Chapter Twenty-Three

1
Chapter Twenty-Three

• Late Adulthood
• Biosocial Development

2
Prejudice and Predictions

• Prejudices about late adulthood are held by
  people of all ages, including children and the
  very old

3
Ageism

• Ageisma term that refers to prejudice against
  older people because of their age
• Why is ageism so strong?
• cultural emphasis on growth, strength, and
  progress
• veneration of youth
• increasing age segregation

4
Gerontology

• Gerontologystudy of old age
• GeriatricsThe medical specialty devoted to old
  age
• Two Different Perspectives
• doctors in geriatrics view aging as an illness
• gerontologists view aging as socially constructed
  problem

5
Gerontology, cont.

• Contrary to popular belief, many
  developmentalists now view aging, like all other
  periods, as marked by gains as well as losses

6
Demography

• A reason ageism is decreasing is that there are
  more aging individuals
• 7 percent of worlds population now over 65 years
• 13 percent in developed nations such as United
  States

7
Demography, cont.

• Changing shape of demographic pyramid
• the population stack has shifted from a pyramid
  to a square
• reflects changes in recent decadesfewer births
  and increased survival
• By 2030 the proportion of those over 65 is
  projected to double worldwideto 15 percent

8
Dependents and Independence

• Dependency ratioratio of self-sufficient,
  productive adults (those between ages 15 and 65)
  to dependentschildren and the elderly
• the greater the number of dependents compared to
  workers, the higher the dependency ratio

9
Dependents and Independence, cont.

• What are some of the problems cultures may face
  as baby boomers age?
• crisis in geriatric medicine
• Medicare, Social Security, and quality private
  health insurance in jeopardy?
• entire tax and caregiving burden may fall on
  shrinking middle cohort

10
Reasons Not to Worry

• Technology and science combining to allow more
  production with fewer workers
• Inverse ratio between birth rates and longevity
• Most people over 65 are not dependent
• only 5 percent in nursing homes or hospitals
• elderly married couples take care of each other
• in other nations, elderly live with their children

11
Young, Old, and Oldest

• Distinctions based on age, health, and social
  well-being
• young-oldhealthy and vigorous, financially
  secure, active in family and community life
• old-oldhave major physical, mental or social
  loses, but still have some strengths
• oldest-olddependent on others for almost
  everything

12
Young, Old, and Oldest, cont.

• Some gerontologists like the following terms
  better
• optimal aging
• usual aging
• impaired aging

13
Anti-Aging Measures

• Aging has many causes
• wear and tear
• cellular accidents
• declining immune system
• programmed senescence

14
Calorie Restriction

• Mammals can almost double their life span if they
  eat half as much food throughout adulthood
• proven for mice and rats probably true for
  monkeys, chimps, and dogs
• true for humansprobably but must be carefully
  done
• Pack more nutrients into fewer calories

15
Calorie Restriction, cont.

• Older people take drugs that are considered
  harmless, but do affect nutritional requirements
• Mammals with reduced calorie intake are stronger,
  more vital, and younger in their appearance as
  long as they consume adequate vitamins and
  minerals

16
Prejudice and Delusion

• Calorie restriction may arise from prejudice and
  delusion
• An important question what impact would calorie
  restriction have on the quality of life?
• would people be constantly hungry, agitated,
  irritable?

17
Primary Aging in Late Adulthood

• Primary agingall irreversible and universal
  physical changes over time
• Secondary agingphysical illnesses or changes
  common to aging but caused by individuals health
  habits, genes, and other influences

18
Primary Aging in Late Adulthood, cont.

• People vary in their selective optimization with
  compensationthe choosing of healthy activities
  that compensate for primary aging being
  experienced

19
Changes in Appearance

• Appearance changes as time passes
• in ageist society, people who look old are
  treated as old
• children quick to see the elderly as old-fashioned

20
The Skin and Hair

• Wrinkles, hair changes
• hair becomes grayer
• hair all over body becomes thinner

