Autonomy and Care for The Frail Elderly

May 1993

A One-Year Project Identifies Effective Interventions For Congregate Housing Residents

Ms. Szwabo is an instructor, Department of Psychiatry and Human Behavior, Saint Louis University School of Medicine; and Dr. Stretch is professor, School of Social Services, Saint Louis University, St. Louis.


In 1989 the St. Louis—based Cardinal Ritter Institute (CRI) conducted a demonstration project to determine how effective its interventions were in enabling the elderly to age in place. Preliminary screenings of persons at a congregate living site for the elderly revealed four major areas of concern:

  • Deficient knowledge of medication regimens, side effects, and purposes.
  • Need for basic social interaction
  • Depression—related primarily to loneliness and isolation
  • Insufficient knowledge of community resources

A multifaceted program developed by CRI staff helped alleviate many of these problems. The program's success shows that early identification of frail elderly at risk for losing their independence can guide interventions that allow them to age in place.

As the number of elderly persons needing assisted living services grows, so does the importance of knowing which services most effectively enable the elderly to age in place. In 1989 the St. Louis-based Cardinal Ritter Institute (CRI), a multiservice gerontological agency, conducted a demonstration project to determine which of its interventions were accomplishing their purposes and where it might change or extend services to improve its effectiveness.

Health Promotion Demonstration Project
For the past 12 years, CRI has addressed the health and wellness needs of older persons living in congregate housing. Although the agency has updated and expanded its services during this period, until recently its health promotion staff relied primarily on personal observation to determine necessary changes in services. But as the number of persons over 85 served by the institute grew, so did the typical client's health problems. It became clear that CRI staff needed an objective way to identify residents at risk of losing their independence and determine whether their observations of these residents' needs were accurate and their interventions effective.

To test the effectiveness of their interventions, CRI health promotion staff studied randomly selected residents at a senior congregate housing facility to which the institute provided services. Each participant had at least one of four diseases—hypertension, arthritis, diabetes, or heart disease.

Objectives Conducted for one year, the Health Promotion Demonstration Project had three major objectives:

  • To identify wellness factors in order to more precisely determine program effects
  • To test the effectiveness of need-specific health promotional interventions and their cost savings
  • To develop a working model for other organizations committed to enhancing the health of frail elderly in congregate housing

Interviews and Screenings In the summer of 1989 CRI interviewed 102 randomly selected residents at the demonstration project site. Quantitative and qualitative data from these interviews were analyzed and served as the needs assessment.

The screenings consisted of a multifaceted battery of tests to determine participants' physical and mental health. These included Activities of Daily Living, Physical Health Scale, General Depression Scale, Mini-Mental State Examination Scale, and Mental Health Scale. A health history developed by CRI staff, which included data regarding residents' utilization of various healthcare services, was also part of the screening.

CRI's health promotion staff used the results of the study to:

  • Design support services that allow frail elderly to remain in their current residence
  • Train staff to identify elderly residents at risk of losing their independence
  • Determine if the health promotion team approach helped meet the frail elderly's health and wellness needs

Identifying Concerns
The interviews revealed four primary areas of concern:

  • Deficient knowledge of medication regimens, side effects, and purposes
  • Need for basic social interaction
  • Depression—related primarily to loneliness and isolation
  • Insufficient knowledge of community resources

Program Interventions
To respond to some of these needs, CRI developed three specific interventions: a medication teaching program, a loneliness intervention group, and services for the memory impaired. Program interventions were geared to the most acute needs among project participants. The health promotion team consisted of two registered nurses, a social worker, two paraprofessional respite aides, a university-based gerontological consultant, and an evaluation consultant.

Medication Teaching Program Data collected revealed that participants' median medication amount was 10 medicines a day, with up to 40 doses per day. Analysis of medication ordered revealed a strong possibility, in many cases, of unwanted drug interactions and side effects. Interviews with residents revealed that many did not understand how to take their medicine, why it was important to take it, or which side effects they should report. Frequent inability to read and comprehend written material contributed to the problem.

To help residents better manage their medications, the care team developed specialized educational tools and information sheets tailored to residents' level of education, attention span, and visual acuity. The team also created small-group educational sessions on each of the 14 floors at the facility. Staff kept logs on all program participants, documenting their response to the program. Participants also kept records of medications they were currently using, which they took with them on visits to physicians.

As a result of the medication program interventions, residents became more familiar with the names and purposes of their medications. They also contacted the on-site health promotion nurse more frequently for information and advice about their medications. Clinical observations and medical records indicated that residents served by this program improved their ability to comply with the medication regimens.

Cognitive Impairment Program Scores from the Mini-Mental survey of research and control group members revealed varying levels of cognitive impairment and memory loss. These results led the CRI care team to initiate a program of intervention to improve residents' cognitive abilities.

In 1990 CRI interviewed 70 tenants at the demonstration site for inclusion in the program. CRI conducted a pilot project—which included planning, orientation, and program organization—from January to June 1990. Fifty residents participated in the program.

A registered nurse, social worker, and two respite aides made up the team. The nurse or social worker visited each selected tenant at least once a month, and aides visited each tenant at least four times. The nurse prepared a care plan for each tenant, stipulating the number of visits the team would make each week and the type of interventions they would provide.

The project design called for frequent, intense interventions early, with reduced professional and paraprofessional involvement as the resident developed competencies. Team members received orientation and training for the project, which included visits to area adult day care centers. The team provided a broad range of services, including meal preparation, reality orientation, shopping, personal care assistance, help with household chores and finances, and reminders to take medications. They also organized activities designed to promote residents' independence.

Evaluations of the program indicated that it improved quality of life for individuals served. Housing managers, maintenance personnel, nursing staff, other residents, neighbors, and family reported that the program enhanced participants' ability to care for themselves. They also indicated that the services enabled many who were at risk for institutionalization to remain in congregate housing.

Loneliness Program CRI also formed a group to address problems of isolation and loneliness for residents with high scores on the Geriatric Depression Scale. An intern from the graduate program at Saint Louis University's School of Social Work developed a project to improve social interactions for residents at the congregate housing site.

Sixteen residents from the original survey group, who had been identified as isolated or depressed, were invited to participate. On average, 6 to 10 residents participated weekly.

The project was not presented as a therapy group, but as a kaffeklatch. The goal was to provide participants an opportunity to get out of their apartments, meet new people, and share stories about old times. Rules were established regarding confidentiality, cross-talk, and criticism. Participants looked back on significant events in their lives with the aim of integrating and resolving unexamined or troubling issues.

Their discussions focused on such topics as persons who had meant a lot to them when they were young, how they had felt about themselves when young and how those perceptions affected them in the present, and the meaning of religion in their lives. Participants shared mementos and photos with the group. Their interactions usually left the group with good feelings that promoted positive conversations in the future and encouraged more socialization.

Early Identification and Implementation
The project's success shows that early identification of frail elderly at risk for losing their independence can guide interventions that allow them to age in place.

The project also validated the care team's original observations about effective interventions for the frail elderly. Overall, the findings suggest that such a program may be beneficially pursued by other groups that deal directly with the congregate living needs of the frail elderly.


Copyright © 1993 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Autonomy and Care for The Frail Elderly

Copyright © 1993 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.