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 The Merrill Social Work and Human Services Series
5TH EDITION
SOCIAL WORK WITH
OLDER ADULTS

MCINNIS-DITTRICH
A Biopsychosocial Approach to
Assessment and Intervention
KATHLEEN MCINNIS-DITTRICH

A Biopsychosocial Approach to Assessment and Intervention

5TH EDITION
SOCIAL WORK WITH OLDER ADULTS
www.pearson.com

ISBN-13: 978-0-13-516807-3
ISBN-10: 0-13-516807-4
EAN
 PREFACE

There is little doubt that social work with older adults is, and will continue to be, the hottest area
of social work practice for the foreseeable future. The edge of the baby boomer generation has
moved into retirement, with 10,000 people turning 65 years old every single day. No social insti-
tution has remained unchanged by this generation as they have moved through the life course.
Baby boomers will forge new models of what constitutes “successful aging.” They will also face
challenges not yet imagined. This is an exciting time to be studying social work with older adults
as endless possibilities for innovation await the next generation of social workers!
As always, I feel I have the great fortune to have met and worked with a phenomenal group
of older adults both in personal and professional contexts. My own maternal grandmother defied
all the conventions of her generation as a woman, serving to “do something that matters and have
fun!” Indeed, social work with older adults has been just that. The older adults I have known in
the New Orleans Central City Housing Project, the Oneida Indian Reservation in Wisconsin, the
foothills of the Appalachian Mountains, older adult housing in Boston, and even my yoga class
have made me a better social worker and a better person. How lucky I am to do this work.
When I wrote the first edition of this text, I was happily ensconced in early middle age. As
a researcher and practicing social worker, I knew both the professional literature and the practice
application of the material. Work with older adults has been my passion for my entire profes-
sional life. As I write the fifth edition, I have just joined the ranks of being an older adult, no
longer studying it from afar. I would like to think I still know the professional literature and the
practice application of the material in this text well. However, I also know some areas better than
others because of my own personal experiences over the past 20 years. I am painfully (literally)
reminded of an old field hockey injury when it revisits me as arthritis. I have lived the heartache
of being a long-distance caregiver and having buried parents and siblings. I have completed my
own and others’ advance directives and know how important it is to have that conversation before
it is time to make difficult decisions. I have watched friends show the early signs of dementia or
struggle with the black cloud of depression. Like every older homeowner, I think about what will
happen when doing yard work is too much or hauling around the snow blower in a typical New
England winter is too challenging. And then, sometimes, I am most happy not thinking about it
at all! I understand denial better than I did earlier in my life.
I also know the power and promise of how many older adults continue to live busy, pro-
ductive lives. As a firm believer in the importance of volunteering, I have experienced the joy of
helping other older adults navigate the Medicare jungle as a volunteer at Ethos, an Area Agency
on Aging in Boston. I support a group of “old progressives” who are fearless in taking on immi-
gration, affordable housing, and a fair minimum wage. I have become a passionate advocate for
better public transportation and accessible health care. I suspect these and other issues facing older
adults will continue to engage me as I approach retirement, but I also look forward to continuing
to enjoy a long, happy marriage and a sailboat named Time Enough.
This text presents a comprehensive overview of the field of social work with older adults,
from the basics of the biopsychosocial changes associated with the aging process through
the assessment of older adults’ strengths as well as challenges to the design and execution of
problem-solving interventions. Social Work with Older Adults is written for both undergraduate
and graduate students. It focuses on social work practice interventions with individual older
adults, older adults’ support systems, and groups of older adults. It is intended to cover topics
vii
viii Preface

as basic as encouraging older adults to exercise to those as complex as the process of differen-
tial assessment and diagnosis of depression, dementia, and delirium. Important macro practice
issues such as creating age-friendly communities, transportation, housing, income programs,
and health insurance are covered in the final chapters of the text. The inclusion of this material
reminds us as social workers that the influence of the greater social environmental system can
be as powerful, if not more so, than the smaller systems of home and family. The most physi-
cally and mentally healthy older adult cannot thrive without adequate income, safe housing, and
access to ongoing health care, all of which are determined by forces outside of the individual
social work relationship with an older adult. The inclusion of this material honors the long
tradition of the social work profession in social change directed at organizations, communities,
and the policy arena.
Unlike many other texts on social work with older adults, this text includes a comprehen-
sive array of topics within a single volume. It includes protocols for traditional and alternative
interventions, recognizing the amazing heterogeneity of the aging population. In many respects,
it can be considered as “one-stop shopping” for content on working with older adults. Content
on diversity of gender, race, ethnicity, and sexual orientation is integrated into the discussion of
each topic.

THE PLAN OF THE TEXT

Instructors who have used earlier editions of the text will see some of the same material as well as
new material and an additional chapter. More material on cultural diversity and sexual orientation
is included in every chapter, with attention to special issues facing LGBT older adults. Chapters
that are clinically oriented contain more case material with questions for class discussion. Each
chapter has Learning Integration Activities that offer suggestions for ways students can apply
new material to their own field settings or communities. These ideas can also serve as projects or
paper ideas, depending on student interest. Each of these ideas has been “field-tested” on my own
graduate students at the Boston College School of Social Work. Students had a very enthusiastic
response to finding out how much, or how little, was being done in their own communities in
these areas of social work practice. Other activities ask students to pursue a topic covered in the
chapter in more depth.

What is New to the Fifth Edition of Social Work with Older Adults?