21
Body Shape and Muscles

• Alteration in overall body height, shape, and
  weight
• With weight loss may come muscle loss
• reduces flexibility
• Self-perception can lead to a feeling of
  fragility and a fear of falling

22
Body Shape and Muscles, cont.

• Falls do occur
• injuries may require medical treatment
• exercise a very effective preventative
• weightlifting should be part of the exercise
  routine
• Flexibility is one of the best predictors of
  vitality

23
Dulling of the Senses

• Sense Organs
• Until a century ago, sensory losses could be
  devastating
• Today, they do not have to be debilitating

24
Vision

• Only about 10 percent of elderly see well
• Cataractsshrinking of lens, causing vision to be
  cloudy, opaque, and distorted
• by 70, 30 percent have some visual loss due to
  cataracts

25
Vision, cont.

• Glaucomaoptic nerve damage, causing sudden and
  total blindness
• 1 percent of people in 70s 10 percent in 90s
• Senile macular degenerationretinal deterioration
• 4 percent under 75 and 18 percent over 75

26
Hearing

• Presbycusisage-related hearing loss
• 40 percent over 65 experience it
• Tinnitisbuzzing or ringing
• 10 percent of elderly experience it

27
Compensation for Sensory Loss

• Compensation, not passive acceptance, is crucial
• Adjustment means finding balance between
  maintaining normal activities and modifying
  routines to fit diminished capacities
• new technology available
• specialists help connect techniques, technology,
  and people
• personal determination helps

28
Compensation for Sensory Loss, cont.

• Critical factor is recognition of the problem and
  willingness to change
• Attitudes make sensory impairments less isolating

29
Compensation for Sensory Loss, cont.

• Younger adults and social practices have not
  caught up
• medical insurance may not pay for devices or
  counseling
• elderspeakway of speaking to elderly that
  resembles baby talk
• simple, short sentences
• exaggerated emphasis
• slower rate, higher pitch, and repetition

30
Major Body Systems

• Primary and secondary aging combine to make all
  major body systems slower and less efficient,
  eventually causing death
• Exercise/physical activity is beneficial
• helps maintain strength of heart muscle and lungs
• lack can lead to heart attack
• improves overall quality of life

31
Compensation for Aging Organs

• Compensation entails
• medical technology
• specialist advice
• personal determination
• cultural accommodation

32
Compression of Morbidity

• Compression of morbidityincreasing time for
  better quality of life without diseases or
  disability and once morbidity occurs, reducing
  amount of time remaining before death

33
Compression of Morbidity, cont.

• Healthier person likely to be
• intellectually alert
• socially active
• Medical science has made compression of morbidity
  possible
• still, each individual must do his or her part

34
Theories of Aging

• Many Theories of Aging (300)
• we will look at two
• Wear and Tear
• Genetic Aging Theory

35
Wear and Tear Theory

• Compares body to machine
• Body wears down because of accumulated exposure
  to inadequate nutrition, disease, pollution, and
  other stresses
• women who are never pregnant live longer
• overweight people tend to sicken and die younger
• today there are replacement parts
• Wear out our bodies by living our lives

36
Genetic Aging

• What makes entire body age?
• focus on whole body rather than individual parts
• Some theorists propose that aging is the normal,
  natural result of the genetic plan for the species

37
Life Expectancy

• Genetic programming to reach biological
  maturation at fixed times and genetically
  programmed to die after a fixed number of years
• Maximums and Averages
• maximum life span (humans 115)
• average life expectancy
• affected by culture, historical and socioeconomic
  factors

38
Selective Adaptation

• Epigenetic theory provides some explanations for
  primary aging
• Early adulthood only nongenetic events are
  likely to cause death
• Genetic diseases that affect older people may be
  passed on from generation to generation

39
Cellular Aging

• Cellular Accidents
• accumulation of minor accidents that occur during
  cell reproduction cause aging
• mutations occur in process of DNA repair
• instructions for creating new cells become
  imperfect
• cellular imperfections and declining ability to
  detect and correct them can lead to harmless
  changes, small functional loss, or fatal damage

