a program for the emotionally disturbed

References 1. Schneider, E. L., and Emr, Marian. Alzheim-

er's disease: research highlights. Ger- latr.Nurs. 6:136, May-June 1985.

2. Working with the confused delirious patient. (CE) Am.J.Nurs. 78:!491-1512, Sept. 1978.

3. Wolanin, M. Principles o f Care for Institu- tionalized Alzheimer Patients: A Proposed Protocol. Paper presented at Beyond Folk- lore: Methods for the Management of Atz- heimer Patients, held in Minneapolis, MN, The Veteran's Administration and the Uni- versity of Minnesota, Sept. 1984.

4. Mace, L., and Rabins, P, V. The 36 Hour Day: A Family Guide to Caring for Persons with Alzheimer's Disease Related Dementing Illnesses and Memory Loss in Later Life. Bal- timore, MD, Johns Hopkins University Press,

1982, pp. 25-27. 5. Trockman, Gordon. Caring for the confused

or delirious patient. A'm.J.Nurs. 78:1495- 1499, Sept. 1978.

6. Hall, G. Standard Care Plan for the Patient with a Dementing Illness. Iowa City, IA, The University of Iowa, 1984.

7. Sobel, E, Anxiety and stress in later life. IN Handbook on Stress and Anxiety: Contempo- rary Knowledge, Theory and Treatment, ed. by I. L. Kutash and others. San Francisco, Jossey-Bass Publishers, 1980, pp. 323-347.

8. White, R. Strategies of adaptation: systematic description. IN Coping and Adaptation, ed. by G. V. Coelho and others. New York, Basle Books, 1974, pp. 47-68.

9. Coyne J., and Lazarus, R. Cognitive style, stress perception and coping. IN Handbook on

Stress and Anxiety: Contemporary Knowl- edge, Theory and Treatment, ed. by I. L. Ku- rash and others. San Francisco, Jossey-Bass Publishers, 1980, pp. 144-159.

10. Selye, H. The stress concept today. IN Hand- book on Stress and Anxiety: Contemporary Knowledge, Theory and Treatment. ed. by I. L. Kutash and others. San Francisco, Josscy- Bass Publishers, 1980, pp. 127-144.

11. Nursing 84 Drug Handbook. Springhouse, PA. Springhouse Book Corp.. 1984, pp. 253, 277, 282, 289-290.

12. Wolanin, M. O., and Phillips, L. R. Confu- sion: Prevention and Care. St. Louis, The C.V. Mosby Co., 1981.

13. CE credit through home study. Confusion: re- cognition and remedy. Geriatr.Nurs. 4:223- 248, July-Aug. 1983.

A Program for the Emotionally Disturbed Started on one unit 10 years ago, the STP now provides c o m m u n i t y as wel l as hospital therapy.

LOIS HANSING Can emotional problems of the elderly be dealt with adequately on an adult psychiatric unit? Are these problems so complex that a special kind of psychiatric unit is needed? Who should be involved in assessment and treatment? What kind of program will serve the elderly best?

Nursing service and administration at Fairview Hospital, in Min-

neapolis, Minnesota, pondered these questions and decided to institute a multidisciplinary team approach on a psychiatric unit exclusively for elderly patients. In June 1976, the Senior Treatment Pro- gram was opened on a 20-bed unit of the hospital's 107-bed psychiatric department.

Today Fairview Community Hospitals includes four hospitals plus two satellites and has a broad range of behavioral services. Forty programs for children, adolescents, adults, and seniors, provide outpatient services, and care for 259 inpatients.

The seniors program has added two units. The Senior Intensive Treatment Program (SITP) was opened in 1984 with a more struc-

tured environment to assess and treat behaviors that are very difficult to manage; SITP has 12 beds. The Senior Outpatient Program was started in 1985 with the goal of helping older persons stay independent as long as possible.

Today STP, the original unit, has an established record of assisting patients and their families to identify problems and develop ways to cope with them successfully.

The STP team includes a medical director; psychiatrists; medical physicians; registered nurses; licensed practical nurses; psychiatric technicians; occupational, recrea-

Lois Hansing, RN, BA, is a team leader on the Senior Treatment Program Unit at the Fairview Community Hospitals, Minneapo- lis, MN.