• New content on the unique challenges baby boomers will face as older adults, including a
detailed discussion of the opioid crisis and Hepatitis C.
• Enhanced content on the experiences of older adults of color in the health and mental
health service system.
• Extensive new content on LGBT older adults.
• Integration of material on decision-making capacity of older adults throughout the text.
• A new chapter, Chapter Thirteen: Community Programs to Support “Aging in Place”:
Age-Friendly Communities, Transportation, and Housing. The chapter provides enhanced
macro-social work content.
• More case examples followed by discussion questions that stress skill development.
• Integrated Learning Activities at the end of each chapter that offer suggestions for class
projects or individual papers. These activities promote the integration of material in the
chapter with students’ experiences in field practicum or community work.
 Preface ix

The following is a chapter-by-chapter summary of major updates to each chapter.

Chapter 1: The Context of Social Work Practice with Older Adults

• Updated demographic information on older adults
• An in-depth discussion of how the experience of aging baby boomers will transform work
in this field
• Additional content on integrated care and hospice as areas of practice
• An enhanced discussion about the unique rewards of social work with older adults
Chapter 2: Biological Changes and the Physical Well-Being of Older Adults
• Inclusion of material on the radical restriction of caloric intake as an approach to lengthen-
ing life
• In-depth discussion of the issue of health disparities between different groups of older
adults
• Material on the troubling prevalence of hepatitis C in baby boomers
• More comprehensive discussion on fall prevention
• More detailed discussion on behaviors and practices that promote healthy aging
Chapter 3: Psychosocial Adjustments to Aging
• Expanded discussion of the role of hydration and nutrition in maintaining healthy cogni-
tive functioning
• More in-depth material on the development and significance of resilience for older adults
• Addition of Queer Theory to the list of theories of aging
• A critical examination of current paradigms about what constitutes “successful aging”
Chapter 4: Conducting a Biopsychosocial Assessment
• In-depth coverage of the significance on the assessment process of decision-making capac-
ity in older adults with cognitive limitations
• Detailed presentation of evidence-based tools for assessing emotional, cognitive, and social
functioning
• Discussion about the social worker’s use of language interpreters
Chapter 5: Differential Assessment and Diagnosis of Cognitive and Emotional Problems of Older
Adults
• Additional content on the differences in the presentation of depression in men and women
• More discussion on mild cognitive impairment as contrasted with dementia
• A tabular presentation of the different kinds of non-Alzheimer’s dementia
• Class discussion questions about each of the cases presented in the chapter as a means of
developing students’ skills in differential assessment
Chapter 6: Interventions for Depression, Anxiety, and Dementia in Older Adults
• An expanded discussion of behavioral management techniques for older adults with
dementia
• Expanded discussion on the use of medication to stabilize dementia
• Enhanced content on the barriers to mental health treatment faced by older adults of color,
including stigma, cultural obstacles, and health care provider bias
x Preface

Chapter 7: Complementary and Alternative Approaches to Treating Socioemotional Conditions

in Older Adults
• The role of the social worker in incorporating alternative and complementary approaches
in therapeutic interventions with older adults
• Exploration of the therapeutic benefits of humor and play on good mental health among
older adults
• Expansion of materials from the National Center on Creative Aging
Chapter 8: Substance Abuse and Suicide Prevention in Older Adults
• Extensive discussion of the Screening, Brief Intervention, Referral to Treatment Model for
the treatment of alcohol dependency
• Discussion of the increase in use and abuse of opioids and other prescription drugs among
older adults
• Presentation of the psychoactive medications prescribed for common mental health issues
among older adults
• Expanded discussion of why older adults contemplate suicide, including the influence of
financial stressors or the development of a functional impairment
• Added material on the NASW Code of Ethics and high risk older adults for mandated
reporting in cases of suicidal
• An additional case example followed by discussion questions to help students learn skills
in identifying suicidal ideation in an older adult
Chapter 9: Social Work Practice in Identifying and Preventing Abuse and Neglect of Older Adults
• Comparison and contrast of guardianship, limited guardianship, representative payee,
and conservatorship as legal arrangements for older adults who lack full decision-making
capacity
• Expanded coverage of the problem of caregiver stress as it contributes to elder abuse and neglect
• Additional material on mandated reporting of elder abuse by social workers
• Expansion of coverage of the vulnerability of older adults of color
• Discussion of current financial scams targeting older adults
• Additional coverage of material on elder abuse and neglect among populations of color
• Class discussion questions following the case example to help students identify the ethical
dilemmas raised by cases of self-neglect
Chapter 10: The Role of Spirituality in Social Work with Older Adults
• Enhanced content on men’s spirituality and how it differs from women’s spirituality
• Additions of guidelines on writing memoirs as an exercise in spirituality for older adults
• Expanded discussion of the role of religion in the lives of older adults and its importance
based on gender, race, ethnicity, and sexual orientation.
Chapter 11: Advance Care Planning and End-of-Life Care for Older Adults
• Exploration of what “a good death” means to older adults and their families
• Suggestions and resources for starting the conversation with older adults and their families
about advance care planning
• Discussion about advance care planning and the range of documents for advance directives
is presented in the first part of the chapter to highlight their importance
 Preface xi

• More comprehensive discussions of Do Not Resuscitate orders and detailed presentation

