N492 Module 2 assignment: older adult therapeutic interview and assessment paper, a full sample

Forty Years on the Signal Line: A Two-Session Therapeutic Interview and Functional Assessment of a 78-Year-Old Widower

Student Name

RN to BSN Program, Aspen University

N492: Community Health I

Instructor Name

Month Day, Year

Forty Years on the Signal Line: A Two-Session Therapeutic Interview and Functional Assessment of a 78-Year-Old Widower

Older adults are usually assessed in clinics and hospitals, in short visits focused on disease. This assignment asks for something different: a therapeutic interview in the person's own setting, carried out over more than one session, that attends to the whole life as well as to current function. This paper describes two interviews with a composite older adult, called Mr. E. here, who agreed to talk about his life and his health. It summarizes his life history, the hardships he has negotiated, and his strengths; reports the results of standardized assessments of daily function and mood; and presents a care plan that builds on his strengths. All identifying details have been changed, and the portrait is a composite for teaching purposes.

Approach to the Interviews

The interviews were modeled on life review, which Butler (1963) described as a natural process in later life of returning to past experiences and unresolved conflicts, and which can support integration and acceptance when it is heard by an attentive listener. Each session lasted about an hour and took place at Mr. E.'s kitchen table. The first session focused on his life story using open questions, such as "Tell me about the work you did" and "What was the hardest time you have been through?" The second session, a week later, revisited themes from the first and included the standardized assessments. Consent was obtained verbally at the start of each session, and Mr. E. was told he could decline any question.

Life History

Mr. E. is 78 years old and lives alone in a one-story house in a small town where he has lived for 50 years. He finished high school, served two years in the Army, and then worked for 40 years maintaining railroad signals, a job he describes with obvious pride: "If the signal was wrong, people could die. I never had one go wrong on my stretch." He married at 24, raised two daughters, and was widowed two years ago after his wife's long illness with heart failure, during which he was her main caregiver. One daughter lives 20 minutes away; the other lives out of state and calls every Sunday.

The significant events he named were his marriage, the birth of his daughters, a train derailment on another crew's section early in his career that he helped clear, his retirement, and his wife's death. The hardships he described were the derailment, which he still thinks about, a period of unemployment during a strike, and the three years of caring for his wife. He spoke about caregiving with pride and exhaustion in equal measure and said that since her death "the days are long."

Strengths

Mr. E.'s strengths are substantial. He is independent in his home, manages his own medications for hypertension and knee osteoarthritis with a weekly pill organizer, and keeps a vegetable garden. He has a strong sense of competence rooted in his work. He is close to both daughters, attends church most weeks, and has a neighbor he helps with repairs. His caregiving years show that he can learn new skills late in life: he learned to manage his wife's diuretic schedule and daily weights, which he explained to me in precise detail. In the language of life review, his account of his life is largely one of meaning and accomplishment, with the loss of his wife as its unresolved chapter.

How He Negotiated Hardship

The way Mr. E. described his hardships says as much about his resources as the hardships themselves. After the derailment, he said, the crew chief sent everyone home for two days, and he spent them rebuilding a fence with his father; he learned then that he copes by working with his hands. During the strike he took odd jobs repairing furnaces and never missed a mortgage payment, which he mentioned twice. While caring for his wife he kept a notebook of her weights and medications, and when her cardiologist praised the notebook, he said, it was the first time he felt useful in months.

Those accounts suggest a consistent pattern: he meets stress through practical action, competence, and routine, and he finds meaning in being relied upon. The pattern also explains his present difficulty. Grief does not respond to repairs or notebooks, and since his wife's death the people who relied on him most are gone or live independent lives. When asked what gets him out of bed now, he paused for a long time and said, "The garden, in summer." It was the only moment in either session when he seemed unsure what to say, and it pointed directly to the assessment findings that followed.

Standardized Assessments

Three standardized tools were used in the second session. On the Katz Index of Independence in Activities of Daily Living, which assesses bathing, dressing, toileting, transferring, continence, and feeding, Mr. E. scored 6 of 6, fully independent (Katz et al., 1963). On Lawton and Brody's instrumental activities scale, he was independent in telephone use, housekeeping, laundry, medication management, finances, and food preparation, and needed help with transportation for longer trips and with major shopping, because he no longer drives at night or on the highway (Lawton & Brody, 1969).

Mood was assessed with the 15-item short form of the Geriatric Depression Scale, a yes-or-no questionnaire developed for older adults (Sheikh & Yesavage, 1986). Mr. E. scored 6. He answered that he had dropped many of his activities, felt that his life was empty, often felt bored, preferred to stay at home, felt worthless the way he is now, and did not feel full of energy. On the 15-item version, five or more positive answers is the usual threshold for a closer look at depression, and because the tool screens rather than diagnoses, the next step is clinical evaluation, not a label. He denied thoughts of harming himself when asked directly.

Other observations were noted. He asked me to repeat questions several times and turned his right ear toward me, suggesting hearing loss that he has not had evaluated. He walks without an assistive device but holds the counter when rising from a chair because of knee pain. His kitchen held mostly canned and frozen foods, and he said he rarely cooks a full meal now that he eats alone.

Care Plan

The care plan builds on Mr. E.'s strengths and addresses four priorities. The first is mood. With his permission, the GDS result and his description of long, empty days will be shared with his primary care provider for further evaluation of depression and complicated grief. He was also given information about a bereavement support group at his church, which he said he might attend if his daughter came with him the first time.

The second priority is social connection and purpose. Mr. E. lit up when describing his work and his caregiving. The local senior center runs a volunteer home repair program for older residents, and a hospital volunteer program seeks caregivers who can mentor families of patients with heart failure. Either would use skills he is proud of. The third priority is hearing. A referral for a hearing evaluation will be discussed with his provider, since untreated hearing loss can deepen isolation and was affecting our own conversation.

The fourth priority is safety and nutrition. A community strength and balance class, offered twice weekly at the senior center, addresses his difficulty rising from a chair. The senior center's congregate lunch program would provide a balanced meal several days a week and additional social contact, and his local daughter agreed to help with a weekly grocery trip. Goals for the next three months are that Mr. E. attends at least one group activity each week, completes the hearing evaluation, and reports on repeat screening that his days feel less empty.

Reflection and Conclusion

The interviews showed me how much a standard clinic visit would miss. A provider seeing Mr. E. for his blood pressure would find a well-groomed, independent man with good medication adherence and might never learn that his days feel empty, that he cannot hear well, or that he once kept trains running safely for 40 years and now has no one to fix things for. The life review gave him a chance to tell his story, and the story explained his screening results better than the scores alone. The care plan that followed asks him to do more of what he has always done well: work with his hands, care for others, and stay connected to his community. That is a plan he is far more likely to follow than one built around what he can no longer do.

Conducting the interviews also taught me something about my own practice. In the hospital I ask older patients about their medications, allergies, and falls, and I rarely ask about their work, their losses, or what gets them out of bed. Mr. E.'s answers to those questions explained more about his health than his blood pressure did. I plan to add one life question to my admission conversations with older adults, such as what they did for work or what they are proudest of, because the answer often reveals both a strength to build on and a loss to acknowledge.

References

Butler, R. N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26(1), 65-76. https://doi.org/10.1080/00332747.1963.11023339

Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W. (1963). Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function. JAMA, 185(12), 914-919. https://doi.org/10.1001/jama.1963.03060120024016

Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3, Pt. 1), 179-186. https://doi.org/10.1093/geront/9.3_Part_1.179

Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist, 5(1-2), 165-173. https://doi.org/10.1300/J018v05n01_09