A 60 years old female XYZ patient was admitted in hospital with organic brain syndrome two years ago. She is still hospitalized. My first interaction with patient was when I entered her room, she told me to get out. In second interaction as I tried to talk to her, she listened to me only for two minutes but didn’t answer me and instructed her care-taker to tell me to leave the room.
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My further attempts at interaction with the patient would result in conversations not lasting 2-4 minutes and then she would remove herself to a place where no one would bother her. Most of the time, she kept herself in her room and become aggressive when someone tried to take her outside. She couldn’t concentrate on one thing more than 2 minutes. Her major symptoms were short attention span, impaired recent memory and poor judgment.
In three weeks rotation I have found she was reluctant to talk with others. She felt more comfortable when no one disturbed her. Initially she was very strongly guarded but very gradually as I worked with her, things began to improve. I made small interventions to make her socialize, such as, every day I took her outside and asked her to greet the health care professionals etc. The end result of these little efforts was very positive. The health care professionals noticed a discernable change in her behavior. Now this patient greets others and responds more positively. The Doctor said she showed very positive improvements and recommended these interventions should be continued.
The concept which came in my mind and very perceptibly I have found in my patient was social isolation. According to Nicholas R, Nicholson Jr. (2009) “Social isolation is suggested, state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts and they are deficient in fulfilling and quality relationships”(p.1346).
Social isolation is a social condition that leaves significant effects on psychological well-being and physical health, with the costs of these conditions particularly higher among old and mentally ill patients. According to Havens et al. cited by Nicholas R & Nicholson Jr. (2009) “Psychological barriers such as decline in cognition, poor or altered mental healthâ€¦ factor that lead to social isolation” (p.1346). If I relate the concept with my patient she likes to live alone, unable to share her life experiences, lack of belongingness with others, unable to do her activity daily living and these all were because of her cognitive impairment and low concentrate level which leads her towards social isolation in her.
Many factors which leads to social isolation. In Pakistan, gradually we are loosing our traditional values, social bonds like family and neighborhood. With changing socio-economic and cultural conditions, we witness the emergence of nuclear families living separately rather than the traditional extended families living together. Literature on social isolation is not available about our country but I have found the South Asian Article (New Delhi India). Indian culture is similar to ours and we can easily relate their findings to our context. Age Well Foundation (2010) stated that “Ever-changing socio-economic scenario of the country has resulted in emergence & popularity of nuclear family â€¦they felt themselves completely isolated and alone” (p.21). According to Age Well Foundation (2010) “In urban areas 39.1% older persons were reported isolated socially as well as emotionally” (p.09).
In late age certain human faculties become enfeebled. For instance cognitive impairment, physical frailty, restricted ability for social interaction. If this is accompanied with social isolation, the chances of depression occurring are much increased. If the situation continues, the person is caught in a downward spiral where social isolation and depression feed on each other, and the person becomes deprived of the ability to conduct social interaction. According to Draper cited by Heather L. Menne et al. (2009) “left untreated depression and depressive symptoms â€¦ intensified problems with cognitive processing” (p.554).
According to Amin A. & Gadit M. (2010) “Among the mental illnesses, depression … 22.9%prevalence of depression among elderly” (p.03). Chronic illnesses, the death of friends and loved ones and feelings of social isolation can add up to social isolation in older adults. According to Ather M Taqui &et al. “The prevalence of depression in the elderly in our study was 19.5%” (p.04). They also mentioned the cause of depression was nuclear family and due to less social interaction with family, elderly suffer from depression.
Stigmatization towards mental illness is very common, which make mentally ill patients socially isolated more. Zahid, J. et al. (2006) stated “The younger respondents felt that people with schizophrenia, depression and drug abuse are dangerousâ€¦ more likely to blame people with drug abuse problems for their drug use” (p.57).
Care-taker perceptions towards old age people and for mentally ill patients are also contributing factor towards social isolation. According to Baltes and Smith quoted by Graeme Hawthorne (2006) “It is a stereotype of later life that there is a network of loneliness, social isolation and neglect” (p.522). During my mental health clinical, I observed that care-takers think that if they fulfill the patient’s physical needs, give them medicine on time, this is more than sufficient. Their attitudes toward old age was as they are very old, there is no hope for them to cure from mental illness. The same thing was happened with my own patient. Her care-taker’s perceptions were “now my patient is very old and you don’t need to make any efforts because since two years I am with her but there are no positive improvements”.
Roy’s Adaption Model (Roy & Andrews 1999) is one conceptual and theoretical model in nursing with which social isolation fits well. In this model she focused on four modes of adaptation, physiologic-physical, Self-concept, Role function and Interdependence Mode. If human declines in one mode it has specific affects on physical and mental health. According to Nicholas R, Nicholson Jr. (2008) “Being socially isolated can be conceptualized as having ineffective self-concept or Interdependence mode responses â€¦ the person has failed to adapt and this is manifested by being socially isolated” (p.1349). Through this model a nurse can observe the behavior of the person is adaptive or maladaptive.
Self-concept mode focused on psychological and spiritual sense of integrity and purpose of living in the universe. When someone looses sense of psychological well being, has no purpose of life, unconcerned with others, this makes a person socially isolated. Cognitive impairment is the major cause which interferes in this mode and the person feels helpless to adapt this mode effectively and goes into social isolation. Interdependence mode deals with human relationships with others, their purpose, structures and how it grows individually and in a group. When a person fails to adapt this mode appropriately and shows less concern towards close relations, or a person’s loved one’s show less concern toward the person it makes the person socially isolated.