on Physician’s Orders for Life Sustaining Treatment
• A detailed comparison of the different end-of-life documents and advance directives dis-
cussed in the chapter, identifying the documents’ purpose and legal standing
• Additional material on racial, ethnic, and religious variations in the use of advance directives
• New section on the unique challenges facing LGBT older adults in completing advance
directives
• Case example about the use of advance directives with class discussion questions that help
students develop skills in how to work with older adults and families at a difficult time
• Case example of anticipatory grief with class discussion questions to help students learn to
identify how an older adult may be using protective mechanisms to process anticipated grief
Chapter 12: Working with Older Adults’ Support Systems in Caregiving
• Expanded definitions of support systems for older adults to include gay and lesbian partners
and families of choice
• Additional material on caregiving among racial and ethnic groups
• Specific guidelines for holding family meetings
• An enhanced section on caregiving burden and sources of stress in caregiving with specific
suggestions for identifying caregiver stress
• More materials on moderators of caregiver stress and ways to support caregivers, including
promoting self-efficacy
• Presentation of options for online support groups for older adults
• Case example of an older adult in need of caregiving with a focus on how the family can
start the process of developing and implementing a caregiving plan
• Case example of grandparents raising grandchildren with discussion questions designed
to help students develop skills to support a grandfamily while maintaining the connection
to the child’s absent parent
Chapter 13: NEW! Community Programs to Support “Aging in Place”: Age-Friendly Communi-
ties, Transportation, and Housing Initiatives
• A discussion of the concept of “aging in place” with attention to populations who might
not benefit from aging in their current residence
• Presentation of the 8 Domains of Livability for Age-Friendly Communities as identified by
the World Health Organization with examples of how those domains influence programs
for older adults
• A comparison between naturally occurring retirement communities and the village move-
ment in providing a context for service provision for older adults
• An exploration of the challenge of older drivers, the significance of driving to older adults,
and recommendations for implementing screening programs
• Discussion of other modes of transportation, such as mass transit, volunteer drivers, sub-
sidized taxis, and ride-hailing services as reasonable alternatives
• Identification of housing choices available to older adults, including home ownership and
subsidized rental properties
• An examination of the growing problem of homelessness among older adults
xii Preface

Chapter 14: Income Programs, Health Insurance, and Support Services for Older Adults: Chal-
lenges and Opportunities for the Future
• Coverage of the financial challenges facing the generation of approaching retirements due to
prior economic conditions in this country and the maintenance of serious debt into retirement
• Inclusion of benefits available to veterans as they age
• Updated language on the Affordable Care Act (ACA)
• Updated information on changes to Part D of Medicare that result from the ACA and new
choices for prescription coverage
• Inclusion of a discussion of the challenges faced by older immigrants as they “age out of
place” rather than in place
• An expanded discussion of the challenges and opportunities the growing population of
older adults presents to both society and the social work profession

ACKNOWLEDGMENTS
I would like to thank the reviewers of this fifth edition of the text and for their suggestions for
additions and improvements. These reviewers include: Donna Drucker, Florida Atlantic Uni-
versity; Denise Gammonley, University of Central Florida; Mary Hart, California University
of Pennsylvania, GTY 320 Alternatives in Long Term Care; Martha Ranney, California State
University, Long Beach; and Tracy Wharton, University of Central Florida.
Special thanks go to my students at the Boston College School of Social Work, who were
brutally honest about what they would like to see changed from earlier editions and were not the
least bit impressed that their professor wrote the textbook! Teaching is the greatest joy of aca-
demic life and often the most humbling.
My deepest gratitude goes to my husband, Bill Dittrich, for his love, patience, support,
and humor for so many years. His love is the anchor in my life. As Robert Browning said so
eloquently, “Grow older along with me, the best yet to be.” We are on that journey!
K.M.-D.
 BRIEF CONTENTS

Chapter 1 The Context of Social Work Practice with Older Adults 1

Chapter 2 Biological Changes and the Physical Well-Being of Older
Adults 26
Chapter 3 Psychosocial Adjustments to Aging 60
Chapter 4 Conducting a Biopsychosocial Assessment 84
Chapter 5 Differential Assessment and Diagnosis of Cognitive and
Emotional Problems of Older Adults 110
Chapter 6 Interventions for Depression, Anxiety, and Dementia in
Older Adults 141
Chapter 7 Complementary and Alternative Approaches to Treating
Socioemotional Conditions in Older Adults 179
Chapter 8 Substance Abuse and Suicide Prevention in Older
Adults 203
Chapter 9 Social Work Practice in Identifying and Preventing Abuse
and Neglect of Older Adults 235
Chapter 10 The Role of Spirituality in Social Work with Older
Adults 262
Chapter 11 Advance Care Planning and End-of-Life Care for Older
Adults 284
Chapter 12 Working with Older Adults’ Support Systems in
Caregiving 319
Chapter 13 Community Programs to Support “Aging in Place”: Age-
Friendly Communities, Transportation, and Housing
Initiatives 346
Chapter 14 Income Programs, Health Insurance, and Support Services
for Older Adults: Challenges and Opportunities for the
Future 372

Appendix: Suggested Answers to Assessment and Case Study Questions 390

Index 395

xiii
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 CONTENTS

Chapter 1 The Context of Social Work Practice with Older

Adults 1
Aging in the Twenty-First Century 1
Diversity within the Older Adult Population 1
The Focus of This Chapter 2
The Demography of Aging 2
The Growth of the Older Population 2
Life Expectancy and Marital Status 3
Living Arrangement 4
Poverty 5
Employment 6
Health Status and Disability 6
How Baby Boomers Will Change Aging in the Twenty-First Century 7
Using the Strengths Perspective in Work with Older Adults 8
Settings for Gerontological Social Work 8
Community Social Service Agencies 9
Home Health-Care Agencies 9
Integrated Care Management 10
Aging Life Care Professional (Geriatric Care Management) 11
Independent and Assisted-Living Settings 11
Adult Day Health Care 13
Nursing Homes 14
Hospitals 14
Hospice and Palliative Care 15
Developing Areas for Direct Practice 16
Legal Services 16
Preretirement Planning 16
Macro Settings for Gerontological Social Workers 17
Community Practice 17
Planning 18
Legislative and Political Advocacy 18
Personal and Professional Issues in Work with Older Adults 19
Ageist Personal and Social Attitudes 19
Countertransference 19
Ageism and Death Anxiety 20
The Independence/Dependence Struggle 20
Self-Awareness and Supervision 22
The Rewards of Working with Older Adults 22