40
Free Radicals

• Some of bodys metabolic processes can cause
  electrons to separate from their atoms and can
  result in atoms with unpaired electronoxygen
  free radicals
• can produce errors in cell maintenance and
  repair, leading to cancer, diabetes, etc.
• Antioxidantscompounds that nullify the effects
  of oxygen free radicals by forming a bond with
  their unattached oxygen electron
• vitamins A, C, and E, mineral selenium

41
Errors in Duplication

• Hormonal changes triggered in brain that switch
  off the genes promoting growth
• The Hayflick Limit
• genetic clockaccording to one theory of aging, a
  regulatory mechanism in the DNA of cells that
  regulates the aging process
• cells stop replicating at a certain point
• Evidence for genetic regulation from diseases
  producing premature aging

42
The Immune System

• Diminished immune system is weakened
• Two types of attack cells reduced in numbers
• B cells in bone marrow, which create antibodies
  that attack invading bacteria and viruses
• T cells, which produce substances that attack
  infection

43
Research on Immune Deficiency

• Scientific support for the immune system theory
  comes from research on HIV/AIDS
• HIV can be latent for many years, but eventually
  becomes AIDS
• Individuals with weakened immune systems do not
  live as long as those with stronger immune
  systems thus, immunity not simply result of aging

44
Who Cares About Living Longer?

• Most people are not interested in living longer
• evidence for lack of interest found in daily
  habits of many adults
• in research budgets, less money spent on
  preventing aging than on treating diseases
• people would rather have better quality of life
  than lengthen it

45
The Centenarians

• People 100 years of age or older

46
Other Places, Other Stories

• Remote regions where large numbers of people have
  unusual longevity have been found in
• Georgia, Russia
• Pakistan
• Peru

47
Other Places, Other Stories, cont.

• Regions share 4 characteristics
• diet is moderate, mostly veggies and herbs
• work continues throughout life
• family and community are important
• exercise and relaxation part of daily life
• But birth records of these regions not verifiable

48
The Truth About Life After 100

• Habits and culture allow for better aging
• Increasing numbers are reaching this age
• some in very good health
• centenarians have shorter period of morbidity
  before death

49
Chapter Twenty-Four

• Late Adulthood
• Cognitive Development

50
Changes in Information Processing

• Schaies study found decline in all 5 primary
  mental abilities
• verbal meaning
• spatial orientation
• inductive reasoning
• number ability
• word fluency

51
Input Sensing and Perceiving

• With age it takes longer for information to
  register in sensory registerholds incoming
  sensory information for a split second after it
  is received
• small reductions in sensitivity and power
• sensory receptors (eyes, ears, etc.) now less
  acute
• deficits can be compensated for if person is
  aware of reduction

52
Input Sensing and Perceiving, cont.

• However, for information to reach perception,
  must cross sensory threshold
• senses must pick up relevant sensations
• this is where significant decline occurs
• problem becomes serious because it is insidious
• person is unaware of things not seen or heard
• after time may miss substantial amount of
  information

53
Working Memory

• Working, or Short-Term Memory
• processing component through which current,
  conscious mental activity occurs
• Two Interrelated Functions
• serves as temporary information storage
• processes information held in mind

54
Working Memory, cont.

• Older adults smaller working memory capacity
  than younger adults
• multitasking especially difficult focusing helps
  to compensate
• Explanations for Decline
• inability to screen out distractions and inhibit
  irrelevant thoughts
• decline in total mental energy

55
Long-Term Memory

• Knowledge Base
• long-term storehouse of information and memories
• evidence suggests memory for vocabulary remains
  unimpaired and can increase with age
• areas of expertise relatively unimpaired
• Source amnesiaforgetting who or what was source
  of fact, idea, or conversation
• increasingly common in late adulthood

