J., & Head, D.W. (1985). Attitudes of rehabilitation professionals toward aging and older persons. Journal of Applied Rehabilitation Counseling, 17, 17-19.

Benedict, R.C., & Ganikos, M.L. (1981). Coming to terms with ageism in rehabilitation. Journal of Rehabilitation, 47, 10-17.

Bengtson, V.L. (1973). The social psychology of aging. New York: Bobbs-Merrill.

Blake, R. (1981). A demographic analysis. Journal of Rehabilitation, 47, 19-27.

Bourescom, N. & Pastalan, L. (1981). The effects of relocation on the elderly: a reply to Borup, J.H., Gallego, D.T. and Heffernan, P.G. Gerontologist 21, 4-7.

Bozarth, J.D. (1981). The rehabilitation process and older people. Journal of Rehabilitation, 47, 28-32.

Bradburn, N. M. (1969). The structure of psychological well-being. Chicago: Aldine.

Bradley, J.C., & Edinberg, M.A. (1982). Communication in the nursing context. New York: Appleton-Century-Crofts, 1982.

Carp, F.M., & Carp, A. (1983). Structural stability of well-being unbiased for age and gender. Journal of Gerontology, 38, 572-581.

Deutsch, P.M. & Sawyer, H.W. (1987). A Guide to Rehabilitation. New York: Matthew Bender.

de Vries, H.A. (1975). Physiology of exercise and aging. In Scientific Perspective and Social Issues. (Ed.) D.S. Woodruff and J.E. Birren. New York: D. Van Nostrand Co.

de Vries, H.A. (1979). Tip on prescribing exercise regimens for older patients. Geriatrics, 34, 75-81.

Dowd, E.T. & Dowd, T.M. (1981). Rehabilitation of mentally ill older adults. Journal of Rehabilitation, 47, 38-43.

Edinburg, M.A. (1985). Mental Health Practice with the Elderly. Englewood Cliffs, New Jersey: Prentice-Hall, Inc.

Ellis, A. & Abrahms, E. (1978). Brief psychotheraphy in medical and health practice. New York: Springer Publishing Co.

Harel, Z. & Noelker, L. (1982). Social integration, health, and choice: Their impact on the well-being of institutionalized aged. Research on Aging, 4, 97-111.

Harris, L. & Associates (1975). The myth and reality of aging in America. Washington, D.C.: National Council on Aging.

Iso-Ahola, S.E. (1980). The social psychology of leisure and recreation. Dubuque, IA: Brown.

Jernigan, J.A. (1981). Loss of physical function and disability. Journal of Rehabilitation 47, 34-37.

Keller, J.F., Croake, J.W., & Brooking, J.Y. (1975). Effects of a program in rational thinking on anxieties in older persons. Journal of Counseling Psychology, 22, 54-57.

Kleff, R., (1980). Beyond the "Me Decade": social gerontology in the eighties. Journal of Social Issues 36, 153-163.

Knight, B. & Walker, D.L. (1985). Toward a definition of alternatives to institutionalization for the frail elderly. The Gerontological Society of America, 25, 358-363.

Krietlow, B., Krietlow, D. (1985, November). The retirement carrer. Paper presented at the National Adult Education Conference, Milwaukee, WI.

Lawton, M.P., Kleban, M. Y., & diCarlo, E. (1984). Psychological well-being in the aged. Research on Aging, 6, 67-97.

Lawton, M.P., Moss, M., Fulcomer, M., & Kleban, N.H. (1982). A research and service oriented multilevel assessment instrument. Journal of Gerontology, 37, 91-99.

Liang, J. (1985). A structural integration of the Affect Balance Scale and the Life Satisfaction Index A. Journal of Gerontology 40, 552-561.

Maguire, G.H. (1983). An exploratory study of the relationship of valued activities to the life satisfaction of elderly persons. Occupational Therapy Journal of Research, 3, 164-72.

McGraw-Hill, SPSS-X Advanced Statistics Guide, Chicago, 1986.

McTavish, D.C. (1971). Perceptions of old people: A review of research methodologies and findings. Gerontologist, 11, 90-101.

Mobily, K.E. (1982). Motivational aspects of exercise for the elderly: Barriers and solutions. Physical and Occupational Therapy in Geriatrics, 1, 43-53.

Mutran, E., Reitzes, D.C. (1981). Retirement identity and well-being: realignment of role relationships. Journal of Gerontology, 36, 733-40.

National Center for Health Statistics: Prevention Profile, by P.M. Golden (Dec. 1986). Health, United States, 1986. DHHS Pub. No. (PHS) 87-1232. Public Health Service, Washington, U.S. Government Printing Office.

Okun, M.A., & Stock, W.A. (1987). Correlates and components of Subjective well-being among the elderly. Journal of Applied Gerontology, 6, 96-112.

Piscopo, J. (1985). Fitness and aging. New York: John Wiley.

Redick, R. W., & Taube, C. A. (1980). Demography and mental health care of the aged. In J. E. Birren & R. B. Sloan (Eds.) Handbook of mental health and aging. Englewood Cliffs, N.J.: Prentice-Hall.

Sager, K. (1983). Senior Fitness: For the health of it. Physician and Sportsmedicine, 11, 31-36.

Salmon, H.E. (1981). Theories of aging, disability, and loss. Journal of Rehabilitation, 47, 44-50.

Sargent, S. S. (1980). Nontraditional therapy and counseling with the aging. Volume 7 in the Springer series on adulthood and aging. New York: Springer Publishing Co.

Smallegan, M. (1985). There was nothing else to do: needs for care before nursing home admission. The Gerontological Society of America, 25, 364-369.

Staats, S. (1985, August), Hope: An ssessment of expected positive affect. Paper presented at the annual meeting of the American Psychological Association, Los Angeles, CA.

Stock, W. A., Okun, M.A., & Benin, M. (1986). The structure of subjective well-being among the elderly. Psychology and Aging, 1, 91-102.

Thomas, W. (1981). The expectation gap and the stereotype of the stereotype: Images of old people. Gerontologists, 21-402-407.

Trieschmann, R.B. (1987). Aging with a disability. New York: Demos Publications.

U.S. Bureau of the Census (1982). Statistical abstract of the United States 1982-1983. Washington, DC: Government Printing Office.

Vanden Bos, G. R., Stapp, J., & Kilburg, R. R. (1981). Health service providers in psychology: Results of the APA human resources survey. American Psychologist, 36, 1395-1418.

Weinberger, M., Darnell, J. C., Tierney, W. M., et al (1986). Risk factors for hospital admission in elderly public housing tenants. Journal of Applied Gerontology, 5, 174-182.

Weksler, M.E., Durmaskin, S.C. & Kodner, D.L. (1983). New goals for geriatic medicine. Annals of Internal Medicine, 99, 856-857.

Williams, M.G. (1981). Independent living and older people. Journal of Rehabilitation, 47, 69-71.

Wright, G.N. (1980). Total Rehabilitation. Boston: Little, Brown and Company.