xv

xvi Contents

Chapter 2 Biological Changes and the Physical Well-Being of

Older Adults 26
What Do Biological Changes Mean for Older Adults? 27
Daily Decisions Are Contingent on Physical Health 27
Abilities and Attitudes Are at Odds 27
Personal Issues Become Public Business 28
Environmental Obstacles Should Challenge Assumptions about
Accessibility 29
Why Does the Body Age? 29
Genetic Programming 29
Cross-Links and Free Radicals 30
Deterioration of the Immune System 31
Biological Changes That Accompany Aging 31
Skin, Hair, and Nails 31
The Neurological System 33
The Cardiovascular System 34
The Musculoskeletal System 35
The Gastrointestinal System 37
The Respiratory System 37
The Urinary Tract System 38
The Endocrine and Reproductive Systems 39
The Sensory System 40
Vision 40
Health Disparities Between Groups of Older Adults 42
Incontinence 43
The Prevalence of Incontinence 43
Types of Incontinence 44
Treatment of Urinary Incontinence 44
HIV/AIDS and Hepatitis C in Older Adults 45
Why Older Adults May Be More Vulnerable to Contracting
HIV/AIDS 46
HIV/AIDS among Older Adults of Color 47
Socioeconomic Status and Health 47
The Stigma Associated with HIV/AIDS 48
Implications for Social Work Practice with HIV/AIDS 48
Expanding Social Networks for Older Adults with
HIV/AIDS 48
Baby Boomers and Hepatitis C 49
What Factors Promote Healthy Aging? 49
The Influence of Diet 50
Exercise and Physical Activity 51
Psychosocial Factors 53
The Effect of Ageism on Physical Health 55
 Contents xvii

Chapter 3 Psychosocial Adjustments to Aging 60

Cognitive Changes That Accompany Aging 61
Intelligence 61
Personality 63
Resilience 65
Memory 65
The Motivation to Remember 66
Learning 67
Social Theories of Aging 67
Prescriptive Social Theories of Aging 68
Descriptive Social Theories of Aging 70
The Life Course Perspective: Gender, Sexual Orientation, and Color 72
Older Adults and Sexuality 73
“Successful” Psychosocial Aging 76
Cognitive and Intellectual Functioning 77
The Significance of Social Support 77
Implications of Psychosocial Changes for Social Work Practice with
Older Adults 78
Provide Opportunities but Respect Choice 78
Everything Takes More Time 79
Psychosocial Health Is Often Contingent on Physical Health 79
Social Isolation Can Be Deadly for Older Adults 79
Change Is Always Possible 79

Chapter 4 Conducting a Biopsychosocial Assessment 84

Assessments Look at Strengths and Challenges 84
The Purpose of a Biopsychosocial Assessment 85
Evaluation of Strengths and Challenges 85
Identification of Ways to Support and Maintain Existing
Functioning 85
Identification of Interventions and Supports that Restore Lost
Functioning 86
Special Considerations in Assessing Older Adults 86
The Heterogeneity of the Older Adult Population 86
The Balance between Independence and Dependence 87
Origin of the Request for Assessment 87
Respecting Personal Privacy 87
Determining Decisional Capacity 88
Conditions for Conducting an Assessment 89
The Physical Environment 89
Optimum Functioning 90
Explaining the Purpose of the Assessment 90
Confidentiality 91
Components of a Comprehensive Assessment 91
Use of Assessment Tools and Instruments 91
xviii Contents

Getting Started on an Assessment 93

Physical Health 93
Self-Rating of Health 95
Competence in the Activities of Daily Living 95
Psychological Functioning 96
Emotional Well-Being 98
Social Functioning 99
Spirituality 101
Sexual Functioning 101
Financial Resources 102
Environmental Issues 102
Professional Intuition 103
Using Collaterals to Gather Additional Information 104
Example of a Comprehensive Assessment 104
Physical Health 104
Competence in the Activities of Daily Living 105
Psychological Health 105
Social Functioning 106
Spiritual Assessment 106
Sexual Functioning 106
Financial Resources 107
Environmental Safety Issues 107

Chapter 5 Differential Assessment and Diagnosis

of Cognitive and Emotional Problems of
Older Adults 110
Differential Assessment and Diagnosis 110
Depression in Older Adults 111
Risk Factors for Depression in Older Adults 111
The Relationship between Race, Ethnicity, Socioeconomic Class, and
Depression 114
Diagnosing Depression in Older Adults 116
Dementia 118
Alzheimer’s Disease 118
Diagnosing and Assessing Alzheimer’s Disease Using Biopsychosocial
Indicators 120
Stages of Alzheimer’s Disease 123
Vascular Dementia 124
Delirium 126
Symptoms of Delirium 126
Causes of Delirium 126
Treatment of Delirium 127
Differentiating Between Depression, Dementia, and Delirium 128
Anxiety Disorders 131
Risk Factors for Anxiety Disorders 132
 Contents xix

Types of Anxiety Disorders 133

Assessing Anxiety in Older Adults 134
Differential Diagnosis of Anxiety 135

Chapter 6 Interventions for Depression, Anxiety, and Dementia

in Older Adults 141
The Intervention Process 142
What Happens in the Intervention Process? 142
Identifying Strengths and Facilitating Empowerment 142
Whose Goals? 143
Barriers to Intervention and Treatment with Older Adults 143
Attitudes About Interventions 143
Stigma and Cultural Barriers 144
Health-Care Provider Bias 144
Developing a Relationship with an Older Adult 145
Helping Older Adults Understand the Purpose and Process of an
Intervention 145
Developing Rapport 145
Interventions for Depression and Anxiety 146
Cognitive-Behavioral Therapy 146
Older Adults Who Respond Best to Cognitive-Behavioral Therapy 147
The Process of Cognitive-Behavioral Therapy 148
Reminiscence Therapy 151
How Effective Is Reminiscence? 151
The Process of Therapeutic Reminiscence 151
Life Review 154
When Can Life Review Be Beneficial? 154
The Process of Life Review 155
Medical Interventions for Depression and Anxiety 158
Drug Therapy 158
Electroconvulsive Therapy 158
Group Approaches to Treat Depression and Anxiety 159
Advantages of the Group Approach 159
The Group Process 160
Stages in the Group Process 160
Specialized Groups for Older Adults 162
Remotivation Groups 162
Social and Recreational Groups 163
Support Groups 164
Behavioral Management Interventions for Dementia 166
Confusion: The Validation Approach 169
The Principles of the Validation Approach 169
The Pros and Cons of the Validation Approach 170
Simulated Presence Therapy 171
Medications Used to Treat Dementia 174
xx Contents

