Respectful Interaction
Working with Older Adults
John Quincy Adams is well. But the house in which he lives at present is becoming dilapidated. It is tottering upon its foundation. Time and the seasons have nearly destroyed it. Its roof is pretty well worn out. Its walls are much shattered and it trembles with every wind. I think John Quincy Adams will have to move out of it soon. But he himself is quite well, quite well.
—John Quincy Adams in a response to a query regarding his well-being on his 80th birthday1
Chapter Objectives
• Discuss in general terms the developmental tasks in the later years of life
• Compare and contrast at least two psychological theories of aging
One of the challenges confronting anyone who attempts to speak of the older adult is to earmark exactly when old age begins, even though it is a phase of life everyone will enter if they are fortunate enough to live past middle age. According to many statements on social policy, eligibility for financial and other supportive benefits begins at age 65, but the usefulness of this age as a distinguishing line largely ends there. In fact, people’s feelings that they are “old” are usually determined by the presence (or absence) of sickness, disability, or other factors rather than simply by their chronological age. For the purposes of this chapter, terms such as “elder,” “old,” and “aged” will refer to individuals in later adulthood—age 65 or older. Late adulthood can be divided into the young old, age 65 to 75; the middle old, age 75 to 85; and the old old, age 85 and older.
The older population numbered 40.3 million in 2010 (the latest census year for which data are available). They represented 13% of the U.S. population. By 2050, there will be about 88.5 million older persons, more than twice their number in 2010.2 The baby boomer generation is largely responsible for this increase in the older adult population. A “baby boomer” is an individual born between 1946 and 1964. Boomers comprise one of the largest generations in U.S. history. The boomers began crossing into the older adult (65+) category in 2011, and they will continue to do so until 2030, shifting the U.S. age structure from 13% of the population in 2010 to 19% of the population in 2030. Geographically, the South contains the greatest number of people age 65 and older, while the Northeast has the largest percentage of people in older ages.3 Even though not all older Americans are sick, it is true that the average patient in a health care facility is likely to be older than 75 years of age. Additionally, the older population—the heaviest users of the health care system—will be far more diverse and will be women, especially among the oldest old, or people older than 85.3 Thus, if you work in an inpatient health care facility you will probably encounter older patients who will likely be women from diverse backgrounds.
Almost every generality advanced about the older person is quickly countered by an individual’s personal experience with a chronologically older man or woman. However, many processes that take place in a person as he or she advances in years differ from one individual to another. This chapter provides an overview of physiological and psychosocial changes, with a special emphasis on the psychosocial aspects of aging as they are relevant to respectful interaction. We urge you to study the burgeoning literature of aging further because the questions and clinical issues surrounding care of older patients are complex.
REFLECTIONSThe days of “over the river and through the woods to grandmother’s house” have disappeared in large segments of today’s society. Indeed, grandmothers may be actively involved outside of the home in a work setting or in voluntary community work. She may be raising grandchildren while mom or dad works.
Older persons are among us in a variety of roles. The rapid societal changes taking place around older people give them greater opportunity for divergent roles than ever before. If they are unable to take advantage of these opportunities, as many are, then they are burdened with greater insecurity and more complex problems than were any of their predecessors. However, if they can make the best of these opportunities, their potential for an active and meaningful old age is excellent.
Views of Aging
“Aging is a highly individualized process that affects each person in unique ways. Aging is the result of the interaction among genetics, environmental influences, lifestyles, and the effects of disease processes.”4 This definition of aging is fairly straightforward, but there is much more to aging than mere physiological changes. Cultural and societal views of aging influence how you understand the aging process and how you work with older patients. The following are various views of aging, with some examples involving older patients.5
Unwelcome Reminder of Mortality
Death is more common in old age in the United States than it is in younger age groups. Thus, it is often seen as an expected part of older age and more “natural.” “The effect of this view is that the more natural and acceptable mortality is thought to be for ‘the elderly,’ as they are sometimes called, the more unthinkable it is for the non-elderly, and the more elderly people are avoided as symbols of the unthinkable.”5 Thus, one of the major problems of working with older people is that we have not come to terms with our own aging and mortality. The presence of the aged is an uncomfortable reminder of the future that is in store for all of us. Health professionals sometimes react to this discomfort by trying to avoid such patients whenever possible.
Underprivileged Citizens
Ageism as a type of discrimination and demeaning behavior was addressed in Chapter 3. “Most people, including healthcare professionals, are more familiar with pathological aging than with healthy aging and tend to generalize and project expectation of pathology. Ageism is thus the composite of stereotypical beliefs and attitudes held about a group of people based on their advanced age.”6 In this view, old adults are not readily accorded the respect they deserve but are forced often to rely on the benevolence of society in an attempt to make up for past and continuing discrimination. Programs such as Medicare and Medicaid, “senior discounts,” and special services for “senior citizens” are examples of programs designed to redress shortcomings in society’s treatment of older people as full citizens. Because we live in a youth-oriented society, older people may seem to have little importance. What young people see or read in the media or hear from adults plays a critical role in shaping their perceptions of older people.7 Thus, it is important to promote representations of elderly people in the full range of activities and health states that comprise old age.