Geriatric Nursing May/June 1986 137

ReferencesJ. Schneider, E. L., and Emr, Marian. Alzheim·

er's disease: research highlights. Geriatr.Nurs. 6:136, May-June 1985.

2. Working with the confused delirious patient.(CE) Am.J.Nurs. 78:1491-1512, Sept. 1978.

3. Wolanin, M. Principles of Care for Inslilutionaflud Alzheimer Patients: A ProposedProtocol. Paper presented at Beyond Folk·lore: Methods for the Management of Alzheimer Patients, held in Minneapolis, MN,The Veteran's Administration and the Uni·versity of Minnesota, Sept. 1984.

4. Mace, L., and Rabins, P. V. The 36 HourDay: A Family Guide to Caring for Personswith Alzheimer's Disease Related DementingIllnesses and Memory Loss in Loter Life. Baltimore, MD, Johns Hopkins University Press,

1982, pp. 25-27.5. Trackman, Gordon. Caring for the confused

or delirious patient. Am.J.Nurs. 78:1495·1499, Sept. 1978.

6. Hall, G. Standard Care Plan for the Patientwith a Dementing /llness. Iowa City, lA, TheUniversity of Iowa, 1984.

7. Sobel, E. Anxiety and stress in later life. INHandbook on Stress and Anxiety: Contemporary Knowledge. Theory and Treatment, ed.by I. L. Kutash and others. San Francisco,Jossey-Bass Publishers, 1980, pp. 323-347.

8. White, R. Strategies of adaptation: systematic description. IN Coping and Adaptation. ed.by G. V. Coelho and others. New York, BasicBooks, 1974, pp. 47-68.

9. Coyne J., and Lazarus, R. Cognitive style,stress perception and coping. IN Handbook on

Stress and Anxiety: Contemporary Knowledge. Theory and Treatment, ed. by I. L. Kutash and others. San Francisco, Jossey-BassPublishers, 1980, pp. 144-159.

10. Selye, H. The stress concept today. IN Handbook on Stress and Anxiety: ContemporaryKnowledge. Theory and Treatment. ed. by I.L. Kutash and others. San Francisco, JosseyBass Publishers, 1980, pp. 127-144.

11. Nursing 84 Drug Handbook. Springhouse,PA. Springhouse Book Corp., 1984, pp. 253,277, 282, 289-290.

12. Wolanin, M. 0., and Phillips, L. R. Confusion: Prevention and Care. SI. Louis, TheC.V. Mosby Co., 198J.

13. CE credit through home study. Confusion: reocognition and remedy. Geriatr.Nurs. 4:223·248, July·Aug. 1983.

SPECIAL UNITS FOR SPECIAL ELDERS

A Program for theEmotionallyDisturbedStarted on one unit10 years ago, theSTP now providescommunity as wellas hospital therapy.

LOIS HANSING

Can emotional problems of the elderly be dealt with adequately on anadult psychiatric unit? Are theseproblems so complex that a specialkind of psychiatric unit is needed?Who should be involved in assessment and treatment? What kind ofprogram will serve the elderlybest?

Nursing service and administration at Fairview Hospital, in Min-

neapolis, Minnesota, ponderedthese questions and decided to institute a multidisciplinary team approach on a psychiatric unit exclusively for elderly patients. In June1976, the Senior Treatment Program was opened on a 20-bed unitof the hospital's 107-bed psychiatric department.

Today Fairview CommunityHospitals includes four hospitalsplus two satellites and has a broadrange of behavioral services, Fortyprograms for children, adolescents,adults, and seniors, provide outpatient services, and care for 259 inpatients.

The seniors program has addedtwo units. The Senior IntensiveTreatment Program (SITP) wasopened in 1984 with a more struc-

tured environment to assess andtreat behaviors that are very difficult to manage; SITP has 12 beds.The Senior Outpatient Programwas started in 1985 with the goal ofhelping older persons stay independent as long as possible.