Chapter 7 Complementary and Alternative Approaches

to ­Treating Socioemotional Conditions in Older
Adults 179
Complementary and Alternative Interventions 179
The Benefits of Creative Arts for Older Adults 180
The Role of Social Work in Complementary Therapies 181
The Therapeutic Use of Music 182
Music as Psychotherapy 182
Receptive or Passive Use of Music 184
Active Participation in Making Music 185
Music Intervention with Older Adults with Alzheimer’s Disease 185
Music Combined with Other Art Forms 186
Art as a Therapeutic Activity 186
Art Therapy 187
Art as a Therapeutic Group Activity 188
Themes and Art Projects 188
Art as Recreation 189
Massage Therapy 190
The Benefits of Massage Therapy for Older Adults 191
Animal-Assisted Therapy 192
The Human–Animal Relationship 192
Animals’ Roles as Social Connections 193
Types of Animal-Assisted Therapy 193
Animal-Assisted Therapy and Older Adults with Alzheimer’s Disease 194
Recreation as Therapy 195
Examples of Recreation as Therapy 196

Chapter 8 Substance Abuse and Suicide Prevention in Older

Adults 203
Alcohol Use and Abuse by Older Adults 204
Early-Onset Versus Late-Onset Alcoholism 204
Risk Factors Associated with Alcohol Dependence 205
Alcohol and Older Women 207
Psychological and Medical Consequences of Problem Drinking 207
Alcohol Problems in Nursing Homes 209
Recognizing Alcohol Problems in Older Adults 210
Treatment of Alcohol Problems in Older Adults 211
Barriers to Treatment 211
The Screening, Brief Intervention, Referral to Treatment (SBIRT)
Model 212
The Detoxification Process 214
Follow-up Treatment for Recovery 215
Drug Abuse, Misuse, and Dependency 216
The Growth in the Use of Illicit Drugs Among Older Adults 216
 Contents xxi

Prescription Drug Abuse: Opioid Addiction 217

The Interaction of Alcohol and Prescription Medications 219
Treatment for Drug Dependency 220
Screening, Brief Intervention, Referral for Treatment (SBRIT) 220
Suicide Among Older Adults 221
Risk Factors for Suicide Among Older Adults 222
Assessing Suicidal Tendencies in Older Adults 225
The National Association of Social Workers Code of Ethics and High-
Risk Older Adults 226
Long-Term Treatment of Suicidal Older Adults 227
Preventing Suicide Among Older Adults 228

Chapter 9 Social Work Practice in Identifying and Preventing

Abuse and Neglect of Older Adults 235
Growing Concern About Abuse and Neglect of Older Adults 235
The Incidence of Abuse and Neglect of Older Adults 236
The Estimates of Abuse and Neglect 236
The Problem of Substantiation 236
Lack of Uniform Definitions of Abuse/Neglect 237
Mandated Reporting 237
What is Considered Abuse or Neglect of Older Adults? 237
Physical Abuse 237
Emotional or Psychological Abuse 238
Financial Exploitation 238
Neglect 239
Older Adults at High Risk for Abuse 241
Gender and Age 241
Health Status of the Older Adult 241
Socioeconomic Class 243
Racial and Ethnic Group Membership 243
Social Support 243
Domestic Violence Grown Old 244
High Risk Factors for Individuals Likely to Abuse an Older Adult 244
Age and Gender 244
Understanding the Causes of Maltreatment of Older Adults 245
Social Learning Theory 245
Social Exchange Theory 246
Assessment of Abuse, Neglect, and Self-Neglect of Older Adults 247
Reporting Abuse or Neglect 247
Assessing an Older Adult for Abuse or Neglect 247
Designing Interventions to Prevent Abuse or Neglect 251
Protecting Against Financial Abuse or Exploitation 251
Developing Support Services 252
Modifying the Environment 253
xxii Contents

Abuse and Neglect in Nursing Homes 254

When an Older Adult Refuses Protective Services 255
The Ethical Dilemma in Reporting Abuse and Neglect in Older
Adults 255
Determining Legal Competence 256

Chapter 10 The Role of Spirituality in Social Work with Older

Adults 262
Defining Religion and Spirituality 263
The Positive Effect of Religion on Older Adults’ Well-Being 264
Religious and Spiritual Diversity by Gender, Race, and Ethnicity 264
The Relationship Between the Social Work Profession and
Spirituality 269
The Common Ground Between Social Work and Spirituality 269
Psychosocial Tasks as Spiritual Tasks 270
A Few Words of Caution 270
Self-Awareness and Spirituality 271
Learning About Religious Traditions and Practices 271
Incorporating Spirituality Into Social Work Practice with Older
Adults 272
Spirituality as an Element in the Assessment Process 272
Spirituality and Social Work Intervention Techniques 274
How These Efforts Differ from Pastoral Counseling or Spiritual
Direction 278