Aging as a Clinical Entity
This view of aging sets it apart from other life experiences shared by all human beings. Aging is seen as a clinical entity in its own right, something to be studied and analyzed through research. The subspecialties of geriatrics in health care and gerontology in the social sciences bear witness to the trend of separating out the unique features of aging. Although considerable positive developments have come from this view of aging, such as recognizing the special strengths of older patients, as well as deficits, the risk remains that older patients will be treated differently from younger ones merely because they are old. An example of this can be found in a study of the recommendations medical students give to older (≥59 years) and younger (≤31 years) women regarding breast-conserving procedures. Although research has determined equivalent results between breast-conservation therapy and modified radical mastectomy, the medical students (N = 116) were biased by patients’ ages when making recommendations. “They recommended breast-conservation therapy for a significantly higher percentage of younger patients than older patients (86% vs. 66%).”8 When age is inappropriately used to determine treatment options, it is a form of ageism. Fortunately, new theories of social and psychological development show that some aspects of development can continue throughout the life span.
Older People as a Cultural Treasure
The most positive view of aging is to see people who have lived a long time as a source of wisdom and experience. Recent interest in obtaining oral histories from elders who have witnessed great and mundane historical events is evidence of this view. The past experience of elderly people is of value to younger generations and fits well with Erikson’s theory about the later stages of adult development.
REFLECTIONS
Historic events in our society and culture greatly influence our lives. You often hear older adults reminisce about these events. For example, they may say – “I remember exactly where I was the day JFK was shot” or “it was a historic day when man landed on the moon”.
Name a historic event that influenced you and/or your family.
When you recount this event to the next generation, what will you say?
Needs: Respect and Integrity
Several basic psychological and social processes are evident in the widely divergent lifestyles of today’s older people. Erikson proposes that the success with which an older person can make psychological and social adjustments will depend on his or her ability to meet the most basic psychosocial developmental challenge of old age—that of integrity. In this last stage of human development, the person “understands, accepts, and loves the life he [or she] has led.”9 The person “possesses wisdom” and is willing to share this wisdom with the younger generation.9 The little girl and older man in Figure 17-1 perfectly illustrate this sharing of expertise across generations.
Health professionals are delighted, and sometimes awed, by an older person who expresses the breadth and depth of acceptance described by Erikson. These older people readily accept the psychological and social adjustments that confront them. However, some older persons despair of being old, the psychological and social adjustments of old age overwhelm them, and they find little from their past to support them in their present situation. Key psychological and social processes assist or deter older persons from achieving a sense of wholeness and integrity in old age. Some of these are discussed on the following pages.
Psychology of Aging
One theory of aging, the disengagement theory, suggests that, even before their friends die, some people contribute to their own isolation. In Elaine Cumming and William Henry’s 1961 book, Growing Old: The Process of Disengagement, the following broad points were made:
Starting from the common-sense observation that the old person is less involved in the life around him than he was when he was younger, we can describe the process by which he becomes so, and we can do this without making assumptions about its desirability. In our theory, aging is an inevitable mutual withdrawal or disengagement, resulting in decreased interaction between the aging person and others in the social systems he belongs to … [The individual’s] withdrawal may be accompanied from the outset by an increased preoccupation with himself; certain institutions in society may make this withdrawal easy for him.10
They view disengagement as a normal process that occurs earlier for some than for others, depending on the person’s physiology, temperament, personality, and life situation. Retirement, they propose, is society’s permission for men to disengage, whereas widowhood serves the same purpose for women; the disengaged person eventually develops a high morale. Some of the postulates of the disengagement theory appear dated, such as the one regarding gender roles.
Many critics, beginning in the 1970s, have questioned whether disengagement theory is a true or desirable indication of successful aging. The theory views the elder as less important in the nuclear family, business, and social arena, which can lead to the dangerous outcome of dependency. It was, however, one of the first attempts at a “grand theory” of aging and, as such, remains of interest to the field of gerontology.11
Contemporary theories of aging include the socioemotional selectivity theory (SST), the continuity theory, the activity theory, and the gerotranscendence theory. The SST states that as people age, they become increasingly selective of their social partners in order to conserve energy and to regulate emotions.12 The continuity theory states that the personality, habits, and preferences that people develop throughout their life experiences are brought into old age. In this theory, how the elder engages in the social environment and the magnitude of this engagement varies according to the person’s established lifelong patterns.13
The activity theory has also received much attention given the societal focus on aging well. In this theory older people must stay active and involved in activities to maintain their own integrity and life satisfaction.14 The nature of activities changes over time. They can be informal, formal, or solitary activities. You often hear older adults state, “I never knew when I retired I would be so busy.” The engagement in leisure, community, and family activities supports the older adult in health and wellness through participation in meaningful roles.