Today STP, the original unit, hasan established record of assistingpatients and their families to identify problems and develop ways tocope with them successfully,

The STP team includes a medical director; psychiatrists; medicalphysicians; registered nurses; licensed practical nurses; psychiatrictechnicians; occupational, recrea-

Lois Hansing, RN, BA, is a team leader onthe Senior Treatment Program Unit at theFairview Community Hospitals, Minneapolis, MN.


tional, and group therapists; a treatment plan facilitator, social workers, and chaplains.

Physical therapists often evaluate mobility problems, and special exercises in the gym may be part of some individualized treatment plans. Speech and language therapists or a psychologist may test psychological and mental status to help differentiate between severe depression and dementia, which can cause many of the same manifestations. Audiometric tests help to diagnose hearing losses, which can affect emotional well-being.

Besides nine single patient rooms and five double rooms, the S T P unit has a lounge-dining area with piano and TV, a smaller lounge, OT clinic and kitchen, group room, and a staff conference room. The kitchen is used primarily by OTs as they evaluate patients' skills in activities of daily living.

Depression is the most common diagnosis of patients treated on STP. Most are in their 70s or 80s; the age range is 59 to 100. The aging process may bring many losses, and for some individuals whose losses exceed their coping capacity an acute depression results. Pa- tients today are more acutely ill on admission, both psychiatrically and physically, than our early admissions were.

Admission may be directly from the community, by transfer within our hospital, from anothel" hospital, or from a nursing home. Nursing homes sometimes refer patients who have become unmanageable or have had a sudden change in behavior. Patients have come from as far away as Florida; most are from midwestern states.

The admissions coordinator, who is a registered nurse, screens applicants for admission. Referrals come from physicians, social workers, family, clergy, and nursing homes. Some individuals request their own admission. Anyone con- cerned about an elderly person's behavior and ability to cope with daily stresses can call for information about the program.

The screening process may in- elude phone conversations with the

"Bal loon" ball offers opportunity for socialization and sedentary exercise.

elderly person, a family member, stituted within 48 hours of the pa- social worker, or physician. The ad- tient's admission. The team meets missions coordinator, in consulta- about a week later to evaluate find- tion with a psychiatrist, determines ings and develop an individualized whether admission to STP, SITP, master treatment plan. Team or an alternative approach to the members identify psychiatric, problem seems appropriate. If the physical, and social problems and elderly person's behavior seems suggest approaches for dealing likely to endanger other slow-mov- with them. While the most com- ing individuals, admission may be mon psychiatric problem is depres- first to SITP. Or an extremely ac- sion, others include dementia, some tire, aggressive elder may be ad- neuroses, and occasionally schizo- mitted to the adult intensive treat- phrenia. The fact that most S T P ment unit until improved sufli- patients have a combinat ion of ciently to benefit from STP. physical and emotional problems

The title, head nurse, has been differentiates this population from changed to program supervisor be- patients on the usual medical-sur- cause the responsibilities include g icalward and the traditional adult more budget and program plan- psychiatric ward. ning, and no direct patient care. Medical disorders may include Two team leaders coordinate the hypertension, cardiac disease, post- day-to-day care. The t r e a t m e n t cardiovascular accident, diabetes, plan facilitator assists the team poor nutrition with weight loss, im- leaders in documenting patient paired mobility, incontinence. The care and planning treatment, identified social difficulty might be

A nurse or psychiatric technician a lack of socialization resulting in interviews each patient on admis- isolation, poor social skills, or sion to the unit. I f possible, a social inability to return to the patient's worker meets simultaneously with former living situation. Treatment one or more family members to plans are reviewed and updated at learn more about the family's view least once a week. of the patient's problem. Days Busy, Pace Slow

Besides evaluation and treatment by a psychiatrist, a medical physi- Days on S T P are busy. Patients clan usually examines the patient, dress in street clothes, eat in a com- The number and kinds of medica- munity dining room, and take part tions may be causing confusion and in group activities. The pace is depression, or poor nutrition may slower than on the usual adult men- be impairing emotional health, tal health unit, in consideration of

An initital treatment plan is in- any physical limitations of the eld-

138 Geriatric Nursing May/June 1986

"Balloon" ball offers opportunity lor socialization and sedentary exercise.

tional, and group therapists; atreatment plan facilitator, socialworkers, and chaplains.

