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Community Resources for Older Adults
Fifth Edition
I am dedicating this book to

Jani Malkiewicz, who, after 30 years, continues to be a steady

and loving source of encouragement to me in all of my
endeavors;

my UNC friends and colleagues whose support I am grateful to

receive; the wonderful UNC Office of Development and Alumni
team at the Judy Farr Center;

Dr. Robert C. Dickeson, a wonderful mentor and colleague, for

his guidance and wisdom; and

finally, to my mother, Alta Wacker, who shared and modeled her

passion for education and belief in its power to change lives and
communities.

—RRW

I am dedicating this book to my husband, Steven Sheetz, for his

never-ending love, support, and encouragement as I pursue the
multiple facets of my academic career, as well as for making
coffee in the early morning hours when most of my writing gets
done, for the calming candlelit dinners to end each day, and for
spending long weekends at the lake house to ensure I take time
to decompress and reenergize.

—KAR

We both dedicate this book to the people who have chosen a

career in gerontology and who work tirelessly and with
compassion to provide older adults the support they need to live
with the dignity they deserve in the last years of their lives—
thank you.
—RRW

—KAR
Community Resources for Older Adults
Programs and Services in an Era of Change

Fifth Edition

Robbyn R. Wacker

St. Cloud State University

Karen A. Roberto

Virginia Polytechnic Institute and State University

FOR INFORMATION:

SAGE Publications, Inc.

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Printed in the United States of America
Library of Congress Cataloging-in-Publication Data

Names: Wacker, Robbyn R., author. | Roberto, Karen A., author.

Title: Community resources for older adults : programs and services in an era of change /
Robbyn R. Wacker, University of Northern Colorado, Karen A. Roberto, Virginia Polytechnic
Institute and State University.

Description: Fifth Edition. | Thousand Oaks, California : SAGE, [2018] | Fourth edition:
2014. | Includes bibliographical references and index.

Identifiers: LCCN 2018025646 | ISBN 9781506383965 (Paperback : acid-free paper)

Subjects: LCSH: Older people–Services for–United States. | Community health services for
older people–United States. | Old age assistance–United States. | Older volunteers in social
service–United States.

Classification: LCC HV1461 .W32 2018 | DDC 362.60973–dc23 LC record available at

https://lccn.loc.gov/2018025646

This book is printed on acid-free paper.

Acquisitions Editor: Joshua Perigo

Content Development Editor: Sarah Dillard

Editorial Assistant: Alexandra Randall

Production Editor: Jane Haenel

Copy Editor: Sarah J. Duffy

Typesetter: C&M Digitals (P) Ltd.

Proofreader: Scott Oney

Indexer: Nancy Fulton

Cover Designer: Anupama Krishnan

Marketing Manager: Jennifer Jones

Brief Contents
The Authors’ Purpose
Acknowledgments
PART I THE SOCIAL CONTEXT OF COMMUNITY RESOURCE
DELIVERY
Chapter 1 On the Threshold of a New Era
Chapter 2 Legislative Foundations for Programs, Services,
and Benefits Supporting Older Adults
Chapter 3 Patterns of Service Use and Theories of Help-
Seeking Behavior
PART II THE CONTINUUM OF SERVICES
Chapter 4 Information and Assistance
Chapter 5 Volunteer and Intergenerational Programs
Chapter 6 Education Programs
Chapter 7 Senior Centers and Recreation
Chapter 8 Employment Programs
Chapter 9 Income Programs
Chapter 10 Nutrition and Meal Programs
Chapter 11 Health Care and Wellness
Chapter 12 Mental Health Services
Chapter 13 Legal Services
Chapter 14 Transportation
Chapter 15 Housing
Chapter 16 Caregiver Support Services
Chapter 17 Care Management
Chapter 18 Home Care Services
Chapter 19 Long-Term Care Services
PART III PREPARING FOR THE FUTURE
Chapter 20 Programs and Services in an Era of Change
References
Index
About the Authors
Detailed Contents
The Authors’ Purpose
Acknowledgments
PART I THE SOCIAL CONTEXT OF COMMUNITY RESOURCE
DELIVERY
Chapter 1 On the Threshold of a New Era
Growth of the Older Population
Growth of the Older Population of Racial and Ethnic
Minorities
Growth in the Number of Older Adults Living Alone
Growth in the Number of LGBT Older Adults
Implications of Demographic Characteristics for
Community Resources
A Text About Programs and Services in an Era of
Change
Organization of the Book
Accessing Updated Information
Chapter 2 Legislative Foundations for Programs, Services,
and Benefits Supporting Older Adults
Legislative Foundations of Social Programs and
Services
Emergence of the Aging Network
▸ Best Practice: Linking Public and Private
Partnerships
Titles of the Older Americans Act
▸ For Your Files: Policy and Planning for Disaster
Preparedness
▸ For Your Files: First Step In-Home 90-Day
Program, Central Plains Area Agency on Aging,
Wichita, Kansas
Funding for the Older Americans Act
Outcomes of the Older Americans Act
 Chapter 3 Patterns of Service Use and Theories of Help-
Seeking Behavior
Social Support and Care for Older Adults
Informal and Formal Interaction
Service Use by Older Adults
Psychosocial Barriers to Service Use
Psychosocial Theories of Service Use
Social Behavior Model
The Psychology of Help-Seeking Behavior
Reactance Theory
Theory of External Attribution
Equity Theory
Threat-to-Self-Esteem Model
▸ Best Practice: Equity Theory in Action
Application of Theory in Practice
For More Information
PART II THE CONTINUUM OF SERVICES
Chapter 4 Information and Assistance
Policy Background
Across the Globe: I&R/A in Scotland: The Age
Scotland’s Helpline
Users and Programs
▸ For Your Files: Eldercare Locator
▸ Best Practice: Information and
Referral/Assistance Services—National Center for
Benefits Outreach and Enrollment
Characteristics of Programs
Developing and Maintaining a Resource Database
Promotion of Information and Referral/Assistance
Services
Information and Referral/Assistance Process
Information Giving
Assessment and Referral
Advocacy and Crisis Intervention
Follow-Up
 ▸ Best Practice: Information and
Referral/Assistance Services
Information and Referral/Assistance Services With a
National Scope
Challenges for Information and Referral Services
Enhancing Information and Referral Services
▸ For Your Files: The Alliance of Information and
Referral Systems
Enhancing Information and Referral/Assistance
Databases
Supporting the Future of Information and
Referral/Assistance
▸ Best Practice: Using New Technologies to
Provide I&R/A
▸ Case Study: Finding and Asking for Help
Learning Activities
For More Information
Chapter 5 Volunteer and Intergenerational Programs
Policy Background
Users and Programs
Characteristics of Older Volunteers
Federal Senior and Volunteer Programs
▸ Best Practice: The Nevada Rural Counties
Retired and Senior Volunteer Program
Other Federally Sponsored Volunteer Initiatives
Public and Private Volunteer Programs
Intergenerational Programs
▸ Best Practice: Aetna Life and Casualty Senior
Volunteer Program
Educational Programs
Recreational Programs
▸ Across the Globe: Magic Me Intergenerational
Arts Programs
Support Programs
Shared Site Programs
 Challenges for Volunteer and Intergenerational
Programs
Tapping Untapped Potential
▸ For Your Files: Generations Serving Generations
Training Volunteers
Retaining Volunteers
Evaluating Volunteer Programs
Funding and Supporting the Future of Volunteer
Programs
▸ Case Study: Reconnecting With the Community
Learning Activities
For More Information
Chapter 6 Education Programs
Educational Level of Older Adults
Literacy in the Older Adult Population
Lifelong Education
Policy Background
▸ For Your Files: Seniors and Literacy
Users and Programs
Institutions of Higher Education
▸ For Your Files: Leadership Asheville Seniors
Community Colleges
▸ Best Practice: Joliet Junior College Plus 50
Workforce Center
Lifelong Learning Institutes
▸ Across the Globe: University of the Third Age
Road Scholar Program (Formerly Elderhostel)
Community-Based Organizations
▸ For Your Files: Women Work
At-Home Educational Experiences
▸ For Your Files: Computer Learning Through
SeniorNet
Challenges for Educational Programs
Increasing Participation of Older Adults
 Expanding the Content and Delivery of Education
Programs
Ensuring the Quality of Education Programs
Financing Education Programs
Addressing the Future of Senior Education
Programs
▸ Case Study: Can Further Education Help a
Downsized Worker?
Learning Activities
For More Information
Chapter 7 Senior Centers and Recreation
Policy Background
Users and Programs
Characteristics of Senior Center Participants
▸ For Your Files: The Los Angeles Gay and
Lesbian Center
Barriers to Senior Center Participation
▸ For Your Files: Manzano Mesa Multigenerational
Center
Models of Senior Centers
▸ Best Practice: Serving Rural Seniors
Programs Offered at Senior Centers
▸ Best Practice: Innovative Programming at Senior
Centers
▸ Across the Globe: Hikarigaoka Senior Center,
Nerima, Tokyo, Japan
Addressing Diversity
Challenges for Senior Centers
Who Will Senior Centers Serve in the Future?
How Will Senior Centers Respond to Diversity
Among Seniors?
The Senior Center of the Future
▸ Case Study: Loneliness of a Caregiver
Learning Activities
For More Information
Chapter 8 Employment Programs
Policy Background
Protecting Older Workers
Training for Older Workers
▸ For Your Files: Sloan Center on Aging and Work
at Boston College
Users and Programs
Characteristics of Older Workers
Employers of Older Workers
▸ For Your Files: Job Seeking Online
▸ Across the Globe: Silver Human Resource
Center, Japan
▸ Best Practice: Vantage Aging
Challenges for Older Workers and Employment
Programs
Increasing Incentives for Older Workers
Providing Opportunities for Older Workers
Increasing Self-Employment
Supporting Encore Careers
Educating Employers
Preparing for Retirement
▸ Case Study: Beginning the Journey to Financial
Independence at Midlife
Learning Activities
For More Information
Chapter 9 Income Programs
Policy Background
Social Security
Pension Benefits
▸ Across the Globe: Canada’s Guaranteed Income
Supplement
Supplemental Security Income
▸ For Your Files: Office of Financial Protection for
Older Americans
Users and Programs
 ▸ Best Practice: Tax Counseling for the Elderly
Program
Challenges for Income Programs
Bouncing Back From the Recession
Maintaining a Person’s Standard of Living
Enhancing the Income of Older Women
Increasing Participation in Income Programs
Ensuring the Long-Term Financing of Social
Security
Maintaining and Enhancing Income Programs in
the Future
▸ Case Study: When the System Fails
Learning Activities
For More Information
Chapter 10 Nutrition and Meal Programs
Nutritional Status Among Older Adults
Physical and Psychosocial Factors That Influence
Nutritional Status
Policy Background
Supplemental Nutrition Assistance Program (Food
Stamp Program)
Nutrition Screening
Users and Programs
Congregate Meal Sites
Home-Delivered Meals
▸ Best Practice: Two Coasts, Two Meals on
Wheels Programs
Senior Farmers’ Market Nutrition Program
Food Banks
Brown Bag Programs
Shopping Assistance Programs
Users of Congregate and Home-Delivered Meal
Programs
▸ For Your Files: Campus Kitchens Project
Challenges for Nutrition Programs
 Enhancing Awareness and Use of Nutrition
Programs
Serving a Diverse Older Population
Implementing Meal Programs for a New
Generation of Older Adults
Supporting the Future of Senior Nutrition
Programs
▸ Case Study: Good Nutrition—Making
Independence Possible
Learning Activities
For More Information
Chapter 11 Health Care and Wellness
Health Status of Older Adults
▸ For Your Files: AbleData
Federal Health Care Policy
Patient Protection and Affordable Care Act
Medicare
Medicaid
Medical Benefits for Retired Veterans
Health Promotion and Wellness
Policy Background
Health Promotion for Older Adults
▸ Across the Globe: Health Promotion Program—
Well for Life, State Government of Victoria,
Australia
▸ Best Practice: REACH Program, Colorado Black
Health Collaborative: The Barbershop and Salon
Program
▸ For Your Files: National Institute on Aging—
Exercise and Physical Activity Resources
▸ Best Practice: EnhanceFitness
Challenges for Health Care and Health Promotion
Programs
Serving Diverse Groups of Older Adults
Increasing Research and Program Evaluation
 Supporting Health Programs and Policies in the
Future
▸ Case Study: Health Concerns After Retirement
Learning Activities
For More Information
Chapter 12 Mental Health Services
Policy Background
Users and Programs
Characteristics of Mental Health Clients
▸ Best Practice: Lifespan’s Geriatric Addiction
Program
▸ Across the Globe: Multidisciplinary Mental
Health Teams
Mental Health Programs
▸ For Your Files: Mental Health Resources and
Toolkits
Geriatric Mental Health Workforce
▸ Best Practice: Gatekeeper Program
Challenges for Mental Health Programs
Connecting the Delivery Systems
Reaching Diverse Groups
Training Providers
Providing Mental Health Programs in the Future
▸ Case Study: Schizophrenia Complicates Care
Needs
Learning Activities
For More Information
Chapter 13 Legal Services
Policy Background
Older Americans Act Support of Legal Assistance
▸ For Your Files: National Resources to Support
Elder Law
Users: Legal Problems of Older Adults
Family Issues
Income
 Employment
Health Care
Criminal Legal Problems
▸ Best Practice: National Association of Triads,
Inc.
Elder Abuse
Legal Assistance Programs
Legal Hotlines
▸ For Your Files: Two National Resources for Elder
Abuse and Neglect Information
▸ For Your Files: The Samuel Sadin Institute for
Law and Public Policy
Bar Association Services
Dispute Resolution Programs
Money Management Programs
▸ Best Practice: Dispute Resolution Center
Challenges for Legal Programs and Services
Removing Barriers to Legal Services
▸ Across the Globe: Legal Aid for Older Adults in
the United Kingdom
Making Legal Programs More Accessible
Supporting Legal Programs in the Future
▸ Case Study: A Widow in Legal Trouble
Learning Activities
For More Information
Chapter 14 Transportation
Policy Background
Users and Programs
Transportation Patterns of Older Adults
Barriers to Public Transit Use
▸ Best Practice: Lane Transit District, Eugene,
Oregon
▸ Across the Globe: Programs to Encourage
Mobility Among Older Adults
Transportation Programs
 Federal Transit Administration
▸ Best Practice: Partners in Care and the Ride
Partners Program
Department of Health and Human Services
▸ Best Practice: Ride Sharing Evolves to Serving
Older Adults
Challenges for Transportation Programs
Meeting Transit Needs by Creating Livable
Communities
Improving Coordination of Resources
Programmatic Concerns: Barriers to Public
Transportation Use
Elderly Drivers
Addressing Mobility Challenges of Ethnically
Diverse Elders
▸ Case Study: A Need for Transportation Planning
and Coordination
Learning Activities
For More Information
Chapter 15 Housing
The Person–Environment Fit Model
Users and Programs: Independent Living Environments
Single-Family Dwellings
Housing Programs
▸ Best Practice: Los Angeles Housing Department
Handyworker Program
Home Sharing
Federal Housing Programs
▸ For Your Files: B’nai B’rith
Naturally Occurring and Planned Retirement
Communities
Senior Cohousing and Other Intentional
Communities
▸ Best Practice: Public–Private Partnerships
Single-Room Occupancy Hotels
 Challenges for Independent Living Programs
Removing Barriers to Shared Housing
Serving Older Adults Living in Public Housing
Promoting Communities for Older Adults
Enhancing SROs
▸ Best Practice: Communities for a Lifetime
Supportive Living Environments
Accessory Dwelling Units
Congregate Housing
Continuing Care Retirement Communities
Assisted Living
Personal Care Boarding Homes
▸ Across the Globe: Old-Age Homes
Foster Care
▸ Best Practice: Mary Sandoe House
Long-Term Care Facilities
Challenges for Supportive Living Environments
Removing Barriers
Enhancing Services
Protecting Residents
Enhancing Opportunities for Foster Care Residents
Developing Housing Options for Marginalized Older
Adults
Expanding Housing Options for Older Adults
▸ Case Study: Finding a New Home
Learning Activities
For More Information
Chapter 16 Caregiver Support Services
Policy Background
▸ Across the Globe: Elder Care in Sweden
Users and Programs
Characteristics of Family Caregivers
Support Programs for Family Caregivers
▸ For Your Files: Families Caring for an Aging
America
 ▸ Best Practice: New York University Caregiver
Intervention
Respite Programs
▸ For Your Files: Alzheimer’s Association
Adult Day Service Centers
▸ Best Practice: Parker Jewish Institute for Health
Care and Rehabilitation
Institutional Respite Care
▸ Best Practice: Social Day Care and Respite
Program
Challenges for Caregiver Support Programs and
Services
Increasing Participation in Programs
Reaching Diverse Groups
Providing Support for Family Caregivers in the
Future
▸ Case Study: A Difficult Decision
Learning Activities
For More Information
Chapter 17 Care Management
Policy Background
Users and Programs
Characteristics of Care Management Clients
▸ Best Practice: Kaiser Permanente’s Care
Management Institute
Care Management Programs
▸ For Your Files: Aging Life Care Association
▸ For Your Files: Connecticut Community Care
▸ For Your Files: Professional Care Management
Institute
Evaluation of Care Management Programs
▸ Across the Globe: Agency for Integrated Care
Challenges for Care Management Programs
Providing Care Management Services
 Ensuring the Effectiveness of Care Management
Programs
Providing Quality Care Management Services
Diversifying Care Loads
Addressing Ethical Issues Facing Care Managers
Promoting Care Management in the Future
▸ Case Study: When Information and Referral Are
Not Enough
Learning Activities
For More Information
Chapter 18 Home Care Services
Home Care
Policy Background
Users and Programs
▸ For Your Files: National Association for Home
Care and Hospice
Challenges for Home Health Care
Working With New Clients
▸ For Your Files: Caring for Lesbian and Gay Older
Adults
Serving Older Adults in Rural Communities
Financing and Paying for Services
Recruiting and Retaining Staff
Ensuring Quality Care
Supporting Home Health Care in the Future
▸ Best Practice: Visiting Nurse Association of the
Treasure Coast
Hospice
Policy Background
Users and Programs
▸ Across the Globe: Hospice Malta
▸ For Your Files: Suncoast Hospice
Challenges for Hospice
Serving a Greater Diversity of Patients
Supporting Patients Without Families
 Assessing Hospice Care
Enhancing Bereavement Programs
Educating Americans on End-of-Life Issues
▸ Case Study: Will Home Health Care Work for
Harriet?
Learning Activities
For More Information
Chapter 19 Long-Term Care Services
Policy Background
Payment for Nursing Home Care
Users and Programs
Resident Characteristics
▸ For Your Files: Long-Term Care Insurance
Long-Term Care Facilities
Levels of Care
▸ For Your Files: Special Care Unit, Lynden,
Washington
Specialized Alzheimer’s Unit
▸ Across the Globe: Special Care for Persons With
Dementia in the Netherlands
Staffing Patterns
▸ Best Practice: Intergenerational Programs at St.
John Lutheran Nursing Home
Activity Programs
Residents’ Rights and the Ombudsman Program
▸ For Your Files: The National Consumer Voice for
Quality Long-Term Care
Improving Quality of Life in Nursing Homes
▸ For Your Files: Two Alternative Models for
Nursing Home Care
Challenges for Nursing Homes in the Future
Reforming Reimbursement and Payment for Long-
Term Care Facility Services
Attracting Qualified Staff and Improving Working
Conditions
 Increasing Family and Community Involvement
Meeting the Care Needs of a Diverse Group of
Residents
▸ Case Study: Defending Individual Rights—a
Nursing Home’s Dilemma
Learning Activities
For More Information
PART III PREPARING FOR THE FUTURE
Chapter 20 Programs and Services in an Era of Change
Social and Political Influences on Aging Policies and
Programs
Challenges for the Older Americans Act
The Role of the Older Americans Act
Reaching Out to the Private Sector
Who Should Be Eligible for Services?
Cost-Sharing
Serving a New Generation of Older Adults: Planning for
21st-Century Aging
References
Index
About the Authors
The Authors’ Purpose

Students preparing for careers in gerontology and related areas need

more than a description of existing community resources available for
older adults. They need to understand how programs come to exist
through federal legislation, who uses these resources, how they are
delivered, and the challenges service providers face in meeting the
needs of the aging baby boom cohort.

We have developed a text that gives students a basic understanding

of aging policy that created the “aging network” and of theories that
can be used to explain help-seeking behavior. Each chapter provides
the reader with a summary of the legislation behind the development
of pivotal programs and services, an in-depth review of the programs
and services provided by the aging network and the private sector,
current scholarship in each topic area, and international, national,
and Internet resources. Students will learn to identify the challenges
inherent in providing services to older adults through case studies,
learning activities, and best-practice models. Instructors can use
these learning activities to stimulate critical thinking about program
and service delivery and to explore what changes might be needed to
support future generations of individuals and families in their later
years. We hope that Community Resources for Older Adults is a text
that both students and faculty enjoy.

Robbyn R. Wacker

St. Cloud State University

Karen A. Roberto

Virginia Polytechnic Institute and State University

Acknowledgments

As is typical of a project of this magnitude, many people have

helped us along the way. Some did so willingly, others by default
because they were in the right (or maybe wrong) place at a time
that we needed help. We would like to take this opportunity to
acknowledge those persons who made undertaking the revisions for
this edition a pleasant and manageable experience. First, we thank
students and staff members at the University of Northern Colorado
(UNC) and at the Center for Gerontology at Virginia Polytechnic
Institute and State University (Virginia Tech) for all their help in
collecting articles, tracking down the latest statistics and references,
and offering feedback. They include gerontology faculty at UNC, Drs.
Susan Collins and Joyce Weil, and gerontology students at UNC, and
Emily Hoyt, Shelby Borowski, Anna Harris, Kevin Lancki, and Drew
Vipperman from Virginia Tech. Our administrative staff, Carlene
Arthur, Valerie Kalos, and Yancey Crawford, supported us in many
ways. We appreciate the assistance of Sharon Larson, Region VIII
Administration on Aging, for providing so much information on the
Older Americans Act and its history. Thanks to Linda Piper, former
director of the Weld County Area Agency on Aging, who was our co-
author for the first two editions of the text.

We are also indebted to the reviewers who offered their insights for
the fifth edition: Patricia Anafi, SUNY Potsdam; Anita Glee Bertram,
University of Central Oklahoma; Dean Blevins, University of Louisiana
at Monroe; Patricia K. Cianciolo, Northern Michigan University; Renee
Michelsen, University of Southern California; Susan A. Myllykangas,
Northwest Missouri State University; and Laura J. Perry, University of
Florida.

A big thank-you goes to Joshua Perigo, Sarah Dillard, Alexandra

Randall, Jane Haenel, and Sarah Duffy at SAGE, who aptly guided us
through this revision.
Robbyn R. Wacker

Karen A. Roberto
Part I The Social Context of
Community Resource Delivery
Chapter 1 On the Threshold of a
New Era

What will society in the United States be like in the year 2030? It is
hard to know exactly how different our daily lives will be, but we do
know that by 2030, our society will be experiencing something that
none other has experienced. As we move through the 21st century,
more Americans than ever before will be in their seventh, eighth, and
ninth decades of life. Between 2011 and 2030, about 10,000 baby
boomers will turn 65 each day (Cohn & Taylor, 2010). By 2030, the
first members of the baby boom generation, born in 1946, will be 84
years of age, and the youngest members, born in 1964, will be 65.
By 2030, there will be about 74 million people age 65 and older—
more than twice the number in 2000 (Federal Interagency Forum on
Aging-Related Statistics, 2016). Demographically, the baby boom
cohort is sandwiched between two smaller cohorts. As a result of its
enormous size and vast racial and ethnic diversity, it has commanded
attention at every stage of its life course. In the 1960s, school
systems were forced to react to the soaring enrollments of the baby
boom cohort; soon, social institutions that serve the older population
will be challenged to respond to the baby boomers as well.

Will this graying of our population dramatically change our society?

As demographers, economists, gerontologists, sociologists, and
others debate this question, we can be relatively safe in predicting
that, because of their unique characteristics, the aging baby boomers
will cause a reexamination of current aging policies and services.
Unlike the generations before them, collectively, they will be better
educated, better off financially, living in the suburbs, and
beneficiaries of the programs and services that were put in place for
their grandparents. On the other hand, this giant cohort is
tremendously diverse. About 84% of boomers have completed high
school and 27% have a bachelor’s degree or more (U.S. Census
Bureau, 2015b). Although boomers’ earnings are comparable to their
parents’ at a similar stage in life, the distribution of wealth in the
United States has become more unequal in the past two decades; it
is projected that 2% of boomers will live in poverty and 5% will live
in near-poverty (up to 125% of the poverty line) in 2030 (K. Smith,
2003). Race and ethnicity are related to poverty in late life. In 2015,
6.6% of White elders lived below the poverty level, compared with
18.4% of Black elders, 11.8% of Asian elders, and 17.5% of Hispanic
elders (Administration on Aging [AoA], 2017).

A Supplemental Poverty Measure (SPM) released by the U.S. Census

Bureau in 2011 provides additional information about the economic
profile of older Americans. In contrast to the official poverty rate, the
SPM takes into account regional variations in cost of living, the impact
of noncash benefits received (e.g., food stamps, low-income tax
credits), and nondiscretionary expenditures including out-of-pocket
medical costs. Using this measure, the number of older people living
in poverty is significantly higher than the official poverty line indicates
—14% versus 10% of all individuals 65 and older (Federal
Interagency Forum on Aging-Related Statistics, 2016). While not
replacing the official poverty measure, the SPM sheds light on the
effect of social safety net programs and the marked impact of out-of-
pocket medical expenses for older adults, raising awareness about
how many older individuals are hovering dangerously close to poverty
at any point in time (Tavernise & Gebeloff, 2011). In the coming
decades, high rates of near-poverty and poverty will no doubt have
implications for the financial well-being and quality of life of persons
of all races and ethnicities in later life.

Another unique characteristic of the boomer cohort is their marriage

and family patterns as compared with those of their parents and
grandparents. Boomers tended to marry later, have smaller families,
and have higher rates of divorce than their parents. In 2009, one in
three boomers (aged 45 to 63 years) was unmarried (31% men;
37% women; Lin & Brown, 2012). This was a 50% increase in the
number of unmarried individuals as compared with the same age
cohort in 1980. Approximately 58% of these unmarried boomers
were divorced, 32% were never married, and 10% were widowed
(Lin & Brown, 2012). There is a greater tendency to never marry
among younger boomers (born 1959–1964): 16.7% of men and
11.4% of women have never married, compared with 7.5% of men
and 7.1% of women who make up the older boomer population (born
1946–1951; MetLife Mature Market Institute, 2010a, 2010b). These
unmarried boomers are changing the economic and social landscape
of late life—they have a poverty rate almost five times higher than
among married boomers; more than three times the number of
unmarried boomers rely on public assistance (e.g., food stamps, SSI)
than do married boomers; and unmarried boomers report twice the
disability rate of married boomers, but are less likely to have health
insurance coverage (Lin & Brown, 2012).

Boomers also are redefining the traditional definition of “family” and

thereby increasing the complexity of kin networks. Boomer families
take many forms, including single-parent families, stepfamilies,
cohabiting heterosexual and same-gender couples, childless families,
intergenerational families, and transnational families (Roberto &
Blieszner, 2015). Because families play a key role in providing
instrumental and emotional support, as well as long-term care, to
their older members, it is uncertain how these changes will influence
family support patterns. Compared with their parents’ generation,
boomers are less likely to have a spouse to rely on and will have
fewer adult children to serve as caregivers (L. H. Ryan, Smith,
Antonucci, & Jackson, 2012). Thus, will adult children feel an
obligation to care for both biological and stepparents? Will families
who choose not to have children be at risk of having fewer informal
resources? Will friends and families of choice be acknowledged and
accepted as important sources of support and caregivers for lesbian,
gay, bisexual, and transgender elders? Although the exact influence
of family composition changes on the use of formal services is not
known, we can anticipate that community programs and services will
play a significant role in the lives of all older adults.
Collectively, these demographic characteristics will shape the type,
amount, and nature of community resources in the future. They will
increase the demand for home health care and retirement housing
options. Many baby boomers will move into third, fourth, and even
fifth careers and seek educational opportunities and greater flexibility
in work and retirement options. The social safety net may need to be
expanded for the underclass and lower class. The sheer numbers of
aged boomers will challenge policy makers to rethink health care,
retirement programs, and pension plans. Even now, projections—both
dire and not so dire—are being made about Social Security and
Medicare. Thus, demographic characteristics of the next generation of
older adults will have direct implications on social policies that, in
turn, support programs and services for older adults. In the next
section, we discuss a few more of the salient demographic
characteristics of the boomer cohort and the current populations of
older adults.

Growth of the Older Population

In 1950, 12.3 million persons (8.2% of the population) living in the
United States were age 65 and older. By 2016, the number of persons
age 65 and older had grown to 49.2 million (15.2% of the
population; U.S. Census Bureau, 2017). The older population will
continue to grow rapidly over the next few decades as approximately
10,000 baby boomers turn 65 every day, a trend that started in 2011
and will not end until 2030. The number of older adults is expected
to reach 74.1 million (20.6% of the population) by 2030 and 98.1
million (23.6% of the population) by 2060 (Exhibit 1.1) (U.S. Census
Bureau, 2014). Members of the older population are also aging. In
2010, 21.7 million persons were between the ages of 65 and 74, 13.1
million persons constituted the 75-to-84 age-group, and 5.4 million
people were 85 years of age and older, including more than 53,400
people 100 years of age and over (L. A. West, Cole, Goodkind, & He,
2014). Moreover, persons 85 years of age and older represent the
fastest-growing segment of the older adult population. The number
of persons age 85 and older is expected to grow to 9.1 million in
2030 and reach 19 million by 2050 (U.S. Census Bureau, 2014).

While growth in the aging population will be seen across the United
States, some states and regions will be more dramatically affected
than others. In 2015, more than half of persons age 65 and older
lived in 10 states: California, Florida, Illinois, Michigan, North
Carolina, New Jersey, New York, Ohio, Pennsylvania, and Texas (AoA,
2017). Almost 80% of persons 65 and older lived in metropolitan
areas, with 27% of these older adults living in principal cities (AoA,
2016). However, older adults also account for a larger proportion of
the U.S. population living in nonmetropolitan rural areas than any
other age-group (Rural Health Information Hub, 2017), with 18.6%
of older adults living in rural areas. This relatively large proportion of
older adults residing in rural communities has stimulated concern
among some policy makers and human services providers about their
access to affordable housing, transportation, general and specialized
health providers, and social services (Goins & Krout, 2006).

States and regions of the country are seeing dramatic growth in their
population proportion of older adults due to migration patterns. Over
the past few decades, some Southern and Western regions have seen
an increase in the older population because they have become
popular retirement destinations, while some states in the Midwest
and Northeast have seen a higher concentration of older adults
largely due to out-migration of younger workers while older residents
remained (L. A. West et al., 2014). Between 2005 and 2015, five
states saw their 65 and older population increase by 50% or more:
Alaska (63%), Nevada (55%), Colorado (54%), Georgia (50%), and
South Carolina (50%; AoA, 2017). The geographic distribution of the
older White population is similar to the geographic distribution of the
total older population (L. A. West et al., 2014). However, among
other racial and ethnic groups, the regional distribution is more
skewed. For example, about 55% of Black older adults reside in the
South compared with 9% who live in the West. Nearly 80% of
American Indian and Alaska Native older persons live in the West, as
do about 57% of Asian older adults. Hispanic older adults are more
likely to live in the South (39.6%) and West (38.7%) than in other
regions of the United States.

Exhibit 1.1 Actual and Projected Growth of the Population Aged 65+
(in thousands): 2015 to 2060

Source: Data from U.S. Census Bureau (2014).

What are the social implications of such an increase in the older adult
population? Many writers in the popular press suggest that the
increase in the number of older adults signals an impending social
and fiscal crisis (Debate.org, 2017) and that aged persons will
become a financial burden to society (e.g., Samuelson, 2005;
Thompson, 2012). Others argue that a “crisis mentality” overlooks
other important demographic factors (e.g., Nikolova, 2016; Singer,
2011). Although it is true that the United States, along with other
developed nations, will experience an increase in the older adult
population, the number of older adults has steadily increased during
the past 130 years. This steady increase has allowed society to adapt
to the changes of an aging population and provided new
opportunities for scientific and business innovation and growth. Many
scholars believe society will be able to adapt to this new cohort of
older adults as well (J. H. Schulz & Binstock, 2006).

The assumption that older adults will place a burden on society is

often based on the economic dependency ratio, which is the ratio of
persons in the total population (including those in the armed forces
overseas and children) who are not in the labor force per 100 of
those who are in the labor force. In 2014, persons not in the labor
force included 42 persons under the age of 16, 38 persons ages 16 to
64, and 24 persons 65 years of age or older per 100 workers (Toossi,
2015). The part of the economic dependency ratio that has been
steadily increasing is the portion attributable to older persons, and
with the aging of the baby boomers, the dependency ratio of the 65+
group is expected to increase to 30 by 2024.

The increase in the number of older adults, however, does not

automatically result in a greater social burden. The aging population
presents serious challenges, as well as major opportunities, for all
sectors of society. Meeting these challenges and seizing opportunities
will require a new vision of American life that reaches beyond the
immediate challenge of the aging of the boomers and promotes
active engagement and a high quality of life throughout the lifecourse
(MacArthur Foundation Research Network on an Aging Society, 2008).

Growth of the Older Population of Racial and

Ethnic Minorities
With the aging of the baby boomers, the older population is growing
more diverse. Approximately 14% of baby boomers are from racial
and ethnic minority groups: 8.7% are Black, 4.0% are Asian alone,
and 1.3% represent all other races alone or in combination (Federal
Interagency Forum on Aging-Related Statistics, 2016). Fewer than
10% of boomers are of Hispanic origin. Although non-Hispanic White
older adults will still represent about 58% of persons over age 65 in
2050 (G. K. Vincent & Velkoff, 2010), the percentages of Hispanics
and of non-Hispanic Blacks and Asian Americans will increase
dramatically. Exhibit 1.2 shows the percentage of older adults by race
for the years 2015, 2030, 2040, 2050, and 2060 (U.S. Census
Bureau, 2008, 2012). This growing minority of the older population
brings new challenges and opportunities for providers of community
programs and services (Goins, Mitchell, & Wu, 2006; Padilla-Frausto,
Wallace, & Benjamin, 2014; Villa, Wallace, Bagdasaryan, & Aranda,
2012).

Growth in the Number of Older Adults Living

Alone
Another demographic characteristic with social service implications is
the increase in the number of older adults who will be living alone. In
2016, 29% of all noninstitutionalized persons age 65 years and older
lived alone, representing 37% of older women (9.2 million) and 20%
of older men (4.1 million; AoA, 2017). Living arrangements also
varied by racial and ethnic group. A greater percentage of non-
Hispanic White women (37%) and Black women (43%) age 65 and
older lived alone, compared with 20% of Asian and 23% of Hispanic
older women. In contrast, 30% of Black older men live alone,
compared with 20% of non-Hispanic White, 10% of Asian, and 15%
of Hispanic older men (Federal Interagency Forum on Aging-Related
Statistics, 2016). Moreover, the percentage of older men and women
living alone increased with age. Among women aged 75 and over, for
example, 46.3% live alone compared with 27.7% of women ages 65
to 74 (Federal Interagency Forum on Aging-Related Statistics, 2016).
Among men age 75 and over, 23.0% live alone, compared with
18.5% of men ages 65 to 74. Differences in living arrangements of
adults age 65 and older by sex, race, and Hispanic origin can be seen
in Exhibit 1.3. Most notable is the generally high percentage of men
who live with their spouses, compared with women and the large
percentage of women living alone, across all groups. Living with
other relatives and nonrelatives occurs more than twice as often with
Black and Hispanic women than with White women.

Exhibit 1.2 Actual and Projected Distribution of Population Aged

65+ by Race: 2015, 2030, 2040, 2050, and 2060 (percentage)

Source: Data from U.S. Census Bureau (2014).

Older adults who live alone are more likely to live in poverty. In 2015,
15.4% of persons age 65 and older living alone were living in poverty
compared with 5.7% of older persons living with families (AoA,
2017). Sex and ethnicity further differentiate the percentage of older
adults living in poverty. For example, 40.7% of older Hispanic women
living alone were in poverty, compared with 8.2% of older Hispanic
women living with their spouses (U.S. Census Bureau, 2016b).
Exhibit 1.3 Living Arrangements of Older Adults by Sex, Race, and
Hispanic Origin, 2015

Source: Federal Interagency Forum on Aging-Related Statistics

(2016).

Growth in the Number of LGBT Older Adults

Of persons in the United States who are 50 or older, 2.4 million
people identify as lesbian, gay, bisexual or transgender (LGBT),* and
that number is expected to double by 2030 (S. K. Choi & Meyer,
2016). LGBT older adults are diverse with regard to many
characteristics, including gender, race and ethnicity, marital status,
socioeconomic status, living arrangements, and disability status.
Unfortunately, most studies of LGBT older individuals are typically not
large enough to assess the influence of diversity on their lives at
these different intersections (S. K. Choi & Meyers, 2016; Otis &
Harley, 2016).
* We use both lesbian, gay, bisexual or transgender (LGBT) and
lesbian, gay, bisexual, transgender or queer (LGBTQ) throughout the
text, and usage depends on how the source we cite referenced the
LGBT/Q community.

In addition to the challenges that all older adults face, such as

physical limitations and changes in income or relationships, LGBT
older adults confront discrimination from informal and formal entities
that most older adults traditionally rely on for support and assistance.
Researchers and advocacy groups have identified four major
obstacles to social support and community engagement for LGBT
elders (Movement Advance Project & Services and Advocacy for Gay,
Lesbian, Bisexual, and Transgender Elders, 2010, p. 48): (1) LGBT
elders lack support from, and feel unwelcome in, mainstream aging
programs; (2) LGBT elders lack support from, and feel unwelcome in,
the broader LGBT community; (3) LGBT elders lack sufficient
opportunities to contribute and volunteer; and (4) housing
discrimination adds to the challenges LGBT elders face in connecting
to their communities. Helping LGBT older adults secure social support
and community engagement requires action from mainstream aging
services providers, LGBT advocates, researchers, and policy makers.

Implications of Demographic Characteristics

for Community Resources
These selected demographic projections and unique characteristics
have a number of implications for the delivery of community
resources to older adults. The growth in the older adult population
will increase the demand for all types of services. Professionals
working to deliver the programs and services designed to improve the
quality of life of older adults will thus be challenged to do even more
with less. Because of the diverse nature of the boomer population
with regard to ethnicity, income, family history, and life experience,
professionals will be expected to be knowledgeable about a wide
range of programs and services that serve both mainstream and
disenfranchised individuals. Community programmers also must
recognize and accommodate cultural diversity and remove the social
and cultural barriers to service accessibility. A concerted effort needs
to be made to design culturally appropriate programs and
interventions that are responsive to the needs of minority
communities (American Psychological Association Committee on
Aging, 2009; Center on an Aging Society, 2004; National Center on
LBGT Aging, 2017). Professionals must be visionaries in planning and
developing programs and services to meet the needs of this new
cohort with its diverse characteristics.

Now that we have had a chance to consider the challenges that lie
ahead for programs and services that assist older adults, let’s return
to the present and consider more immediate issues. In every
community, resources are designed to assist older adults in a variety
of ways. Therefore, individuals working with older adults need to
have a good understanding of these resources as well as the patterns
of service use by older adults and their families. Anyone who has
ever worked with older adults knows that the problems they confront
tend to be complex and multifaceted.

Consider the case of Mrs. Duran, who confides that she is about to be
evicted from her apartment. Further questioning reveals that she has
not received her Social Security check for 2 months. She has limited
resources for food, has received a utility shutoff notice, and has been
unable to renew her insulin prescription for her diabetes. Or consider
Mr. Jackson, who does not know what to do with himself since he
retired. He has played golf or fished almost every day but is getting
bored and disillusioned with retirement life. What community
resources can be accessed to help Mrs. Duran and Mr. Jackson?
Advocates who have an understanding of various programs and
services assisting older adults can recommend appropriate options for
both Mrs. Duran and Mr. Jackson.

A Text About Programs and Services in an Era

of Change
Because of the multiple challenges that older adults can experience
and the changing demographics of the older adult population, we
have created a text that provides a broad-based discussion of
community resources. We believe that to effectively meet the needs
of older adults who can benefit from using programs and services,
professionals must understand the social and psychological dynamics
of help-seeking behavior. It is not enough to know what services are
available and appropriate; practitioners must also be armed with
theoretical knowledge to understand why a daughter, despite her
exhaustion, refuses to bring her father to the local adult day program
and why an older adult, who barely survives on a small pension,
refuses to apply for additional income support that would make life a
bit more bearable. In addition, we believe that practitioners must
understand service use patterns and how families interact with the
formal network when they need assistance in caring for their older
family members. Greater understanding of these patterns can better
prepare students and practitioners for understanding the dynamics of
when and how families choose to use the formal network.

We also believe that simple descriptions of existing programs and

services that assist older adults provide an incomplete picture.
Practitioners and students should benefit from the interplay that
exists between research and practice because research results have
practical applications for the delivery of programs and services. In
each chapter, we draw from empirical research to describe who uses
and who provides such programs and services. We also include
information about program outcomes when available.

Next, professionals need to be alerted to the infinite number of

programs and services in communities that exist outside those
funded through the Older Americans Act (OAA) of 1965 and
subsequent amendments. Thus, we attempt to introduce readers to
many programs and services that are both publicly and privately
funded. Moreover, we discuss the different ways in which aging
programs and services have successfully networked with one another
to develop public and private partnerships in an attempt to reach
more older adults.

In preparing the fifth edition of this book, we maintained the

organizational structure of previous editions while updating and
expanding the content to address the changes in community
programs and services available to older adults throughout the United
States. In addition to including the most up-to-date statistical data
available, we have described important updates and additions to
federal policies that provide the underlying framework for aging
services. Each chapter includes reference to the latest research and
highlights some programs and services throughout the United States
and across the globe that serve as examples of innovative ways in
which communities are meeting the needs of older adults and their
families. We acknowledge the increasing diversity among members of
the aging population by addressing the need for cultural competency
in service delivery and by including new research findings (when
available) and illustrative examples of resources, programs, and
services for older adults from different racial, ethnic, and cultural
groups, as well as older persons living in rural areas, and for older
adults who are gay, lesbian, bisexual, or transgender. The increasing
availability of information online has allowed us to add many new
web-based resources for readers to access further information about
a particular issue, policy, program, or service.

Organization of the Book

This book consists of three parts. In addition to this chapter, Part I
has two other chapters. Chapter 2 presents a brief review of major
aging policies, including Social Security, Medicare, and the OAA, the
basis for the existence of many older adult programs and services.
Chapter 3 explains the patterns of service use by older adults and the
theories that can predict help-seeking behavior.

Part II is based on the concept of the continuum of care.

Conceptually, the continuum of care is a system of social, personal,
financial, and medical services that supports the well-being of any
older adult, regardless of the person’s level of functioning. The goal,
of course, is to have the appropriate services available to match the
presenting needs. The continuum is often conceptualized in a linear
way—older adults move from one end of the continuum
(independence) to the other (dependence), and services exist at
every point along the continuum to meet their social, medical, and
personal needs. In addition, services impinge differently on the
personal autonomy of their participants. For example, those who
attend senior centers come and go as they please and make choices
about their level of participation. In contrast, a nursing home is the
most restrictive environment and impinges a great deal on personal
autonomy and choice.

We have opted to depict the continuum of services as a more

dynamic and interactive system (see Exhibit 1.4). Rather than moving
in a linear fashion from independence to dependence, older adults
move in and out of areas of service need as they experience
changing levels of independence and dependence, health and illness,
and financial stability and instability. For example, older adults just
discharged from the hospital may need in-home services as well as
home-delivered meals. Yet, as they become less dependent, they
may access services offered at the senior center. Those who are
striving to maintain their independence can access services along the
continuum.

Therefore, Part II presents the variety of community resources

available for older adults and is divided into three sections, based on
our depiction of the continuum of services. The first section presents
information about community services. These are services that
benefit older adults with low levels of dependency and impinge little
on their personal autonomy. These services offer participants
opportunities to enhance personal and social well-being. Specifically,
we address information and referral services (Chapter 4), volunteer
and intergenerational programs (Chapter 5), education programs
(Chapter 6), senior centers (Chapter 7), employment programs
(Chapter 8), and income assistance programs (Chapter 9).

Support services are discussed in the second section of Part II. These
services help older adults who need assistance in maintaining their
level of functioning. Support services include nutrition programs
(Chapter 10), health and wellness programs (Chapter 11), mental
health services (Chapter 12), legal services (Chapter 13),
transportation services (Chapter 14), and housing options (Chapter
15). In addition, new to this edition is the inclusion of specific
programs and services designed to support family caregivers
(Chapter 16).

The final chapters in Part II provide information about community-

based and institutional long-term care services. These are services to
assist individuals who have greater dependency needs. Chapters in
this section are on care management (Chapter 17), home care
(Chapter 18), and nursing homes (Chapter 19).

We have organized each chapter in Part II to include policy

background, a description of users and programs and services, and
future concerns. Each chapter includes case studies to help readers
think critically about the service delivery issues. These cases were
developed on the basis of actual experiences we have encountered
(names and situations were altered to protect individuals’ identity). In
addition, best-practice models that highlight creative and unique
programs and sources for additional information are presented. The
best-practice models are representative of the programs and services
that exist in various communities. Learning activities designed to
expand understanding of the issues are also included. Additional
resources, including the names and addresses of professional
organizations and Internet resources, are located at the end of each
chapter.

Exhibit 1.4 Continuum of Services

Another random document with
no related content on Scribd:
child who has scarcely coughed at all during his waking hours.
Witness the voiding of urine in the bed by nervous children during
the early hours of sleep. Witness the phenomena of night-terrors,
which always occur at the time of night when sleep should be most
tranquil.

It appears, therefore, that the harmonious activity of all parts of the

nervous system is indispensable to the highest exercise of the
conscious mind. Healthy intellectual life is the perfectly-balanced
outcome of the complex polygon of forces which has its seat within
the brain. But the suppression of certain lines of this polygon does
not suppress life, nor does it necessarily destroy consciousness. It
only occasions a redistribution of force and a proportionate
narrowing of the stream of related ideas. Since the suppression just
mentioned is not an absolute quantity, but a variable factor, the
polygon of forces in the brain and the corresponding succession of
ideas in consciousness must necessarily be in a state of continual
change. Accordingly, our dreams are as variable as the clouds that
drift upon the currents of the air. As on a hot day in summer, when
the steady equatorial draught has ceased to guide the wind, we may
observe all manner of local tides in the masses of vapor which arise
from the earth, so in sleep, when the guiding influence of the senses
is withdrawn from the brain, the ideas that still arise are chiefly
dependent upon its automatic and reflex action for their origin and
association. Undisturbed by impulses from the external world, the
brain seems then more sensitive to impressions that originate within
the body. An overloaded stomach, an enfeebled heart, a turgid
sexual apparatus, or an irritable nervous ganglion may become the
source of irregular and uncompensated movements which may
invade the cerebral cortex, and may there set in motion a whole
battery of mechanisms whose influence upon consciousness would
be quite unnoticed were the external senses in full operation.

Night-Terrors.
The preceding argument will render it easy to comprehend the
phenomena of night-terrors. These are commonly observed in young
children of a highly nervous temperament before the conclusion of
their second dentition. The subjects of the disorder are generally of
neurotic descent. Insanity, hysteria, neurasthenia, epilepsy, chorea,
and nervous dyspepsia are often discovered among their near
relatives. Not infrequently they have been or will become themselves
choreic.

The attack is often preceded by symptoms of indigestion, but it may

result simply from the commotion of a brain wearied by the
excitement and effort of the previous day. The little patient starts up
out of an apparently sound sleep crying with alarm, calling for his
mother, and staring wildly with every possible expression of terror.
Sometimes he springs from his couch and runs headlong into a
corner or seeks to hide under the bed, as if escaping from some
frightful object. The eyes are open, tears flow, perspiration covers
the skin, there is the greatest excitement, and the little one,
convulsively clinging to its parent, will not be quieted. Only after
fifteen or twenty minutes, as tranquillity gradually returns, does the
child seem to recover the power of recognizing his friends. Presently,
however, he lies down and falls quickly asleep, waking in the
morning without the slightest recollection of the unpleasant event.

Such paroxysms occur during the early part of the night, one or two
hours after the child has been put to bed, just at the time when,
according to the previously-quoted experiments of Kohlschütter,
sleep is passing from its maximum intensity to a lesser degree of
depth. This, then, is the time when the controlling power of the
sensory apparatus over other portions of the nervous system has
already reached its minimum. The spinal centres and those
intracranial ganglia which do not share in the full measure of this
repose are therefore in a condition of relative exaltation.
Disturbances of internal organs consequently produce inordinate
excitement of these waking portions of the nervous apparatus. The
morbid quality of this excitement is attested both by the history of the
patient and by the fact that it does not arouse the whole brain. The
distribution of motion in the cerebrum is impeded, so that certain
portions of the organ remain asleep while other regions are thrown
into a state of tumultuous uproar. Disconnection of these different
organs of the nervous system, by withdrawing particular portions
from the inhibitory influence of the remaining parts, gives opportunity
for violent explosions of nervous force analogous to the convulsions
of a headless fowl or to the course of an epileptic paroxysm. Now, in
sleep, in somnambulism, in hypnotism, in delirium, in certain stages
of intoxication with alcohol or with narcotics, such ungearing of the
different nervous ganglia is more or less completely effected. In
narcotic and anæsthetic sleep besides the disassociation of ganglia
there is paresis of the nervous molecules; hence the phenomena
soon merge into insensibility and coma. But in natural sleep, in
somnambulism, or in hypnotism there is no toxic paresis; hence the
dissociated portions of the brain and nervous system, if aroused, are
in a physiological condition to dispense great stores of force. Hence
the vividness of certain dreams and the astonishing vigor of
particular nervous functions in somnambulism and hypnotism.

Somnambulism.

The phenomena of night-terrors constitute merely a special form of

somnambulism, a condition of which the mechanism, so far as the
present state of cerebral physiology will permit, has been already
suggested. The affection should not be ranked by itself as a
particular variety of disease, but should rather be considered a
violent perturbation in the cerebral organs of a neurotic subject
during the period of sleep. In ordinary dreaming the muscular
apparatus usually remains passive, even though the dream be a
nightmare or an incubus of the most terrifying character. But when
the desires and the emotions are powerfully addressed by the
dream, a certain amount of muscular movement may ensue, as
when a dog barks in his sleep, or when a child laughs upon his
nurse's lap, or when a weary soldier marches on though
overpowered by sleep. One night, when parched with thirst during a
voyage at sea,9 I saw in sleep a sparkling fountain, by the side of
which appeared a young girl holding out a cup of cold water.
Awakened by the excitement, I found myself sitting up in bed with my
right arm extended in the direction of the tantalizing vision: my dream
had merged itself in action. In like manner, the victim of night-terrors
not only moves his body, but gives vocal expression of his feeling of
apprehension and alarm. In like manner, projecting his dream into
action, a sleep-walker may arise from his bed; he climbs out of the
window and descends to the ground, executing all manner of
complicated and dangerous movements; he walks long distances,
and finally returns to his couch without waking. In the morning no
recollection of the event of the night survives. Again, the movement
may be less locomotive in its character. The intellectual faculties
chiefly may be aroused, and then only such movements are
executed as may be necessary to give expression to the mental
process.
9 A proclivity to dreaming has often been remarked among the consequences of
partial starvation.

Such, then, are the principal characteristics of somnambulism, a

state in which dreams are supplemented by more or less complete
and appropriate action, ordinarily without subsequent recollection of
either dream or action.

The somnambulistic dream generally occurs during or soon after the

period of deepest sleep, when the influences of the external world
are largely suppressed. Released from the control of its sensory
portion, the remainder of the brain awakes and becomes aroused to
a condition of functional exaltation. No longer distracted by the
recollection of the special senses, the attention is concentrated upon
the hallucinations which constitute the dream. In the simpler forms of
noctambulism only the automatic locomotive apparatus is awakened,
and the sleeper moves in accordance with the impressions derived
from habit aided by exaltation of the muscular sense. But in some of
the more complicated cases a certain amount of special sensibility
seems to exist. The patient is capable of exercising just that amount
of sensation which is necessary to accomplish his purpose, though
blind and deaf and insensible to every other impression. The more
complete the waking of the organs of sense, the closer the
resemblance to the condition of ecstasy in which cerebral exaltation
is the prominent feature. Accordingly, it sometimes happens that the
somnambulist can recall the events of his paroxysm.10 In such cases
the power of recollection is due to the same conditions that control
the recollection of our ordinary dreams. We remember very
imperfectly, if at all, the dreams that occur during sound sleep, but
the visions with which sleep sometimes commences (hypnagogic
hallucinations) and those that occupy the period of morning slumber
are very easily reviewed in memory, because they are associated
with impressions directly derived from the partially-waking organs of
sense. Such dreams are therefore chiefly recalled through their
association with the train of our waking thoughts. But the dreams of
somnambulism and the dreams of night-terrors, and all other visions
during profound sleep, are as completely as possible cut off from all
connection with the mental activities which arise directly from the
action of the senses. By reason of such isolation the ordinary
association of ideas affords no help to the memory, and the dream
remains in the limbo of oblivion.
10 A. Bertrand, Traité du Somnambulisme, p. 80.

Alfred Maury expresses the opinion11 that the principal cause of

forgetfulness of the events of somnambulism consists in the
exhaustion of the cerebral elements through the intensity of the
excitement to which they are subjected during the paroxysm.
Doubtless this in certain cases may contribute to the loss of memory,
but it should be remembered that the excitement may be relative
rather than absolute. Certain elements wake while others are asleep,
and the waking cells may be aroused to a degree far in excess of
what is usual during the sleep of the brain without attaining to the
level of their diurnal activity. The mind, undisturbed by external
impressions, gives its attention to the activity of these waking
organs, and a dream with all its consequences, somnambulic or
otherwise, is the result. In other words, the plane of consciousness,
so to speak, is lowered during sleep to the level of these molecular
vibrations. But when the whole brain is again awakened after sleep
the residual vibrations of those elements which yielded the physical
basis of the dream, and which, had they occurred during the waking
state, might have persisted with energy sufficient to furnish a
groundwork for recollection of the ideas which they had originally
suggested, are no longer sufficiently energetic to be felt in
consciousness. Recollection of mental states thus generated must
necessarily be impossible so long as the mind is dependent upon the
brain as its register of events. Sometimes, however, the
somnambulist, who while awake had forgotten all the incidents of his
somnambulic experience, can remember in a subsequent paroxysm
all that occurred during the preceding attack. Facts of this kind have
been observed in the waking life of certain hysterical persons,12 but
the apparent interruptions of their personality attach to the waking
state, while in ordinary somnambulism it is only in sleep that the
alternations of memory and forgetfulness occur. A similar recollection
of previous visions is sometimes experienced in dreams, showing
the close relation that subsists between the dreams of sleep and of
somnambulism. The bond of association between these events thus
isolated in time must be sought in a renewal of like conditions of the
brain during the successive periods of somnambulic exaltation. We
must suppose that the molecules which were in a state of functional
excitement during the first paroxysm are again aroused in like
manner after a period of waking quiescence. If, during sleep, their
movements, though of an exalted character, have only just sufficed
to arouse consciousness in the form of a dream, it would not be
probable that during the phase of comparative inactivity which
supervenes when the whole brain is awake their residual motion
could disturb the sphere of consciousness. Hence the time occupied
by their somnambulic vigor must remain a blank in memory during
the waking state. But when the original state of exaltation has been
reproduced by a second period of disorder, if the same molecular
movements be in any way renewed, the conditions of memory are
fulfilled; consciousness is once more aroused as before, and the
patient remembers the dream or the events of the previous attack.
 11 Le Sommeil et les Rêves, p. 226.

12 Annales Medico-psychologiques, 5e Série, t. xvi. p. 5, 1876.

Artificial Somnambulism, or Hypnotism.

The phenomena which have now been passed in review are of

apparently spontaneous origin during the ordinary period of sleep.
But from the remotest antiquity it has been known that certain
persons may be thrown into an artificial sleep which closely
resembles the condition of the somnambulist. During the persistence
of this state certain portions of the nervous system become utterly
insensible to external impressions, while other portions acquire an
exalted degree of sensibility. The subject of the experiment can then
by special methods be placed in such relations with other waking
individuals that his surviving sensations, mental processes, and
physical actions shall be no longer regulated by his own volition, but
by the will of another. Such susceptibility is not common to all
persons. About 20 per cent. of the ordinary population is, by some
observers, considered capable of experiencing this condition.
Heidenhain,13 experimenting upon a class of medical students, found
only one in twelve who was thus susceptible. Charcot, whose field of
observation covers the inmates of the Salpêtrière Hospital, finds the
best exemplars of the hypnotic state among the hystero-epileptic
females in that asylum. To these experimenters we are largely
indebted for the most extended scientific observation of the
phenomena of hypnotism, giving precision and publicity to the
knowledge of facts which, though equally well known within a narrow
circle of investigation14 during the earlier decades of the present
century, have been compelled to await the development of cerebral
physiology before their full significance could become apparent to
the mass of the medical profession.
13 Animal Magnetism: Physiological Observations, by Rudolph Heidenhain.
 14 Braid, Neuro-hypnology considered in Relation with Animal Magnetism, London,
1843.

The antecedent condition most favorable to the production of the

hypnotic state is a highly unstable constitution of the nervous
system. For this reason the larger number of qualified subjects is
furnished by the female sex, especially by those who possess the
hysterical temperament. Frequent repetition of hypnotic exercises
renders the subject still more susceptible. Heidenhain was at first
inclined to believe that such experiences were not prejudicial to the
health of the subject, but the observation of Harting in the University
of Utrecht, and of Milne-Edwards in Paris,15 have demonstrated
danger to the health of animals subjected to similar experiments. It is
easy to discover, in the various clinical narratives published by
Charcot and his pupils,16 evidence that hysterical patients often
manifest considerable exhaustion after hypnotic exhibitions;
consequently, it cannot be admitted that the practice is devoid of risk
to the health of the individual.
15 Lancet, July 29, 1882, p. 164.

16 Paul Richer, L'hystéro-Epilepsie, Paris, 1881; Le Progrès médical, 1881-82.

Numerous methods of inducing the hypnotic state have been

employed by different experimenters. The greater number consist in
modifications of the sensory impulses derived from the periphery of
the body. Gentle pressure upon the closed eyelids; convergence of
the axes of the eyeballs upon some object nearer than the proper
focal distance of the eyes; fatigue of the retina by gazing upon any
brilliant or luminous object; monotonous excitation or sudden
surprise of the auditory nerve; various impressions through gentle
friction or pressure upon different regions of the body,—all these are
capable of inducing hypnotic sleep. An appeal to the imagination, or
even the mere attempt to abnegate the possibility of vigorous
thought by confining the attention to the most trivial of things,
sometimes suffices to produce the desired phenomenon. Thus,
Heidenhain put one of his students to sleep at a distance by merely
informing him beforehand that at a certain hour he would hypnotize
him in his absence. The state of ecstatic meditation into which the
monks of Mount Athos plunged themselves by the practice of
omphaloscopy affords an illustration of the hypnotic effects of
concentrated attention.

The duration of hypnotic sleep is exceedingly variable, but if left to

himself the patient usually wakes spontaneously, without recollection
of anything that has happened. If it be desirable to awaken him
before the natural termination of the paroxysm, consciousness can
be restored by almost any sudden and energetic appeal to the
senses, such as an electric shock, a sudden illumination of the eye
with vivid light, or a sharp puff of air upon the face.

According to Charcot,17 three principal types may be remarked

among the hysterical subjects upon whom he experimented: (1) the
cataleptic, (2) the lethargic, and (3) the somnambulic. Of these, the
first may be developed primarily by any abrupt and powerful
impression upon an organ of sense, as a bright light or a loud noise
(gong). Fixing the eyes upon some object may produce the same
result. Dumontpallier, for example, has reported the case of a young
woman18 who accidentally hypnotized herself by gazing at her own
image in the mirror before which she was dressing her hair. The
cataleptic state may also be secondarily induced by merely opening
the eyes of a patient in whom a condition of hypnotic lethargy has
been previously developed. If only one eye is thus opened, the
corresponding side of the body alone becomes cataleptic. Closing
the eyes causes the disappearance of this symptom, with complete
restoration of the purely lethargic state. During the cataleptic
condition the several tendinous reflexes disappear, neuro-muscular
hyperexcitability ceases; the skin becomes insensible, but the
special senses, particularly those of sight and hearing, maintain a
partial activity. In this state the senses may become avenues of
suggestion for the production of muscular movements, but if left to
themselves the limbs remain motionless.
17 Le Progrès médical, Feb. 18, 1882, p. 124.

18 Ibid., March 25, 1882, p. 223.

The lethargic state may be induced by simply closing the eyes of the
patient or by causing him to fix his gaze upon some definite object.
The paroxysm begins with a deep inspiration causing a peculiar
laryngeal sound, followed by the appearance of a little foam on the
lips. The eyelids are either wholly or partially closed, and are in a
state of continual tremulous motion. The eyeballs are generally
turned upward and inward. The muscles are completely relaxed. The
tendinous reflexes are exaggerated; pressure over a muscle or upon
a nerve arouses a peculiar contraction of synergic muscles and of
groups of muscles which are supplied by the excited nerve-trunk.
The facial muscles, however, do not thus become contractured: they
merely contract during the application of the stimulus. If the lethargic
patient be rendered cataleptic by opening the eyes, these
contractions persist even after awaking, and they can only be
dispelled by renewing the lethargic state before resorting to pressure
upon the antagonistic muscles—a process by which the contractures
peculiar to this species of lethargy may always be annulled. By the
approach of a magnet to a contractured limb the phenomenon may
be completely transferred to the corresponding muscles upon the
opposite side of the body. If upon a limb of a lethargic patient who
has been rendered cataleptic by opening the eyes an Esmarch's
band be applied, pressure over the bloodless muscles excites no
contracture until the band is removed. A contracture is then
developed, and it may even be transferred to the opposite limb by
the approach of a magnet. To this phenomenon has been applied the
term latent contracture.

The extraordinary muscular excitability manifested by these

hysterical hypnotics is further illustrated by an observation recorded
by Dumontpallier.19 If one end of a caoutchouc tube one centimeter
in diameter and five or six meters in length be applied over a muscle
in the leg, and if the other end be in like manner connected with a
watch, every movement of the second hand will be followed by a
slight contraction in the muscle. The same result follows connection
with the wire of a telephone, and if a microphone be introduced into
the circuit the incidence of a ray of artificial light upon the instrument,
or even its glancing reflection from the eye, will arouse a responsive
muscular contraction. Charcot has sometimes observed muscular
contractions upon the opposite side of the body when a mild galvanic
current was applied to the parietal surface of the head. During the
manifestation of muscular hyperexcitability there is complete
analgesia, but the senses of sight and hearing seem to preserve
some degree of activity. The patient, however, does not manifest any
susceptibility to influence by suggestion.
19 Ibid., Jan. 14, 1882, p. 25.

The somnambulic state may be directly induced by fixed attention

with the eyes, by feeble and monotonous excitation of the senses,
and by various other methods of an analogous character. This forms
the most common variety of the hypnotic condition. It may very easily
supervene during either the lethargic or the cataleptic state as a
consequence of pressure or gentle friction upon the top of the head.
Thus, Heidenhain caused muscular paralysis by rubbing the scalp.
Unilateral friction of the same surface produced paralysis of the
opposite side of the body without notable affection of consciousness.
The eye and the eyelids behave as in the lethargic state. The patient
seems asleep, but there is less muscular relaxation than in hypnotic
lethargy. There is no exaggeration of the tendinous reflexes, and
muscular hyperexcitability is absent. But by lightly touching or
breathing upon the surface of a limb its muscles may be thrown into
a condition of rigidity which differs from the contracture of the
lethargic state in the fact that it does not yield to excitation of the
antagonistic muscles, though yielding readily to a sudden repetition
of the same form of excitement by which it was originally produced.
From the immobility of the cataleptic state it also differs by a greater
degree of resistance to passive motion. Though analgesia may be
perfectly developed in this state, there is generally an exalted
condition of certain forms of cutaneous sensibility and of the
muscular sense. Strange perversions of other special senses are
sometimes remarked. Cohn20 discovered that a patient who was
naturally color-blind “when unilaterally hypnotized was able to
distinguish colors which were otherwise undistinguishable.”
Conversely, when the cataleptic state is induced the eye becomes
incapable of discerning colors. Spasm of accommodation is also
present, and is one of the earliest demonstrable symptoms of the
hypnotic condition.
20 Brain, vol. iii. p. 394.

These remarkable exaggerations and perversions of special

sensibility have been the cause of much scepticism on the one hand
regarding the verity of the phenomena of hypnotism, and of much
credulity on the other, extending even to a belief in the existence of
supernatural and miraculous gifts. But when the fact is once
comprehended that in this capacity for uncommon feats of vision,
hearing, touch, etc. we observe merely the exaggeration of a
process which occurs in every act of attention, the miraculous
semblance of the phenomena disappears. Attention implies an
increase of activity in certain portions of the brain, with diminution of
the function in the remainder of the organ. In the wild excitement of a
cavalry charge the soldier feels not the sabre cut which will fill his
consciousness with pain so soon as his attention is released from
the fetters imposed by the more engrossing events of the combat.
So in the somnambulic sleep those parts of the brain which remain
awake perform their functions with a vigor that is enhanced by a
concentration of cerebral energy in certain restricted portions of an
organ that, by reason of its naturally excessive instability, had been
previously fitted for the liberation of an inordinate amount of
molecular motion. Hence the slightest suggestion of sense may
suffice for the most extraordinary perception. Such persons see
through their eyelids and hear at a surprising distance. The memory
of past events, the recollection of long-forgotten words and thoughts,
supplies in this state an abundance of materials out of which an
exalted imagination may construct the most astonishing scenes. By
this method of combination are produced those remarkable oratorical
utterances which by the ignorant have been so widely attributed to
the supervision of guiding spirits from another world. In this condition
the essential characteristics of the mind of the so-called medium
become the real guides of his mental processes. Hence the infinite
variety and contrariety of the utterances of such declaimers.
Among other consequences of this exalted susceptibility of the
waking portions of the brain may be noticed the effect of suggestions
by others upon the mind of the somnambulist. Numerous examples
scattered through the literature of the subject21 illustrate the manner
in which the course of our ordinary dreams may be thus directed.
The hypnotic dream is far more easily modified.22 The simplest
manifestations of such influence are exhibited in movements in
obedience to the command of the hypnotizer. Next in rank are those
more complicated actions that are effected by excitement of the
imitative faculties of the subject. Every suggested movement that
can be in any way perceived by the patient will be at once
reproduced. Various emotions and passions may thus be aroused by
simply placing the sleeper in the appropriately suggestive attitudes.
Under the influence of a pregnant idea intruded upon the mind of the
patient the subsequent association of ideas will suffice for the
evolution of a complicated series of hallucinations, as in the case of
a young woman, who on being directed to put out her tongue
immediately began to feel sensations of uneasiness in her stomach,
followed by nausea and attempts at vomiting, accompanied by the
impression of being on shipboard. In the lowest grades of the
hypnotic state consciousness may remain, and the subsequent
recollection of the events of the paroxysm may be quite persistent. In
such cases illusions that were produced by suggestions from other
minds generally survive in memory and become the causes of
serious delusion. Witness the manner in which susceptible
individuals, partially hypnotized in a so-called spiritual circle, believe
in the reality of the illusions which have occupied their senses during
a séance.
21 Carpenter's Physiology, 8th ed., p. 765; Le Sommeil et les Rêves, par L.-F. Alfred
Maury, 4th ed., p. 153 et seq.

22 Loc. cit., p. 357.

A higher degree of insensibility to ordinary impressions is necessary

to the production of the phenomena of passive obedience and of
automatic imitation. It is probable that the degree of sensory
hyperæsthesia which enables certain hypnotic patients to read the
thoughts of others belongs rather to the first than to the last of these
classes. This capacity is usually associated with preservation of
consciousness and memory, and is, essentially, a mere exaggeration
of that power which all possess in greater or less degree. Numerous
well-authenticated examples of a surprising manifestation of this
faculty have been recorded, so that the possibility of its existence no
longer admits of doubt.23 In all cases it has been remarked that the
hypnotic mediums can only respond correctly to questions for which
the true answer is present in the mind of the questioner. For all other
interrogations the replies are delivered purely under the influence of
random suggestion. In certain of these cases the pathway of
communication lies through actual physical contact, as in ordinary
mind-reading, where the insensible molecular oscillations of the
muscular elements of one individual serve to guide the movements
of another. But more frequently the transmission of ideas is effected
through the eyes. With these organs the table-rapper or the
planchette-writer reads the unspoken words of the questioner in a
manner very like, yet vastly more deliberate than, that by which deaf-
mutes now learn to interpret the movements of the lips of persons
with whom they converse. This fact is well illustrated by the
experience of Maury24 in an interview with a celebrated table-rapper,
who without the slightest hesitation made known to him the age,
name, and date of death of a brother whom he had lost. She also
gave the same information regarding his father, and related the
names of other persons upon whom he had fixed his attention. But if
he turned away his face or concealed his eyes, so that the woman
could no longer watch their expression, her responses ceased to be
of any value.
23 Luther V. Bell, Two Dissertations on what are termed the Spiritual Phenomena,
read at the meetings of the Association of Medical Superintendents of American
Insane Hospitals at Washington and Boston in 1854 and 1855.

24 Le Sommeil et les Rêves, 4th ed., p. 361.

In these partial developments of the hypnotic state it is worthy of
note that the phenomena of sleep are so few and so comparatively
insignificant that they are usually overlooked. Hence the veil of
mystery which has so often obscured the interpretation of such
cases. Careful observation, however, will always detect some
characteristic departure from the normal standard—some loss of
balance between the different parts of the nervous system—by
means of which the true relations of each example may be
determined.

TREATMENT.—A large proportion of the phenomena of somnambulism

and hypnotism depend rather upon an originally irritable organization
than upon a specially diseased condition of the nervous system.
Their treatment, therefore, frequently resolves itself into the
management of hysteria or of cerebrasthenia. But if the
manifestations of somnambulism develop for the first time in a
person advanced in years, who has previously enjoyed good health
and a sound mind, it should be regarded as an omen of grave
import, signifying the imminence of organic cerebral disease. Though
the meaning of such incidents is less sinister in early life, they reveal
an ill-balanced state of the nervous system and an imperfect process
of nutrition in the growing body. Such children are the frequent
victims of night-terrors, the form of disorder most commonly evolved
by their somnambulistic proclivities. The treatment of night-terrors
should therefore be chiefly directed to the invigoration of the general
health of the patient. Indigestion and malnutrition are among the
most prominent antecedents, and they should constitute the principal
objects of therapeutical attention. Constipation is usually present.
This may be relieved by the use of compound rhubarb powder or any
other gently stimulating laxative. Digestion should be aided with
pepsin as soon as the catarrhal condition of the alimentary canal, so
uniformly present, has been measurably improved. Cod-liver oil or its
substitutes should be administered for a long period of time. If the
nocturnal paroxysms be frequently renewed, it may be well to
employ the bromides, either with or without chloral hydrate; but as a
general rule it is better to rely upon hygienic and restorative
treatment, rather than upon any form of merely hypnotic medication.
 INSOMNIA.

The departures from the course of natural sleep which have been
thus considered are not so much the direct consequence of acute
disease as the result of structural deviation from the normal type of
the nervous system. We must now briefly review the strictly
pathological modifications to which sleep is liable.

Lithæmic Insomnia.

Among those who indulge freely in the pleasures of the table a form
of insomnia is not uncommon. Originating at first in mere overloading
of the stomach, and consisting in a direct irritation of the brain
through the medium of the intervening nervous apparatus,
sleeplessness finally becomes a symptom of more serious mischief.
The tissues become charged with nitrogenous waste, and a
lithæmic25 or gouty condition is established. Such patients are
wakeful, or if they sleep their slumbers are imperfect and
unrefreshing.26 Grinding of the teeth,27 noticed by Graves during the
sleep of the gouty, is a symptom indicative of a highly irritable
condition of important ganglia at the base of the brain. These
symptoms are sometimes associated with turgidity of the superficial
vessels of the head, indicating imperfect function of the circulatory
organs, with a tendency to accumulation of the blood in the venous
channels of the body. The sleep of such partially-asphyxiated
patients is fitful, irregular, and akin to stupor. Occurring in the
subjects of periodical gout, these disturbances of sleep become
increasingly serious as the paroxysm is approached, until loss of
sleep and the unrefreshing character of such slumber as may be
obtained become important factors among the causes of failing
health.
25 DaCosta, “Nervous Symptoms of Lithæmia,” Am. Journ. Med. Sci., Oct., 1881.

26 Dyce Duckworth, “Insomnia in Persons of Gouty Disposition,” Brain, July, 1881.

27 Trousseau, Clinical Medicine, Am. ed., vol. iv. p. 362.

For all such patients a proper recognition of the cause of their

disorder is essential. This must be corrected by measures
appropriate to the treatment of the gouty diathesis. Since the
condition of the cerebral tissues is a state of irritation caused by the
presence of excrementitious substances, such hypnotic remedies
must be selected as will not interfere with the defecation of those
tissues. Bromide of potassium, valerian, scutellaria, hyoscyamus,
hops, and cannabis indica are useful, together with all that class of
drugs which quiet the brain without hindering the process of
excretion. Chloral hydrate often produces an excellent result, but
care should be taken to prevent its habitual use.

Febrile Insomnia.

Closely related with the sleeplessness of lithæmia are the

disturbances of repose which attend the evolution of the various
specific fevers. In many cases the condition varies all the way from
stupor to delirium. Excessive somnolence, such as often ushers in
the fever, is an indication for evacuant treatment. Cerebral
excitement calls for remedies like the bromides and chloral hydrate,
which do not interfere with elimination. If pain, like headache or
backache, be a symptom demanding attention, the addition of
morphia in small doses forms a valuable reinforcement for the
hypnotic mixture; but, as a general rule, opiates should be used with
a sparing hand. The various resources of hydrotherapy are often
invaluable when wakefulness results from the cutaneous irritability of
the eruptive fevers. During the later stages of a protracted illness the
occurrence of insomnia should direct attention to the nutrition of the
patient. Wakefulness is then the symptom of an irritable weakness of
the brain, demanding remedies which delay the process of
disassimilation. The failing power of the heart requires attention, and
diffusible nutriment must be given to convey the elements needful for
restoration of the exhausted brain. These indications are most
perfectly answered by the associated administration of opiates with
alcohol, milk, and beef-juice in small and frequent doses.

Insomnia from Exhaustion.

Cerebral exhaustion is a not uncommon cause of wakefulness in

cases uncomplicated with fever. It is usually the result of chronic
conditions of ill-health and depression, such as are often
encountered as the result of various cachexias or of dyspepsia, with
or without the abuse of alcohol, tea, coffee, or tobacco. Overwork,
debilitating discharges, pregnancy, parturition, mental anxiety,
depressing emotions, chronic heart disease, and incipient insanity
are fruitful causes of the exhaustion which produces this most
distressing form of insomnia. In such cases the cessation of healthy
nutrition leads to a condition of excessive instability in the cerebral
tissues. The oxygen which they receive from the blood is not stored
with any degree of permanence, but tends to pass directly into stable
combinations with the oxidizable elements of the brain.
Consciousness is thus continually aroused. The state of such a
patient presents a very close analogy to the condition of the victim of
diabetes whose liver refuses to retain its glycogen. The inordinate
discharge of sugar into the blood not only exhausts the tissues of the
liver, but also excites other organs—notably the kidneys—to
excessive and unwholesome activity. In somewhat similar fashion,
the failure of the brain to assimilate and to retain oxygen leads to an
abnormal intramolecular oxidation, which excites an excessive and
unwholesome activity on the part of the Ego in another region—
namely, in the field of consciousness. Such wakefulness might justly
be termed a psychical diabetes.

This variety of insomnia has frequently been ascribed to cerebral

anæmia occurring as a part of a general spanæmia. But this
universal impoverishment of the blood, though a sufficient cause of
the morbid instability, the irritable weakness, of the cortical tissues,
does not necessarily imply a comparatively bloodless condition of
the brain. Unequal circulation and local hyperæmia in different
organs of the body are no unusual consequences of the anæmic
state. Slight disturbances suffice to arouse the brain of such a
patient. The vaso-motor apparatus shares in the general irritability,
permitting blood to inundate the cortical substance almost without
provocation. The unstable protoplasm is only imperfectly renovated,
usually at the expense of the other tissues of the body. The weary
patient, busying himself with an unwilling review of the events of the
day, tosses long upon his couch before he can secure the approach
of “tired Nature's sweet restorer, balmy sleep.” When at length he
yields, his slumbers are brief, and the latter part of the night is but a
repetition of the earlier vigil.

Such patients need a very radical course of general treatment. A

complete change of habits should be effected. A long vacation in the
country, or, best of all, a protracted voyage in a sailing vessel, is
desirable. Hot foot-baths, with cold affusion upon the head, and
warm sponge-baths, or even the full bath in tepid water, at bedtime,
are of great service as means of tranquillizing the nervous system.
The indications for medicinal treatment, besides attention to the
predisposing cachexia, are twofold—to calm and to nourish the
enfeebled nervous substance. Opiates calm, but do not nourish—
they hinder the process of nutrition; hence the sufferer wakes
unrefreshed by the sleep which they procure, and is soon in a
condition worse than ever. The same objection lies against the
continuous use of the bromides. But alcohol and its hypnotic
derivatives (chloral, paraldehyde, etc.) not only calm the excitable
brain, but they also furnish to the tissues a certain amount of
diffusible nutriment which suffices to steady the brain until a change
of occupation, with rest and wholesome food, can produce a
complete restoration of its normal stability. To this effect of alcohol
must be ascribed its value as an hypnotic in the wakefulness of old
people who cannot sleep without a preliminary nightcap. A moderate
draught of hot toddy in such cases serves to arouse the feeble heart
and to equalize the circulation by the production of a moderate
degree of general vascular dilatation. The sugar and water afford an
easily assimilated food, while the alcohol benumbs the cortical
protoplasm to a degree which favors the cessation of conscious
perception. If administered in excessive doses, it is not sleep but
anæsthetic intoxication which follows. If this condition be unduly
repeated, the phenomena of chronic alcoholism supervene, with all
the horrible forms of insomnia that accompany cerebral starvation
and delirium tremens. Non-alcoholic nerve-stimulants and tonics,
with careful administration of easily-digested food, are then more
than ever needed to overcome the neurasthenic wakefulness.

Insomnia from Active Cerebral Congestion.

Still another form of sleeplessness is often experienced as a result of

actual inflammation in some portion of the body, either involving the
intracranial contents directly or reacting upon the brain through the
medium of its circulation. In such cases many of the symptoms of
acute inflammation are present. The head aches, the temples throb,
the face and eyes are suffused with blood, the temperature is
considerably increased. The senses become exalted, ideas pursue a
tumultuous course, there may be actual delirium. These
disturbances are due to an active hyperæmia of the brain. The
substance of the cortex becomes hyperexcitable, and the ordinary
incitements of sense produce an exaggerated effect in
consciousness. The patient does not sleep, and he feels no need of
sleep, because the nutrition of the brain is sustained at the expense
of the remainder of the wasting body. The most speedy and effectual
relief in such cases is obtained through a diminution of the current of
blood in the brain. Moderate compression of the carotid arteries has