Social isolation has strong connection with mental illness. Social isolation and cognitive impairment go side by side. According to Ellis and Hickie cited by Graeme Hawthorne (2006) “In addition there are associations between social isolation and mental illnessâ€¦ premature death” (p.522).
My patient was socially isolated due to impaired cognitive abilities, short attention span and impaired recent and immediate memory. Older people need more concentration and care as I relate the above with my patient, she was 60 years old and struggling to remember recent events and concentrate on one point. When she failed to do these tasks which hinder her communication and daily activities, this made her more agitated and led to social isolation.
In old age cognitive impairment decline daily activities, loss of interest in social interaction, face difficulties to express their own feelings and to understand other’s ideas. All these things also play a significant role in social isolation. According Van Oostrom cited by Graeme Hawthorne (2006) “Related to difficulties with mild cognitive impairmentâ€¦partner loss and institutionalization” (p.522).
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Research conducted on social isolation has identified many different factors that might contribute to social isolation in older adults, Physical environment factors such as place of residence, geographic distance from family or friends. According to Kaneda cited by Barratt J. (2007) “In developing countries growing numbers of older â€¦isolation bereft of the traditional environment of an extended family” (p.02). In the light of literature, my patient was dependent on the care-taker in hospital although she fulfills her physical needs but I never observed her encourage the patient to mingle with others. In my view this was also one of the causes for her social isolation.
Maintaining relationships and participating in social activities have been associated with improved memory and intelligence in the elderly. There are many strategies which as a nurse we can develop to take out a person from isolation. Studies found that educational and social activity, group interventions that target specific groups of people can alleviate social isolation among older people.
Patient assessment I have covered in the scenario. I had planned strategies at the individual, family, group and institutional level. But I just got a chance to implement on the individual and institutional level.
Strategies for individual: I worked on her short attention span and on social isolation. Initially I asked her to come out from the room, we would take a round in corridor. She refused but gradually she accepted. I made her friend of the other staff, explored her life achievements and acknowledged it in front of other staff; made her sit in the garden and in the television room, Every day I took her outside and encouraged her greet the health care professionals.
I involved her in occupational therapy although out of eight days occupational therapy sessions she only attended three sessions and only in the last session she sat for as long as ten minutes and talked with doctor and answered the questions appropriately. I asked her the old admitted patient’s names and she could recall most of their names. I encouraged her to sit and talk to them. I tried to involve her in a daily routine, like, to decide what she would like to wear next day and to ensure to brush her teeth and wash her face herself. I think to involve the socially isolated patient in her daily routine is the best technique to take them out from their condition. I gave her the opportunity for decision making, such as I wanted to talk to her and where would she want to sit and for how long could we sit together. As a result, it made her talk and use her cognitive ability.
I asked her about her interests. She told me, she liked to recite her religious verses and “Nat” I asked her to recite in the occupational therapy session. There everybody acknowledged her and she was encouraged to talk about herself. She said she had performed “Hajj” with her husband and now my husband is not alive. I tried to involve her in drawing but for this she strictly refused me, but asked me to write down the name of “Allah”. She promises to color it but later on she refused.
On a group level, I tried to engage her in group activities but due to time constraint, I was not able to implement. I was planned to involve her in psycho education and in cognitive behavioral therapy, group discussions with set agendas, exercises group to promote physical activity. It was also difficult for my patient to cope at that time, but I believe if I could stay longer with her or at least go every week on clinical rather than alternate weeks, I could achieve this task as well. We can involve them in occupational therapy sessions and make a play group where they can play small native games. According to Dana A Glie, et al. (2005) “elderly non demented subjects found that participating in cognitively stimulating leisure activities (e.g. playing board games) protected against development of dementia” (p.865).
My patient was interested in reciting the Quran and if she recites in a group it make her socialize with others and women who are gathered there can share their interests as well. According to Andersson cited by Cattan M. (2005) (1) “found that among small groups of older women who lived alone and who discussed health-related topics, significantly reduced loneliness and increased social contact, self-esteem and participation in organized activities was found. (p.05)”
Family can also follow the above individual level strategies which I had done with my, if person lives at home. They can give appropriate time to them, involve them in their discussion. As a nurse I could conduct teaching on patient disease process and on social isolation with family and teach them how to deal with the isolated patients.
At institutional level we can conduct the workshops, seminars, can make nurses group who entirely deal with isolated patient, provide more information on social isolation in different disease. Attendant nurse teaching should be conducted because they should also know the reasons; consequences of social isolation. I have conducted the teaching on social isolation and on major symptoms of my patient disease which leads to social isolation with two attendant nurses (N/A). At community level we can make community support group for old people, plan activities which they can do easily.
Initially when I start reading this topic my understanding about it, was very limited. I thought loneliness and isolation are the same topic but as I read more about it I have found loneliness is purely a person’s own feeling and even though a person who involves in a group or sits in a group can go through the loneliness feelings. Whereas social isolation is with-drawl from surrounding, a person has no concern with others. Before dealing with this patient I felt that to approach this patient was very difficult because this patient was not only mentally ill but also isolated and would not let others interact with her. Gradually I started and noticed the difference.
Social isolation in older people is very common and it leaves its great impact on mental health. It does not only impair the cognitive ability, it also declines the daily activities. As a nurse it is our responsibility to deal these patients with endurance, educate the family and care takers to overcome the physical and mental health problems. I also learnt that there is a great contribution of care-takers to make patient socially isolated and if we as a care-taker take a responsibility to give them psychological support and treat them according to their capacity they can also spend a normal life or even we can prevent them from deteriorating.
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