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Increasing the Social Emphasis to Override Mechanistic Clinical Standards

Published July 10, 2008 10:22 AM by Brian Garavaglia

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 due to 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.  One can see how misconceptions and variable levels of dehumanization can emanate from viewing older adults and their bodies quite mechanically in the clinical realm. 

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.

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. Most individuals who are older adults as a whole 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 face 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. 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 older adults as 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 later.

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.

It must be remembered that boredom, lack of sensory and mental stimulation, depression, metabolic instabilities, the increasing number of medications used among this group, as well as 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. 

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 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 needs to be individuals in a long-term care environment that 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 that focus their needs to 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 has to be individuals that remain focused on nurturing, maintaining and enhancing the social being. Again, ultimately there needs to be an understanding of the importance for all individuals in long-term care to nurture the social being of older adults, including those who are clinically involved with their biological functioning. They should not see themselves as any less absolved or responsible for nurturing the social self.     

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.  Paying attention to the social and emotional development of the person, being sensitive to areas of social regression, and understanding how to enhance the lives of older adults in an often sterile, physical environment can only lead to greater pleasure for the elderly that they service and help enhance their very important niche in this important area of healthcare.       



Butler, R (1969).  Ageism: Another form of Bigotry.  The Gerontologist, 9, pp. 243-246.

Christiansen, J. L & Grzybowski, J. M (1999).  Biology of Aging, McGraw-Hill, New York.

Garavaglia, B. (2007).  The Pitfalls of Diagnosing Dementia: Looking beyond Patient Age. Long-term Care Interface, July/August, 2007, Vol 8, No 4, pp.46-48.

Goffman, E. (1961).  Asylums: Essays on the Social situation of Mental Patients and Other Inmates.  Doubleday Anchor, New York.


posted by Brian Garavaglia


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About this Blog

    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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