Chapter 11 Advance Care Planning and End-of-Life Care for Older

Adults 284
End-of-Life Care as Part of Social Work with Older Adults 284
The Meaning of Death to Older Adults: What is a “Good
Death”? 285
Starting the Conversation About Advance Care Planning 286
The Social Worker’s Role in Talking about Advance Care Planning 287
Advance Directives 288
Instructional Directives 288
The Durable Power of Attorney for Health Care 289
The Controversy Surrounding Advance Directives 292
Palliative and Hospice Care 296
Palliative Care 296
Hospice Care 296
Hospice Care Services 297
The Dying Process 299
Physical and Psychological Manifestations of Dying 299
The Needs of Dying Older Adults 300
 Contents xxiii

The Role of the Social Worker in the Dying Process 301

Providing Emotional Support 301
Advocating on Behalf of the Older Adult and the Family 302
Providing Information 302
Self-Care for the Social Worker 303
Bereavement and Grief 304
Manifestations of Grief 304
Stage Theories of Grief 305
Factors Affecting the Grieving Process 307
Complicated or Prolonged Grief 310
Social Work Interventions with Bereaved Older Adults 311
Providing Information 311
Accessing Support Groups 312
Ethical Considerations in End-of-Life Care 313

Chapter 12 Working with Older Adults’ Support Systems in

Caregiving 319
Older Adults’ Support Systems 319
Caregiving in the United States 320
Family Structure and Potential Caregivers 320
The Family Meeting 323
Planning a Family Meeting 323
Roles in Caregiving and Care Receiving 324
Caregiving in the LGBT Community 325
Caregiving Among Racial and Ethnic Groups 325
Caregiving Burden 327
Sources of Stress in Caregiving 327
Depression among Caregivers 330
Moderators of Caregiver Stress 330
Social Work Interventions with Caregivers 331
Promoting Caregiver Self-Efficacy 331
Psychosocial Interventions 332
Improving the Caregiver–Care Receiver Relationship 332
Promoting Self-Care for the Caregiver 333
Caregiver Support Groups 334
Grandparents Raising Grandchildren 337
Challenges to Grandparents 337
Challenges to Grandchildren 338
Social Work Roles in Supporting Grandfamilies 339

Chapter 13 Community Programs to Support “Aging in Place”:

Age-Friendly Communities, Transportation, and Hous-
ing Initiatives 346
Aging in Place 347
Aging in Place Doesn’t Work for Everyone 347
xxiv Contents

Transportation Options for Older Adults 353

Older Drivers 353
Assessing the Ability of Older Drivers 355
Alternative Transportation Options for Older Adults 357
Housing Options for Older Adults 360
Owning a Home 360
Rental Housing With or Without Subsidies 362
Assisted Living 363
Continuing Care Retirement Communities 363
Homelessness Among Older Adults 365

Chapter 14 Income Programs, Health Insurance, and Support

Services for Older Adults: Challenges and Opportuni-
ties for the Future 372
Social Insurance and Public Assistance Programs 372
Income Support Programs for Older Adults 373
Social Security Retirement and Survivors Benefits 373
Medicare: Health Insurance for Older Adults 376
Parts A and B 376
Part C and Supplemental Insurance 377
Part D: Prescription Drug Coverage 378
Medicaid or Medical Assistance 378
Employment-Related Programs for Older Adults 379
Older Adults in the Labor Market 379
Senior Community Service Employment Program 380
Support Services Available to Older Adults 380
Support Programs Authorized by the Older Americans Act of
1965 381
Choices for Independence 382
Finding Services for Older Adults: The Eldercare Locator 383
National Center for Benefits Outreach & Enrollment 383
Older Immigrants: “Aging Out of Place” 384
What Challenges and Opportunities Lie Ahead? 385
Generational Differences 385
Health Care in the Future 386
Age-Friendly Initiatives 387
The Future of Social Work with Older Adults 387

Appendix: Suggested Answers to Assessment and Case Study Questions 390

Index 395
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Chemical
warfare
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
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you are located before using this eBook.

Title: Chemical warfare

Author: Amos A. Fries

Clarence J. West

Release date: October 22, 2023 [eBook #71931]

Language: English

Original publication: New York: McGraw Hill, 1921

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*** START OF THE PROJECT GUTENBERG EBOOK CHEMICAL

WARFARE ***
CHEMICAL WARFARE

McGraw-Hill Book Co. Inc.

PUBLISHERS OF BOOKS FOR
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CHEMICAL WARFARE
BY
AMOS A. FRIES
Brigadier General, C. W. S., U. S. A.
Chief, Chemical Warfare Service

AND
CLARENCE J. WEST
Major, C. W. S. Reserve Corps, U. S. A.
National Research Council

First Edition

McGRAW-HILL BOOK COMPANY, Inc.

