Introduction

ElderCare Online is dedicated to bringing you educational materials that help you to enhance the quality of life your elderly loved one. We have begun working closely with RSI, a leader in the development of health assessments, care plans and training materials for frail elderly people and their caregivers.

RSI pioneered the idea of care management for the "whole person" for elderly residents of assisted living facilities. In the course of years of research, they developed a comprehensive training and care management program that helps the elderly person stay active physically and mentally.

Together, ElderCare Online and RSI have tailored key components of the Caring Community program to meet the needs of family caregivers. Over the next several months, we will be presenting a new series of Skill Builders that focus on how caregivers – at home and in residential facilities – can learn more about chronic conditions and improve quality of care to their loved ones.

Research findings indicate that social support is a human necessity. People who are socially isolated, without meaningful relationships, are at increased risk for physical deterioration, mental illness, and even death.

The term "loneliness" can mean more than one thing. Social loneliness has to do with quantity of contacts: not having enough people or enough activity in one’s life. But emotional loneliness is about quality of contacts, not having a close, intimate relationship with one other person – in other words, being "lonely in a crowd."

In an eldercare facility, surrounded by people, it is possible, nevertheless, to be lonely in both ways. Residents can be socially lonely if they choose not to talk with others or to participate in planned activities or if the activities are not meaningful to them. They can be emotionally lonely if all their contact with others is superficial.

Signs of Social Isolation: How do caregivers determine whether an elder is lonely? Expecting your elder to speak up and ask for help meeting people seldom works because people often find it hard to admit that they are lonely. Therefore, it is the caregiver’s responsibility to look for signs of social isolation. They can include:

• aggression, anger
• powerlessness, withdrawal from life

Note that those are opposite extremes, both signs of the same problem.

• self-doubt, shame
• confusion of past with present
• feeling confined or deserted
• difficulty setting goals and making decisions

Note that these are also symptoms of clinical depression.

Research suggests that long-standing relationships enhance well-being more profoundly than new friendships. Given the difficulties inherent in frailty, how can people in assisted living facilities or home care environments maintain relationships with old friends?

Here are some findings:

     - One half of people in their eighties still have at least one "close" friend.
     - 78% are still in weekly contact with people they call friends
     - Most did not have confidantes, however. Many said they felt it was inappropriate to bother others with their problems. (This is not common among younger old people, around 65, who feel the opposite.)
     - Relationships with friends do not necessarily require face to face visits. Emotional benefits do not depend on the number of contacts, but rather on the quality of intimacy.
     - This is key: Those who remain active with friends tend to revise the way they define friendship. They no longer require being nearby or face-to-face. Letters and phone work to sustain closeness. "My best friend calls me every morning at eight o’clock. Neither of us can get out any more, so we haven’t seen each other for six months." This also reduces the need for reciprocal hospitality, which is difficult to sustain.

Strategies for helping build connections

We have talked about the difficulty of maintaining old friendships and acknowledged that friendships are essential to physical and psychological well-being. Those two facts, tugging in opposite directions, would doom elderly people to loneliness if it were not possible to bring new relationships into their lives. Fortunately, research tells us that proximity is a true catalyst for friendship. As the song goes, "If I can’t be near the one I love, I love the one I’m near." (Brigadoon)

The fact is, people do adjust to their limits and find new ways to make friends. Here are some findings:

     - 45% reported making a new friend after age 85.
     - The most common sources of new friendships are community associations, like church and senior centers. (Clearly, an assisted-living facility provides the same sort of group experiences.)
     - Men are more likely to meet new people at association meetings, women more in their neighborhoods. (Remember that men usually require "doing something" with others – "instrumental" activity. Women can make friends sitting around a room and talking – "expressive" activity.)
     - Older people change their criteria for defining friendships and begin to sustain friendships in different forms. (This is a key point.)

What facts should caregivers take into account when trying to help people find the kinds of social relationships they need?

     - Long standing relationships enhance well-being more profoundly than new friendships. (So it follows that helping our residents to maintain their old relationships is time well spent.)
     - Though everyone needs intimacy, some people react to life’s difficulties by developing a strong defense against social contacts to avoid the pain of possible and expected rejection. Interfering with such an established pattern of defensive self-sufficiency may be impossible. It is nevertheless appropriate to try, bearing in mind what the resident fears and bearing in mind that your efforts may fail. (Here, the key must be understanding that individual and seeking contacts and experiences for him/her that are not threatening.)
     - Caregivers should determine whether a person needs one close one-to-one relationship or a group of more casual friends.
     - The longer a person lives in a long-term care facility the fewer visitors he/she receives. Caregivers should monitor changes in support available to their elders over time. (What is enough staff intervention this year may not be enough next year.)
     - People with a good self-image and strong social skills may need only short-term help building new relationships when they move in, but others may require help continually.

Here are three elements that have been identified as basic to diminishing feelings of loneliness.

• Opportunities to compare: Loneliness is diminished when people have a chance to compare their own pasts with other people’s.

• Sense of control: Loneliness is diminished when people have a sense of control of some aspect of their environment.

• Someone to confide in: Loneliness is diminished when people have a confidante.

We all need to ask ourselves whether the activities and interventions we plan address these three essential needs.

A partial list of interventions for helping elders overcome limitations and make new friends

This is not a definitive list but it is a start. Let it help you begin thinking of what you could do.

1. For the visually impaired

• Finding a "seeing-eye friend" to read to them, write letters for them, guide them through unfamiliar places, as necessary
• Teaching others to identify themselves when coming into the visually impaired person’s company
• Giving point-of-the-clock directions. "The door is at two o’clock."
• Providing lots of activities that require listening and little seeing (music, lectures, etc.)

1. For the hearing impaired

• Understanding hearing aids so that you can help your elder use theirs well
• Talking slowly enough, with a lower tone. Keeping your face turned toward the hearing-impaired person. Being sure that your face is not obscured by your hand or hair, or back-lit and in shadows.
• Providing lots of visual activities that require little hearing (crafts, closed captioned television, exercise)

1. For those with difficulty walking, climbing (if your elder lives in a care facility)

• Arranging for another resident to accompany the frail person to events if he/she needs an arm to be steady.
• Going yourself or asking another staff person to help the person get to activities.
• Be sure the resident understands the uses of the phone system: to call to find out times of activities, to chat on the phone with other residents.
• Locating some activities in the Great Rooms near the person’s apartment (e.g. a foursome for cards, a committee meeting, etc.)

1. For those with poor memory

• Asking another resident to stop by for the person on the way to an activity that you know he/she wants to attend
• Seating the forgetful person near another forgetful person who is, perhaps, less likely to be frustrated by repeated stories

1. For the shy, fearful, reclusive

• Establishing a trusting relationship with the person yourself first, before trying to introduce the person to others.
• Trying to match people who have similar backgrounds and interests.
• Building the person’s acquaintances one or two people at a time, not expecting larger groups to accomplish much bonding for shy people.
• Seating two people together in a small, quiet room instead of a large, bustling one.
• Taking care to introduce people well, giving enough background so that they can easily discover things they have in common as topics for conversation.
• Staying in the conversation yourself for a couple of minutes, in order to help them achieve some comfort before you leave.
• Finding or creating unthreatening, simple occasions for the person to spend a little time with one or two other people (walking to a meal together or walking for exercise; sitting down with two people in a Great Room or other sitting place and starting a conversation topic before leaving; inviting two people in your neighborhood to watch your "favorite program" for you and tell you about it later, etc.)
• Putting items conducive to activity in the Great Rooms to encourage involvement: large print books, picture books, magazines, games, jigsaw puzzles.

 For the sociable, outgoing

• Being aware of their interests and trying to create opportunities for them to pursue those interests with others.
• Encouraging them to take leadership roles; then following through once you have mentioned a possibility.