Physical therapists often evaluate mobility problems, and specialexercises in the gym may be part ofsome individualized treatmentplans. Speech and language therapists or a psychologist may test psychological and mental status tohelp differentiate between severedepression and dementia, whichcan cause many of the same manifestations. Audiometric tests helpto diagnose hearing losses, whichcan affect emotional well-being.

Besides nine single patient roomsand five double rooms, the STPunit has a lounge-dining area withpiano and TV, a smaller lounge,OT clinic and kitchen, group room,and a staff conference room. Thekitchen is used primarily by OTs asthey evaluate patients' skills in activities of daily living.

Depression is the most commondiagnosis of patients treated onSTP. Most are in their 70s or 80s;the age range is 59 to 100. The aging process may bring many losses,and for some individuals whoselosses exceed their coping capacityan acute depression results. Patients today are more acutely ill onadmission, both psychiatrically andphysically, than our early admissions were.

Admission may be directly fromthe community, by transfer withinour hospital, from another hospital,or from a nursing home. Nursinghomes sometimes refer patientswho have become unmanageable orhave had a sudden change in behavior. Patients have come from asfar away as Florida; most are frommidwestern states.

The admissions coordinator, whois a registered nurse, screens applicants for admission. Referralscome from physicians, social workers, family, clergy, and nursinghomes. Some individuals requesttheir own admission. Anyone con-.cerned about an elderly person'sbehavior and ability to cope withdaily stresses can call for information about the program.

The screening process may include phone conversations with the

138 Geriatric Nursing May/June 1986

elderly person, a family member,social worker, or physician. The admissions coordinator, in consultation with a psychiatrist, determineswhether admission to STP, SITP,or an alternative approach to theproblem seems appropriate. If theelderly person's behavior seemslikely to endanger other slow-moving individuals, admission may befirst to SITP. Or an extremely active, aggressive elder may be admitted to the adult intensive treatment unit until improved sufficiently to benefit from STP.

The title, head nurse, has beenchanged to program supervisor because the responsibilities includemore budget and program planning, and no direct patient care.Two team leaders coordinate theday-to-day care. The treatment·plan facilitator assists the team·leaders in documenting patientcare and planning treatment.

A nurse or psychiatric technicianinterviews each patient on admission to the unit. If possible, a social

'worker meets simultaneously withone or more family members tolearn more about the family's viewof the patient's problem.

Besides evaluation and treatmentby a psychiatrist, a medical physician usually examines the patient.The number and kinds of medications may be causing confusion anddepression, or poor nutrition maybe impairing emotional health.

An initital treatment plan is in-

stituted within 48 hours of the patient's admission. The team meetsabout a week later to evaluate findings and develop an individualizedmaster treatment plan. Teammembers identify psychiatric,physical, and social problems andsuggest approaches for dealingwith them. While the most common psychiatric problem is depression, others include dementia, someneuroses, and occasionally schizophrenia. The fact that most STPpatients have a combination ofphysical and emotional problemsdifferentiates this population frompatients on the usual medical-surgical ward and the traditional adultpsychiatric ward.

Medical disorders may includehypertension, cardiac disease, postcardiovascular accident, diabetes,poor nutrition with weight loss, impaired mobility, incontinence. Theidentified social difficulty might bea lack of socialization resulting inisolation, poor social skills, orinability to return to the patient'sformer living situation. Treatmentplans are reviewed and updated atleast once a week.

Days Busy, Pace Slow

Days on STP are busy. Patientsdress in street clothes, eat in a community dining room, and take partin group activities. The pace isslower than on the usual adult mental health unit, in consideration ofany physical limitations of the eld-

erly, but staff constantly encourage participation in a full program. About 15 minutes of physical exercises are part of the daily routine. If standing is difficult, many exercises can be done sitting down.

Occupational and recreational therapists evaluate level of functioning, social skills, and interactions with others as the therapists direct participation in activity groups.

The nutrition group discusses and practices meal planning, grocery buying, and meal preparation. The elders' ability to provide for their nutritional needs is assessed, and the basic principles of nutrition are reviewed. Taking part in the leisure craft group is an opportunity for elders to work with their hands, a means to relieve tension, and an introduction to new skills that may be pursued after discharge. Attention span and ability to follow directions and to plan and complete a project are observed.

The living skills group deals with many practical aspects of daily living--development of new ways to spend leisure time, use of public transportation, managing a checking account, learning about opportunities for volunteer work, and observation of social skills with help to improve them. Outings introduce patients to community activities available at little or no expense.

In group therapy, patients are encouraged to share feelings about losses they have experienced, other changes that come with aging, and the coping skills that work for them. As patients see how their peers deal with life's challenges, they often find the motivation to work on their own problems. Grad- ually, healing takes place.

Evening activities include games, group singing, visits from family members, and other forms of socialization and entertainment. There is one-to-one counseling time with an assigned staff person.

Besides the milieu therapies mentioned, medications are adjusted and, for some patients, electroconvulsive therapy is prescribed. At a weekly family group meeting, relatives share feelings about aging

and problems dealing with an elderly family member. A family conference for each individual brings together family, physician, social worker, therapists, and nursing staff to share findings and formulate discharge plans. The patient is encouraged to take part, but often the family and team discuss some problems before the patient joins the conference. The family's feelings of grief, loss, or helplessness can be expressed and often are alleviated through sensitive discussions with the staff.

Family support is especially important in discharge planning because adjustments are often needed in the patient's environment to continue the healing process.

The purpose of the 12-bed (8 private & 2 double rooms) SITP is to stabilize behavior so that appropriate aftercare may be provided. The most common diagnosis is dementia, with a high rate of pseudodementia.

Many patients appear psychotic because of acute medical problems, and their behavior has made accurate evaluation impossible. The most common therapies are milieu and medication, plus ECT in some instances. The staff headed by the program supervisor and two team leaders includes RNs, LPNs, a social worker, and a treatment plan facilitator. Occupational and recreational therapies are minimal.

Patient Outcomes

The average length of stay is about 16 days and growing shorter. In 1985, 34 percent of STP patients were discharged home, 46 percent to nursing homes, and the others either to SITP or a medical unit.

In the same year, 53 percent of SITP patients went to nursing homes, 30 percent to STP, 15 percent to medical units, and 2 percent home. The two units are on the same floor, so transfer is easy. A highly agitated STP patient may be moved to the more structured SITP; the improved SITP patient may go to STP as a step toward discharge.

Patients who return to home or apartment usually are referred to

such community services as public health nursing, day care centers, homemaker services, congregate dining, seniors counseling services, social services, senior companions, or our outpatient program. If nursing home placement is the best disposition, a care plan is sent to help caregivers ease the patient's adjustment to the new residence.

The new Senior Outpatient Pro- gram deals directly with the severe emotional conflicts that hamper the elderly person's ability to live independently and lead to institutionalization. Most of the severely depressed or severely agitated clients are facing major changes, multiple losses, or both. The age range thus far has been 63 to 82, with most in their early seventies.

The clients participate in a twoday-a-week program for two to six months. Treatment includes 11/2 hours of verbal group therapy, a half hour of physical exercise, and therapeutic recreation with a focus on leisure activities such as volunteering, community involvement, and activities to pursue at home alone. Lunch in the hospital cafeteria is included. There may be medication counseling with the registered nurse, individual or couples' counseling, or family therapy.

The staff consists of a program supervisor, one registered nurse, a psychiatric technician, and a recreational therapist.

The most recent addition to the outpatient program is a two-hour, once a week session for nursing home residents with significant emotional problems. One hour is devoted to verbal therapy, the other to recreational and movement therapy. These clients attend the program from six to eight weeks.

Eighty percent of the current outpatient clients are referred from STP, but the program supervisor anticipates more direct referrals from the community as the program becomes better known.

The Senior Treatment Programs have amply demonstrated that elderly persons can be helped to cope with disabilities or life changes in ways that reinforce their personal worth and integrity. GN


erly, but staff constantly encourageparticipation in a full program.About 15 minutes of physical exercises are part of the daily routine. Ifstanding is difficult, many exercises can be done sitting down.

Occupational and recreationaltherapists evaluate level of functioning, social skills, and interactions with others as the therapistsdirect participation in activitygroups.

