Before I tell you how I defend my mother from learned helplessness, I need to bring you up to date on her history. As you may remember from previous editorials,2,3 she fell again in 2005 and suffered a right, non-displaced, subcapital hip fracture, a left brachial plexus injury resulting in a paralyzed left arm and hand, and a Stage 4 pressure ulcer in her left axilla which resulted from the trauma of the fall itself and from lying on the floor for 20 hours before she was found. Over the past 4 years of her recovery, her mobility has deteriorated to the point where she requires a full 2-person assist with transfer from the bed to the wheelchair, which she can no longer self propel. Now she is totally dependent in her basic activities of daily living (ADL) except for feeding and is cared for by a dedicated, skilled staff at her nursing home.
Here are 3 examples of how I have made conscious efforts to defend my mother from acquiring the syndrome of learned helplessness:
First, when she was initially hospitalized and was too weak to feed herself, I did feed her. During each meal, however, I repeatedly put a fork or spoonful of food in her right hand and asked her to put it in her mouth and feed herself. If she could not, then I helped guide it to her mouth. I repeatedly told her that she had to be able to feed herself and that if she did not eat, the pressure ulcer would not heal. Eventually, it did heal, as did the Stage 3 sacral pressure ulcer she developed on a second hospitalization. She has always enjoyed a hot dog with "everything on it" from Jimmy's Quick Lunch in Hazleton, Pennsylvania, and when I visit her in the nursing home, I bring her one with a chocolate milkshake. While it's easier for me to feed her the hot dog, I cut it in half so she can pick it up and feed herself.
Second, prior to entering the nursing home she was living in an assisted living facility. At that time she would get from her room to the dining room (about 150 feet) by walking about halfway before tiring and then using her right arm and left foot to propel herself the remainder of the distance in her wheelchair. When I came to see her on weekends, she wanted me to push her the entire distance in her wheelchair. I refused to do it, telling her that if she didn't "use it, she will lose it." She was unhappy with me but I knew that if I had acquiesced, I would have helped her lose her ambulation and wheelchair skills. Eventually she did lose them, but I know she maintained them longer because I helped her fight off learned helplessness.
Finally, even though my brother and I have power of attorney and can write all our mother's checks, up until recently she made all her financial decisions and signed all checks. During the period when her capacity was waning, we encouraged her to make as many decisions as she could. We did this because we knew that if we took away all her financial decision making, she would prematurely lose her ability to handle her affairs.
Everyday at the bedside and in the office, I see students, house-staff, and other colleagues in the "helping" professions encourage learned helplessness. Here are a few examples, that you may also do:
When you ask the hospitalized older adult to rise from a chair, you grab their arm to assist them even though s/he neither asks for your help nor appears unsteady. By offering this help, you learn nothing about the person's ability to rise from a chair independently and you have helped them when they may not have needed it, thus encouraging them to become dependent on you and others for future help.
Here's another. When you are making your morning hospital rounds, you find that your frail older adult has an untouched breakfast tray sitting on the lap table. You are not sure how much she is eating so you want to observe for yourself. To save time, you take the top off the bowl of oatmeal, open the carton of milk, pour some of the milk on top of the oatmeal, stir in some sugar, and then give a spoonful to your patient and ask her to eat it. Once again, look what valuable information you have lost—you don't know whether your patient can do any of the tasks you did for her and you have encouraged her to be dependent on you for assistance.
If we don't stop encouraging learned helplessness, we health care professionals will unleash an epidemic of disability that will add to the growing burden of care that strains our health care workforce and financially drains the coffers of state and federal governments. We need to teach all members of the helping professions to offer help only when needed, hence my prescription: "HELP, PRN."
If you are guilty of encouraging learned helplessness in your older patients, write me at fsherman@advanstar.com
with what you have been doing and how you plan to change your behavior.
Dr Shermanis professor of geriatrics and medicine, The Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, and medical director for Senior Health Partners, New York, NY. He won the 2008 Jesse H. Neal award for opinion columns from American Business Media. fsherman@advanstar.com
References
1. Hwang U, Morrison RS. The geriatric 1. Seligman, M.E.P. (1975). Helplessness: On Depression, Development, and Death. San Francisco: W.H. Freeman. ISBN 0-7167-2328-X
2. Sherman FT. A fall lands close to home: human factors may thwart our best efforts to protect older patients form injury. Geriatrics. 2001;56(3):11,15.
3. Sherman FT. This geriatrician's greatest challenge: caregiving. Geriatrics. 2006;61(3):8-9.
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