Another new theory of aging is gerotranscendence, a shift in perspective from a materialistic and rational vision to a more cosmic and transcendent one. Gerotranscendence is the final step in individual maturation and toward achieving wisdom, a new construction of reality for the aged individual.15
Recently, healthy aging has been described as a lifelong process optimizing opportunities for improving and preserving health and physical, social, and mental wellness; independence; quality of life; and enhancing successful life-course transitions.16 This definition of healthy aging requires that older adults work to overcome the natural losses that occur with age. As you can see, there is still considerable disagreement about what counts as successful old age. Older adults have defined healthy aging more simply as having the physical, mental, and financial means to go and do something worthwhile.17
REFLECTIONSFriendship and Family Ties
The amount of contact older people maintain with their families and friends varies greatly. Many persons lose a valuable source of natural physical contact and companionship with the diminution of friendship and family ties, whereas others remain actively integrated into family and community circles. If you take time to assess how many of your patients’ needs for physical contact are still being met by friends and family, you will understand a lot about their conduct during their time with you. It is not unusual for people to transfer their needs to health professionals once they have lost other contacts.
Friendships
Until the present ultramobile way of life in the United States, the acquisition of a single set of friends continued throughout early life and tapered off when one settled down in a community.
One’s job seldom changed during the entire period of employment, and, as a result, the community (and the friends therein) remained the same up through old age. In one sense, this is a secure mode of existence, but reliance on lifelong friendship carries with it the risk that, if these friends all die, the person will be left alone. Many people who have depended on lifelong friendships find it difficult to make new acquaintances at 70 or 80 years of age. Friendships have been demonstrated to influence a person’s psychological well-being. An older person’s attitudes toward friendships and the makeup of the physical environment play a role in the maintenance and development of friendships in old age.18
The older person’s ability and desire to make new friends depend partly on the extent to which friendship has been considered an important individual value throughout life and therefore on the extent to which friendship skills have been cultivated. Another important determinant is the types of friendships the person established in younger years.
There are basically four types of friendships, which vary in number and importance over the years:
Therefore, an older person whose fusion or complementary friendship, made at an early age and, centered on his or her occupation, may find that after retirement the friend is very much alive, but their friendship is dead. Conversely, a substitution or competition friendship may thrive after retirement because energy directed elsewhere can now be devoted to the friend. In this sense, the basis of a friendship is an important determinant of its longevity. In working with patients, you can understand some important things by exploring who the person’s friends are and how the friendships were generated and sustained.
Family
As we discussed in Chapter 14, the family structure is changing. Participation in families is one of the most lasting and significant roles a person assumes.
In married relationships or other long-term couple relationships, the history is that the couple usually had an opportunity to spend much time alone together. When children become a part of the relationship, attention is transferred to them, and in many families much of the communication for many years takes place in the presence of at least one child. For persons with no children, jobs often become the center of attention. Only after the children have left home or the working years end is the couple alone again. Their attempts to reestablish direct communications are sometimes futile, causing them to withdraw, literally or symbolically, from the family. Other couples find this to be an opportunity to engage in activities together that they put off in their younger years.
In the present oldest population, those 85 years and older, there are many married or formerly married people. Older men are more likely to be married than older women are. You may work with elderly women who are not prepared to cope with financial and other business affairs because in their youth it was considered improper for women to be thus involved. You may work with elderly men who have never had to prepare a meal or wash clothes because it was considered improper for a man to do “woman’s work.” There is generally a balance of tasks that most married couples maintain. In the examples given earlier, the husband did the bills and the wife cooked. When a spouse can no longer perform his or her essential role due to illness or injury, the partner may become overwhelmed by the need to complete additional tasks. The death of a spouse or partner can be extremely difficult for older adults. Sometimes they turn to children, nieces, or nephews for help. Elderly people often turn to siblings when they find themselves alone. A sibling has the added benefit of a shared history, as is evident in the following poem:
HOMECOMING
I
after 45 years
of writing letters
& calling, Estelle sent word
to find a contractor—
she wants a home
built next to her sister
the house, brick & modern,
is an oddity—
sits prominently among shotgun houses,
cows, chickens, fish ponds, bait shops
& trailer homes
Celeste walks the clay red road
to her Oakland-California-sister—
they have forty-five years to catch up on
II
Estelle & Celeste talk of the other two sisters
who died in their early 70s—
bring out boxes of black & white worn photos
Estelle rakes arthritic fingers
through Celeste’s hair
conjuring memory
she parts the white/yellow-stained strands—
braids her sister’s hair.
—Andrea M. Wren20
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