The nutrition group discussesand practices meal planning, grocery buying, and meal preparation.The elders' ability to provide fortheir nutritional needs is assessed,and the basic principles of nutritionare reviewed. Taking part in theleisure craft group is an opportunity for elders to work with theirhands, a means to relieve tension,and an introduction to new skillsthat may be pursued after discharge. Attention span and abilityto follow directions and to plan andcomplete a project are observed.

The living skills group deals withmany practical aspects of daily living-development of new ways tospend leisure time, use of publictransportation, managing a checking account, learning about opportunities for volunteer work, and observation of social skills with helpto improve them. Outings introducepatients to community activitiesavailable at little or no expense.

In group therapy, patients areencouraged to share feelings aboutlosses they have experienced, otherchanges that come with aging, andthe coping skills that work forthem. As patients see how theirpeers deal with life's challenges,they often find the motivation towork on their own problems. Gradually, healing takes place.

Evening activities include games,group singing, visits from familymembers, and other forms of socialization and entertainment.There is one-to-one counseling timewith an assigned staff person.

Besides the milieu therapiesmentioned, medications are adjusted and, for some patients, electroconvulsive therapy is prescribed.At a weekly family group meeting,relatives share feelings about aging

and problems dealing with an elderly family member. A family conference for each individual bringstogether family, physician, socialworker, therapists, and nursingstaff to share findings and formulate discharge plans. The patient isencouraged to take part, but oftenthe family and team discuss someproblems before the patient joinsthe conference. The family's feelings of grief, loss, or helplessnesscan be expressed and often are alleviated through sensitive discussionswith the staff.

Family support is especially important in discharge planning because adjustments are often neededin the patient's environment to continue the healing process.

The purpose of the 12-bed (8 private & 2 double rooms) SITP is tostabilize behavior so that appropriate aftercare may be provided.The most common diagnosis is dementia, with a high rate of pseudodementia.

Many patients appear psychoticbecause of acute medical problems,and their behavior has made accurate evaluation impossible. Themost common therapies are milieuand medication, plus ECT in someinstances. The staff headed by theprogram supervisor and two teamleaders includes RNs, LPNs, a social worker, and a treatment planfacilitator. Occupational and recreational therapies are minimal.

Patient Outcomes

The average length of stay isabout 16 days and growing shorter.In 1985, 34 percent of STP patientswere discharged home, 46 percentto nursing homes, and the others either to SITP or a medical unit.

In the same year, 53 percent ofSITP patients went to nursinghomes, 30 percent to STP, 15 percent to medical units, and 2 percenthome. The two units are on thesame floor, so transfer is easy. Ahighly agitated STP patient may bemoved to the more structuredSITP; the improved SITP patientmay go to STP as a step toward discharge.

Patients who return to home orapartment usually are referred to

such community services as publichealth nursing, day care centers,homemaker services, congregatedining, seniors counseling services,social services, senior companions,or our outpatient program. If nursing home placement is the best disposition, a care plan is sent to helpcaregivers ease the patient's adjustment to the new residence.

The new Senior Outpatient Program deals directly with the severeemotional conflicts that hamper theelderly person's ability to live independently and lead to institutionalization. Most of the severely depressed or severely agitated clientsare facing major changes, multiplelosses, or both. The age range thusfar has been 63 to 82, with most intheir early seventies.

The clients participate in a twoday-a-week program for two to sixmonths. Treatment includes 11/2hours of verbal group therapy, ahalf hour of physical exercise, andtherapeutic recreation with a focuson leisure activities such as volunteering, community involvement,and activities to pursue at homealone. Lunch in the hospital cafeteria is included. There may bemedication counseling with the registered nurse, indiv1dual or couples'counseling, or family therapy.

The staff consists of a programsupervisor, one registered nurse, apsychiatric technician, and a recreational therapist.

The most recent addition to theoutpatient program is a two-hour,once a ~eek session for nursinghome residents with significantemotional problems. One hour isdevoted to verbal therapy, the otherto recreational and movement therapy. These clients attend the program from six to eight weeks.

Eighty percent of the currentoutpatient clients are referred fromSTP, but the program supervisoranticipates more direct referralsfrom the community as the program becomes better known.

The Senior Treatment Programshave amply demonstrated that elderly persons can be helped to copewith disabilities or life changes inways that reinforce their personalworth and integrity. GN


a program for the emotionally disturbed

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