NEW YORK: 370 SEVENTH AVENUE
LONDON: 6 & 8 BOUVERIE ST., E. C. 4
1921

Copyright, 1921, by the

McGraw-Hill Book Company, Inc.
 PREFACE
Shortly after the signing of the Armistice, it was realized that the
story of Chemical Warfare should be written, partly because of its
historical value, and partly because of the future needs of a textbook
covering the fundamental facts of the Service for the Army, the
Reserve Officer, the National Guard, and even the Civilian Chemist.
The present work was undertaken by both authors as a labor of
patriotism and because of their interest in the Service.
The two years which have elapsed since the initial discussion of
the outlines of the book have thoroughly convinced us of the need of
such a work. The Engineers, the Medical Department, and most of
the other branches of the Army have their recognized textbooks and
manuals. There has been no way, however, by which the uninformed
can check the accuracy of statements regarding Chemical Warfare.
The present volume will serve, in a measure, to fill this gap. That it
does not do so more completely is due in part to the fact that secrecy
must still be maintained about some of the facts and some of the
new discoveries which are the property of the Service. Those familiar
with the work of the Chemical Warfare Service will discover, though,
that the following pages contain many statements which were
zealously guarded secrets two years ago. This enlarged program of
publicity on the part of the Chief of the Service is being justified
every day by the ever increasing interest in this branch of warfare.
Where five men were discussing Chemical Warfare two years ago,
fifty men are talking about the work and the possibilities of the
Service today. It is hoped that the facts here presented may further
increase the interest in Chemical Warfare, for there is no question
but that it must be recognized as a permanent and a very vital
branch of the Army of every country. Reasons for this will be found
scattered through the pages of this book.
It should be explained that this is in no sense a complete
historical sketch of the development and personnel of the Chemical
Warfare Service. At least two more volumes are needed,—one on
the Manufacture of Poisonous Gases and one on the Tactics of
Chemical Warfare. We have purposely refrained from an attempt to
give credit to individuals for the accomplishments of the various
Divisions of the Service, because such an attempt would have made
the book too voluminous, and would have defeated the primary
purpose, namely, that it should present the information in as concise
manner as possible. The published and unpublished materials of the
files of all the Divisions have been freely drawn upon in writing the
various chapters, and many old C. W. S. men will undoubtedly
recognize whole sentences which they wrote under the stress of the
laboratory or plant “battle front.” May these few lines be an
acknowledgment of their contributions. Those who desire to consult
the literature of Chemical Warfare will find a fairly complete
bibliography (to about the middle of 1919) in “Special Libraries” for
November, 1919.
Special acknowledgment is made to Dr. G. J. Esselen, Jr., for
having read the manuscript and for helpful and constructive
criticisms. Many of the figures are reproduced by permission of the
Journal of Industrial and Engineering Chemistry; those showing the
Nelson cell were furnished by the Samuel M. Green Company.

Amos A. Fries,
Clarence J. West.
Aug. 1, 1921.
 FOREWORD
After all peaceful means of settling disputes between nations
have been resorted to and have failed, war is often declared by one
of the disputants for the purpose of imposing its will upon the other
by force. In order to accomplish this, a superiority must be
established over the adversary in trained men and in implements of
war.
Men are nothing in modern war unless they are equipped with the
most effective devices for killing and maiming the enemy’s soldiers
and thoroughly trained in the use of such implements.
History proves that an effective implement of war has never been
discarded until it becomes obsolete.
It is impossible to humanize the act of killing and maiming the
enemy’s soldiers, and there is no logical grounds on which to
condemn an appliance so long as its application can be so confined.
Experiments in this and other countries during the World War
completely established the fact that gas can be so confined. The
range of gas clouds is no greater than that of artillery and the
population in the area behind the front line must, if they remain in
such range, take their chance. The danger area in the future will be
known to all.
As the first Director of the Chemical Warfare Service, U. S. Army,
I speak with some experience when I say that there is no field in
which the future possibilities are greater than in chemical warfare,
and no field in which neglect to keep abreast of the times in research
and training would be more disastrous.
Notwithstanding the fact that gas was used in the World War two
years before the United States entered the fray, practically nothing
was done in this country before April, 1917, towards the
development of any chemical warfare appliances, offensive or
defensive, and had it not been for the ability of an ally to supply our
troops with such appliances, they would have been as defenseless
as the Canadians were at Ypres when the Germans sent over their
first gas cloud.
This book recites the troubles and successes of this new service
under the stress of war for which it was unprepared and I trust that
its perusal will create a public opinion that will insist upon chemical
preparation for war.
I feel that this book will show that the genius and patriotism
displayed by the chemists and chemical engineers of the country
were not surpassed in any other branch of war work and that to fail
to utilize in peace times this talent would be a crime.

William L. Sibert,
Major General, United States Army,
Retired.
 CONTENTS
page
Preface vii
Foreword ix
chapter
I. The History of Poison Gases 1
Modern Development of Gas
II. 10
Warfare
III. Development of the
Chemical Warfare Service 31
The Chemical Warfare Service in
IV. 72
France
V. Chlorine 116
VI. Phosgene 126
VII. Lachrymators 137
VIII. Chloropicrin 144
IX. Dichloroethylsulfide (Mustard Gas) 150
X. Arsenic Derivatives 180
XI. Carbon Monoxide 190
XII. Development of the Gas Mask 195
XIII. Absorbents 237
XIV. Testing Absorbents and Gas Masks 259
XV. Other Defensive Measures 272
XVI. Screening Smokes 285
XVII. Toxic Smokes 313
XVIII. Smoke Filters 322
XIX. Signal Smokes 330
XX. Incendiary Materials 336
XXI. The Pharmacology of War Gases 353
XXII. Chemical Warfare in Relation to
Strategy and Tactics 363
XXIII. The Offensive Use of Gas 385
XXIV. Defense against Gas 405
XXV. Peace Time Uses of Gas 427
XXVI. The Future of Chemical Warfare 435
Index 440
CHEMICAL WARFARE
 CHAPTER I
THE HISTORY OF POISON GASES [1]

The introduction of poison gases by the Germans at Ypres in

April, 1915, marked a new era in modern warfare. The popular
opinion is that this form of warfare was original with the Germans.
Such, however, is not the case. Quoting from an article in the Candid
Quarterly Review, 4, 561, “All they can claim is the inhuman
adoption of devices invented in England, and by England rejected as
too horrible to be entertained even for use against an enemy.” But
the use of poison gases is even of an earlier origin than this article
claims.
The first recorded effort to overcome an enemy by the generation
of poisonous and suffocating gases seems to have been in the wars
of the Athenians and Spartans (431-404 b.c.) when, besieging the
cities of Platea and Belium, the Spartans saturated wood with pitch
and sulfur and burned it under the walls of these cities in the hope of
choking the defenders and rendering the assault less difficult. Similar
uses of poisonous gases are recorded during the Middle Ages. In
effect they were like our modern stink balls, but were projected by
squirts or in bottles after the manner of a hand grenade. The legend
is told of Prester John (about the eleventh century), that he stuffed
copper figures with explosives and combustible materials which,
emitted from the mouths and nostrils of the effigies, played great
havoc.
The idea referred to by the writer in the Candid Quarterly Review,
is from the pen of the English Lord Dundonald, which appeared in
the publication entitled “The Panmure Papers.” This is an extremely
dull record of an extremely dull person, only rendered interesting by
the one portion, concerned with the use of poison gases, which, it is
said, “should never have been published at all.”
That portion of the article from the Candid Quarterly Review
dealing with the introduction of poisonous gas by the Germans, and
referred to in the first paragraph above, is quoted in full as follows:

“The great Admiral Lord Dundonald—perhaps

the ablest sea captain ever known, not even
excluding Lord Nelson—was also a man of wide
observation, and no mean chemist. He had been
struck in 1811 by the deadly character of the fumes
of sulphur in Sicily; and, when the Crimean War was
being waged, he communicated to the English
government, then presided over by Lord
Palmerston, a plan for the reduction of Sebastopol
by sulphur fumes. The plan was imparted to Lord
Panmure and Lord Palmerston, and the way in
which it was received is so illustrative of the trickery
and treachery of the politician that it is worth while to
quote Lord Palmerston’s private communication
upon it to Lord Panmure:

“Lord Palmerston to Lord Panmure

“‘House of Commons, 7th August, 1855 “‘I
agree with you that if Dundonald will go out himself
to superintend and direct the execution of his
scheme, we ought to accept his offer and try his
plan. If it succeeds, it will, as you say, save a great
number of English and French lives; if it fails in his
hands, we shall be exempt from blame, and if we
come in for a small share of the ridicule, we can
bear it, and the greater part will fall on him. You had
best, therefore, make arrangement with him without
delay, and with as much secrecy as the nature of
things will admit of.’

“Inasmuch as Lord Dundonald’s plans have

already been deliberately published by the two
persons above named, there can be no harm in now
republishing them. They will be found in the first
volume of ‘The Panmure Papers’ (pp. 340-342) and
are as follows:

“‘(Enclosure)
“‘Brief Preliminary Observations
“‘It was observed when viewing the Sulphur
Kilns, in July, 1811, that the fumes which escaped in
the rude process of extracting the material, though
first elevated by heat, soon fell to the ground,
destroying all vegetation, and endangering animal
life to a great distance, and it was asserted that an
ordinance existed prohibiting persons from sleeping
within the distance of three miles during the melting
season.
“‘An application of these facts was immediately
made to Military and Naval purposes, and after
mature consideration, a Memorial was presented on
the subject to His Royal Highness the Prince
Regent on the 12th of April, 1812, who was
graciously pleased to lay it before a Commission,
consisting of Lord Keith, Lord Exmouth and General
and Colonel Congreve (afterwards Sir William), by
whom a favorable report having been given, His
Royal Highness was pleased to order that secrecy
should be maintained by all parties.

“‘(Signed) Dundonald
“‘7th August, 1855’

“‘Memorandum
“‘Materials required for the expulsion of the
Russians from Sebastopol: Experimental trials have
shown that about five parts of coke effectually
vaporize one part of sulphur. Mixtures for land
service, where weight is of importance, may,
however, probably be suggested by Professor
Faraday, as to operations on shore I have paid little
attention. Four or five hundred tons of sulphur and
two thousand tons of coke would be sufficient.
“‘Besides these materials, it would be necessary
to have, say, as much bituminous coal, and a couple
of thousand barrels of gas or other tar, for the
purpose of masking fortifications to be attacked, or
others that flank the assailing positions.
“‘A quantity of dry firewood, chips, shavings,
straw, hay or other such combustible materials,
would also be requisite quickly to kindle the fires,
which ought to be kept in readiness for the first
favourable and steady breeze.

“‘Dundonald
“‘7th August, 1855’

“‘Note.—The objects to be accomplished being

specially stated the responsibility of their
accomplishment ought to rest on those who direct
their execution.
“‘Suppose that the Malakoff and Redan are the
objects to be assailed it might be judicious merely to
obscure the Redan (by the smoke of coal and tar
kindled in ‘The Quarries’), so that it could not annoy
the Mamelon, where the sulphur fire would be
placed to expel the garrison from the Malakoff,
which ought to have all the cannon that can be
turned towards its ramparts employed in
overthrowing its undefended ramparts.
 “‘There is no doubt but that the fumes will
envelop all the defenses from the Malakoff to the
Barracks, and even to the line of battleship, the
Twelve Apostles, at anchor in the harbour.
“‘The two outer batteries, on each side of the
Port, ought to be smoked, sulphured, and blown
down by explosion vessels, and their destruction
completed by a few ships of war anchored under
cover of the smoke.’
“That was Lord Dundonald’s plan in 1855,
improperly published in 1908, and by the Germans,
who thus learnt it, ruthlessly put into practise in
1915.
“Lord Dundonald’s memoranda, together with
further elucidatory notes, were submitted by the
English government of that day to a committee and
subsequently to another committee in which Lord
Playfair took leading part. These committees, with
Lord Dundonald’s plans fully and in detail before
them, both reported that the plans were perfectly
feasible; that the effects expected from them would
undoubtedly be produced; but that those effects
were so horrible that no honorable combatant could
use the means required to produce them. The
committee therefore recommended that the scheme
should not be adopted; that Lord Dundonald’s
account of it should be destroyed. How the records
were obtained and preserved by those who so
improperly published them in 1908 we do not know.
Presumably they were found among Lord
Panmure’s papers. Admiral Lord Dundonald himself
was certainly no party to their publication.”
One of the early, if not the earliest suggestion as to the use of
poison gas in shell is found in an article on “Greek Fire,” by B. W.
Richardson.[2] He says: