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Chapter 15

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Social Aspects of Later Life:
Psychosocial, Retirement,
Relationship, and Societal Issues
Leon Kraybill, MD, CMD
Lancaster General Geriatric Fellowship
October 2010
A visual introduction to aging….
Brought to you by YouTube
Ages in Order
1 to 100
http://www.youtube.com/watch?v=GUHLa1qSy24
Cases
Case #1
Case #2
Case #3
Thoughts on aging
“For to those who have not the means within
themselves of a virtuous and happy life, every age is
burdensome”
Cicero 106-43 BC
“We loved the earth but could not stay”
Loren Eiselely
“After sixty you are aware of how vulnerable
everything is, including yourself”
Wallace Stegner
What is the goal for aging?
Successful aging is a paradoxical term as
aging traditionally brings to mind images of
loss, decline, and ultimate death, whereas
“success” is represented by achievement.
Successful aging?
Science has given us the possibility of
additional years of life.
Can we make those additional years more
worth living?
Life extension and successful aging
Science suggests an influence through
exercise, diet, sleep, and genetics
Growing evidence to suggest that
psychological and sociological factors also
influence how an individual ages
Successful transition into late adult hood
More then continuation of midlife skills
Requires a new set of skills and adjustments
Aging research suggests that successful
aging correlates with one’s religious beliefs,
social relationships, perceived health, self
efficacy, socioeconomic status, and coping
skills
The challenge
A world designed for young people, but an ever
growing group of older citizens.
How will we respond to those who:
-can’t walk through shopping malls or airports
-can’t deal with rushed doctors or new insurance plans
-can’t handle stairs, small print, or menus in darkened
restaurants
-can’t pay for the many modern technological advances
-won’t request or accept assistance
-don’t understand the complexities of a computer, much less
using one to sign up for a prescription plan with 20 options
-want to be independent but need societal accommodation
Objectives
Theoretical constructs of aging
Ageism
Successful aging
Psychosocial issues that the older individual
faces
Dr. Leon’s prescription for successful aging
Opening questions that foster discussion
Theories of Psychosocial Aging
Erikson, 1963 – integrity versus despair
Accept life and history, as it has unfolded
Assume responsibility for successes and
failures
Or lapse into depression, despair, anger
Theories of Psychosocial Aging
Role theory
Aging individual is subjected to multiple role
changes as a function of aging
Society imposes a growing number of
restrictions on the roles available, which may
adversely affect self-concept
May result in withdrawl, isolation, and
depression
Theories of Psychosocial Aging
Continuity theory proposes that people use
familiar strategies to cope with daily life.
– Too little continuity promotes a feeling that life is
too unpredictable.
– Too much continuity promotes boredom.
– Optimal continuity allows for challenges and
interest without overwhelming.
Theories of Psychosocial Aging
Competence and Environmental Press
Competence is the upper limit of a person’s
ability to function in physical health, sensoryperceptual skills, motor skills, cognitive skills,
and ego strength.
Environmental press is the physical,
interpersonal, or social demands of the
environment.
Theories of Psychosocial Aging
Competence and Environmental Press (cont.)
Both factors change as we move through life and
interact with life’s changes.
Our adaptation level is the level at which press level
is average for a particular level of competence.
Slight increases in press show results in the zone of
maximum performance potential, which results in
increased performance, but maybe increased tension
Slight decreases in press show results in the zone of
maximum comfort in which people are able to live
without worrying about environmental demands.
Theories of Psychosocial Aging
Competence and Environmental Press (cont.)
When people exert control over their lives by
choosing new behaviors to meet their needs
or desires, it is called proactivity.
When people allow the situation to dictate
their options, they show docility.
Research shows people with high
competence more often choose proactivity.
Low competence results in more docility.
Ageism
Simply…discrimination based on age
Pervasive through society
Rooted in language, attitudes, beliefs,
behaviors, and politics
Aging profoundly influences physiology. Our
challenge is to accommodate but not
discriminate
Ageism
Language:“Our seniors”, “the elderly”, or “your loved one”
Falter for a moment because they are unsure of themselves and
are immediately charged with being 'infirm.'
Constantly "protected" and their thoughts interpreted.
Forget someone's name and are charged with senility and
patronized.
Expected to 'accept' the 'facts of aging.‘
Miss a word or fail to hear a sentence and they are charged with
'getting old,' not with a hearing difficulty.
Called 'dirty' because they show sexual feelings or affection to
one of either sex.
Called 'cranky' when they are expressing a legitimate distaste
with life as so many young do.
Charged with being 'like a child' even after society has ensured
that they are as dependent, helpless, and powerless as
children."
Ageism
Negative aging stereotypes
– “ inevitability of decline”
– nothing to do to avoid decline in health and
function
The older individual internalizes, starts to
believe, and live out the messages heard
throughout a life time
“Successful aging”
1987 Landmark paper
– Many age-related changes may be preventable
– “Successful aging”
• Low probability of disease and disease-related disability
• High cognitive and physical functional capacity
• Active engagement with life
– Not all can achieve, most do not, but it should be
our goal
Rowe JW, Kahn RL. Human Aging: Usual and successful. Science 1987; 237; 143-239
Expectations of aging
Study of 800 people >65 yo, independent
– Four groups: 65-69, 70-74, 75-79, 80
Generally (regardless of age group):
–
–
–
–
–
–
–
–
–
High satisfaction in their lives
A desire to learn new things
Enjoyed meeting new people
Knowledgeable of world events
Trusting (90%)
More fortunate than most (85%)
Age brought wisdom and respect
Little worry about depression or boredom (aprox. 20%)
Almost no preoccupation with mortality or dying
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Expectations of aging
Over 80
– Concerns for functional mobility and physical appearance
increase significantly
Life satisfaction factors
– Income
– Living status
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Expectations of aging
Study of 429 community dwelling, 65-100 yo
– >50% felt it was an expected part of aging:
•
•
•
•
•
to become depressed
to become more dependent
to have more aches and pains
to have less ability to have sex
to have less energy
– Those with low expectations were less likely to
seek health care for age-associated conditions
“Do older adults expect to age successfully?” Catherine Sarkisian, et al. JAGS November 2002, 1837-1843
Expectations of aging
Modifiable conditions
– Depression
– Memory impairment
– Urinary incontinence
Lower expectations (redefining health) may be a
compensatory mechanism to maintain life satisfaction
Conclusions: Modifiable conditions remain
underdiagnosed and undertreated
“Do older adults expect to age successfully?” Catherine Sarkisian, et al. JAGS November 2002, 1837-1843
Life Meaning
The search for existential place in life
– how did my life matter?
– was my time well spent?
– what did I mean to others?
– what can I look back on with pride?
– did I love the right people?
Integrity Versus Despair: Erik Erikson Stage 8 *
Older people engage in the life review in which they reflect often
and long on the events and experiences of their lifetime.
– Some individuals judge their life to have been meaningful and
productive and feel good about the choices they have made,
resulting in ego integrity.
– Others feel a sense of meaninglessness and blame others for their
problems, resulting in despair.
Life Meaning
Successful aging is inextricably intertwined
with developing a sense of life satisfaction.
The accomplishment of this is harder than the
recognition….
Subjective well-being may be based on
marital status, social network, chronic illness,
and stress.
Women may experience less subjective wellbeing.
A period of losses
Loss from death (spouse, children, friends)
Loss of work structure and income
Loss of home and neighborhood
Loss of social network
Loss of primary control over decisions
regarding health, mobility, living situation,
finances
Losses
The question is not whether there will be
losses, but how you will deal with the losses
that occur.
Grief processing
Phases of grief are similar to those described
in younger adults: numbness, depression,
and resolution.
Bereaved persons should be encouraged to
discuss the deceased rather than the avoid
the subject.
Sometimes the provider’s task is to unplug
the drain for tears of grief
Dependency
Generational mantra - “I don’t want to be a
burden”
Diminishing control in work, finances, and
family life
Anticipation: Frightening, humiliating
Reality: intense anger, guilt, boredom,
loneliness, alienation, shame
Response: Listen, normalize, verbalize, and
sometimes set limits
Socioeconomic status
Socioeconomic status correlates with
successful aging
– better sources and opportunities
– superior methods for problem solving and coping
with change
– better occupational opportunities and social status
– greater financial stability
Religiosity & Spiritual Support
Religious faith and spirituality are important
means by which older people cope with life.
– Spiritual support is involvement with organized
and unorganized religious activities and pastoral
care.
– Faith in God’s help is described by elders as
distinguishing between what can and cannot be
changed, doing what one can to change the things
they can, and letting go of those things that cannot
be changed.
Religiosity & Spiritual Support
Nationally: 75% of older persons say religion
is “very important” (vs 30% < 30 yo)
52% of those > 65 yo attend religious
services weekly
Various studies have associated
religiousness with well-being, life satisfaction
or happiness
Religiosity & Spiritual Support
Religious participation enables elderly people to cope
with and overcome emotional and physical problems
more effectively, leading to a heightened sense of
well-being in late adulthood
Less depression, lower risk of death after cardiac
surgery, suicide is four times less likely
Exact mechanism is unclear
– ?positive emotions to stimulate the immune system
– ?better access to social and psychological resources
Language and emotion
Language of feelings
– older generation was not schooled in expressing
feelings, and perhaps were taught to keep feelings
to themselves
– particularly women did not state their own needs
– men particularly were emotionally constricted,
without license to show sorrow or self doubt
– may not be comfortable with openness
– lack of talk does not equate with lack of feeling
Another Country: Navigating the Emotional Terrain of our elders, Mary Pipher, Ph.D.
What Does Being Retired Mean?
Retirement does not always mean complete
withdrawal from the work environment.
Some elders have a bridge job, or a job one
holds between ending their primary
employment and final retirement.
Bridge jobs are associated with both
retirement and overall life satisfaction.
Why Do People Retire?
Today, more people retire by choice than for
any other reason.
– Most people retire when they feel they are
financially secure.
– Some people retire when physical health problems
interfere with work.
– People with jobs that are physically demanding
tend to retire earlier.
Retirement & gender
Gender Differences
– Women enter the workforce later and have more
interruptions in their work history. They also may
have different financial needs.
– Women with husbands that have poor health or
with larger numbers of dependents tend to retire
earlier. The opposite is true for men.
Retirement & environment
Urban/rural differences
– Elders in rural areas
• more worried about being to get around
• More often report boredom
– Elders in suburban areas
• Less satisfied with their lives than urban or rural
– Elders in urban areas
• Report highest levels of life satisfaction
• More likely to categorize their health status as good or excellent
• Highest average level of liquid assets (? cause of higher
satisfaction)
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Adjustment to Retirement
People’s adjustment to retirement develops over time
as a function of an interplay between physical health,
financial status, voluntary retirement status, and
feelings of personal control.
Men who place high priority on family report more
retirement satisfaction.
Women’s satisfaction with retirement does not seem
to be associated with any specific roles.
Research does not find the belief that health begins
to decline right after retirement to have any validity.
Keeping Busy in Retirement
Organizations for retirees such as the AARP
have increased the availability of activities
and interests among the retired.
Retirees volunteer and find ways to provide
service to others.
Volunteering supports a personal sense of
purpose.
Friends & Family in Late Life
As we care for our parents, we teach your
children to care for us.
As we see our parents age, we learn to age
with courage and dignity.
If the years are handled well, the old and
young can help each other grow.
Unfortunately, we tend to segregate our age
groups
Friends & Family in Late Life
The ability to develop and maintain strong
relationships and social support systems is
very important
Loneliness and social isolation will kill you
faster than many other diseases
The effects of loss of established social ties
are greater in men than women - ?less
developed social networking
Friends & Family in Late Life
Patterns of friendships in late life are similar
to those in young adulthood
Older adults have fewer relationships than
younger adults
Friendships form on the basis of many factors
that are more relevant at different times, a
process known as socioemotional selectivity
Siblings in Late Life
Sibling Relationships: 5 Types:
–
–
–
–
–
Intimate sibling relationships- 14%
Congenial sibling relationships- 30%
Loyal sibling relationships- 34%
Apathetic sibling relationships- 11%
Hostile sibling relationships- 11%
Older African Americans have apathetic or
hostile relationships with siblings 5 times less
often than European Americans.
The meaning of marriage
Study
– Live in companions – similar contentment patterns to those
married, but not as strong
– People living alone (40%) feel less attractive, have more negative
feelings about themselves, and report more depression & boredom.
This may reflect economic factors (ie widows @ poverty level)
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Marriage Partnerships
– Older couples are more likely to be similar in mental and physical
health and show fewer gender differences in sources of pleasure.
– Older couples usually have developed effective ways to avoid
conflict.
What research has been done has not shown differences
between older gay and lesbian relationships and those of
heterosexuals, in terms of quality.
Caring for a Partner
Caring for a chronically ill partner is more stressful
and challenging than caring for a chronically ill
parent.
The dynamics of the relationship may change.
Division of labor has to be readjusted.
Spouses of Alzheimer’s patients report more
depression and decreased marital satisfaction.
Older adults who have higher feelings of competence
report few hassles in caring for partners.
Being a care giver can give meaning to some
Widowhood
For most people, the death of a spouse is
among the most traumatic experiences they
will have.
More than half of all women over 65 are
widows. Only 15% of men the same age are
widowers.
Friends & family may not visit or socialize as
much with elders after the death of a spouse.
Widowhood
Men are at a higher risk of dying, themselves soon
after the death of a spouse.
– Some researchers believe that a man’s wife is often his only
close friend and confidant.
– There is evidence that older men are less likely to be able to
carry out routine activities such as shopping and financial
responsibilities.
Women are usually less financially secure when
widowed and are more likely to enter poverty status.
Widowers are 5 times more likely to remarry than
widows.
Great-Grandparenthood
For most adults, grandparenting is an
enjoyable and important role.
Three important aspects of greatgrandparenthood:
– It gives a sense of personal and family renewal.
– Great-grandchildren provide new diversions and a
positive new role.
– Great-grandparenthood is seen as a major
milestone of longevity, which is usually viewed
positively.
What is young and what is old?
Young old vs old old
– determined mainly by loss of physical and/or cognition, and
less by actual age
Young old
– take pleasure in many things…grandchildren, reading,
learning new skills
– read, play cards, travel, visit friends, care for pets
– savoring of the ordinary
– time, not money, is the precious commodity
Another Country: Navigating the Emotional Terrain of our elders, Mary Pipher, Ph.D.
Old old
Old old
–
–
–
–
–
–
pain, low energy, poor appetite, inadequate sleep
loss of friends and family, habits and pleasures, house
loss of autonomy
situations that worked before no longer work
often need relatives or assistants or others nearby
homeostenosis
Another Country: Navigating the Emotional Terrain of our elders, Mary Pipher, Ph.D.
Frailty
Frail older adults have physical disabilities, are very
ill, or may have cognitive or psychological disorders.
A minority of older adults are frail but the percentage
increases with advancing age.
Activities of daily living (ADLs) assess the basic daily
living task competencies of older adults.
Instrumental activities of daily living (IADLs) are tasks
that require intellectual competence and planning.
Frailty
Prevalence of Frailty
– Less than 5% of adults aged 65 to 74 need assistance.
– Incidence of needing assistance increases dramatically
thereafter.
– Older adults may also have higher rates of anxiety and
depression.
Study – who required help of family?
– 61% reported receiving emotional support
– Next most common – fixing things in house
– IADL needs (shopping, transportation) most common >80
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Frailty
Frailty and perception of health
– Reported health status of fair or poor
• Lowers life satisfaction
• Interferes with enjoyment of wide range of activities (learning
about new things, reading, walking, hobbies)
• Worry more
• Feel less useful
• More bored and helpless
• More frequently report feeling depressed
– Yet, when actual activities where monitored, they had done
as many things as those who reported health status as good
or excellent
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Living in Nursing Homes
~ 5 percent of 65+ : occupy nursing homes,
congregate care, assisted living, and boardand-care homes
~ 4.2 percent are in nursing homes
About 50% of those who live beyond 85 will
spend at least some time in a nursing home.
Rate of nursing home use increases with age
– 1.4 percent of the young-old
– 24.5 percent of the oldest-old
US Census Bureau
Nursing Home Alternatives
The sheer cost of nursing home care, as well as the
baby boomer generation has increased the push for
alternatives
The increase in the number of assisted-living
facilities, for older adults who need help but are not
so impaired to require 24-hour care, is decreasing the
number of older adults in nursing homes.
Life programs, adult day programs, home health
support, Waiver program, aging
consultants/managers
Living in Nursing Homes
Who Lives in Nursing Homes?
– Usually widowed or divorced, financially disadvantaged,
possibly without living family, very old and European
American.
Risk factors include:
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–
–
–
–
–
–
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Over age 85
Female
Recently admitted to a hospital
Lives in retirement housing
Unmarried or living alone
Has no children nearby
Has cognitive impairment
Has problem with IADLs
Visiting in Nursing Homes
Concentrate on the elder’s expertise and wisdom
Allow the older person to have control over the visit
Listen attentively
Talk about things the resident likes to remember
Engage in joint activities
Record your visit on audiotape or videotape
Bring children
Stimulate as many senses as possible.
Elder abuse
Elder abuse prevalence
– Estimates are that there were 551,000 people
over the age of 60 abused or neglected in the U.S.
in 1996.
– The most common types of abuse were:
• Neglect- 60%
• Physical abuse- 16%
• Financial or material exploitation- 12%
Elder abuse
Characteristics of Elder Abuse Victims
– People over the age of 80 are 2 to 3 times more
likely to be abused than those under age 80.
– In 90% of the cases where the perpetrator of elder
abuse is known, it was a family member, 2/3 of
which were a spouse or adult child.
– Recently, telemarketing fraud has become a larger
problem.
Elder abuse cause
Research fails to support the theories that
stress alone, or that patterns of abuse
transmitted across generations, cause abuse
Abuse is more likely to be caused by a
combination of:
– Intrapersonal problems of the caregiver
– Interpersonal problems of the caregiver
– Social characteristics of the care recipient
Interaction with medical system
and doctors
Generally high level of satisfaction:
–
–
–
–
With physicians
The quality of care provided
Physician’s understanding of the issues of aging
Ability to ask questions and get satisfactory response
Problems
– Only 50% reported being offered choices
– <50% felt they take an active role in own healthcare
– 31% leave decisions completely to physician
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Medical interactions
Duration of physician – elder interaction
– Average office visit for patients over 75 is…??
17 minutes!
– This contributes to lack of diagnosis:
• Alcoholism 78%
• Depression 75%
• Severe cognitive impairment 25%
Genesis ElderCare Poll, Lieberman Research Inc, sponsored by Genesis ElderCare
Summary
Our culture persists in seeing old age as a disease
state
Current social and healthcare system reacts well to
crisis and illness, but flounders in prevention,
wellness and fostering independence
We focus too much on a small part of the life of each
elder, rather than treating the whole person
Since the family is the primary care giver for most
Americans as they age, we need to give them more
investment
Dr. Leon’s prescription for
successful aging
Be financially secure
Maximize your health and wellness
Practice accommodating and welcoming
change
Love yourself and your family
Seek connection to family and community
Find a faith community and spiritual peace
Develop broad interests
Opening questions handout
The meaning of illness
Dependency
Uncertainty/fears for the future
Spirituality
Coping style
Family and social support
Emotional health
Cicero 106-43 BC
“For just as I approve of the young man in
whom there is a touch of age, so I approve of
the old man in whom there is some flavor of
youth. He who strives thus to mingle
youthfulness and age may grow old in body,
but old in spirit he will never be.”
On Old Age, from De Senectute
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