56
Control Processes

• Part of the information-processing system that
  regulates analysis and flow of information
• e.g., selective attention, retrieval strategies,
  storage mechanisms, logical analysis
• Older adults unable to gather and consider all
  data relevant to logical analysis and decision
  making
• rather, they rely on prior knowledge,
  rule-of-thumb, general principles

57
Control Processes, cont.

• Use of retrieval strategies also declines with
  age
• possible to learn better retrieval strategies,
  but does not overcome age-related problems in
  memory and control

58
Explicit and Implicit Memory

• Explicit memoryinvolves facts, definitions,
  data, concepts, etc.
• learned consciously through deliberate repetition
  and review
• because of rehearsal, usually easily retrieved
• Implicit memoryinformation that is an
  unconscious or automatic memory such as habits,
  emotional responses, routines
• contents not deliberately memorized

59
Resistance

• Rather than direct result of aging, decline may
  be result of
• refusal to guess
• deliberate choice
• resistance to change
• reluctance to use memory aids

60
Reasons for Age-Related Changes

• Causes of declines in cognitive functioning
• primary aging
• secondary aging
• ageism
• either reflected in self-perception
• or embedded in way scientists measure cognition

61
Primary Aging

• Brain Slowdown
• reduced production of neurotransmitters that
  allow nerve impulses to jump across synapse from
  one neuron to another
• decrease in total volume of neural fluid
• decrease in speed of cerebral blood flow
• slower pace of activation of various parts of
  cortex
• Slowdown may affect learning new material, but
  the types of thinking not involving speed are
  less affected

62
Compensation

• Strategies of Older Adults
• employ memory tricks
• use written reminders
• allow for more time to solve problems
• repeat confusing instructions
• Older adults slower but not less accurate than
  younger adults

63
Terminal Decline

• Overall slowdown of cognitive abilities in days
  or months before death
• marked loss of intellectual power
• results not from agerather from being close to
  death
• Change in cognitive ability and increased
  depression often precede visible worsening of
  health

64
Secondary Aging

• Several diseases impair cognition among aging
• dementia, hypertension, diabetes,
  arteriosclerosis, and diseases affecting lungs
• Lifestyle habits contribute to these diseases
• poor eating, smoking, lack of exercise

65
Secondary Aging, cont.

• Brain deterioration due to poor lifestyle habits
  can be halted by
• improved nutrition and exercise
• various drugs, e.g., long-term use of
  anti-inflammatory steroids
• aspirin and ibuprofen

66
Attitudes of the Elderly

• Influence of Expectations and Stereotyping
• people aged 5070 overestimate their early
  adulthood memory skills, which can lead to loss
  of confidence that impairs present memory
• confidence in memory skills also eroded when
  others interpret hesitancy as sign of impaired
  memory

67
Ageism in Research

• Laboratory research may favor younger adults,
  rather than older because
• older adults at intellectual best early in day at
  home
• Experiments on memory biased toward people used
  to being tested
• in school setting, young adults regularly
  memorize information not immediately relevant to
  daily life
• older adults unpracticed at, and may be
  suspicious of, exams

68
Beyond Ageism

• Laboratory research on memory
• uniformly reports some memory loss in late
  adulthood
• but few older adults consider memory loss
  significant handicap
• Compensate by using reminders
• the more realistic the circumstances, the better
  older people remember
• supportive environments aid memory

69
Dementia

• Dementiairreversible loss of intellectual
  functioning caused by organic brain disease
• Symptoms
• confusion and forgetfulness
• More common with age
• More than 70 diseases can cause dementia
• Difficult to diagnose

70
Alzheimers Disease

• Disorder characterized by proliferation of
  plaques and tangles
• abnormalities in cerebral cortex that destroy
  brain functioning
• Plagues formed from protein called B-amyloid
• Tangles are twisted mass of protein threads
  within cells

71
Risk Factors for Alzheimers

• Gender, ethnicity, and especially age affect odds
  of developing it
• women at greater risk than men
• more common in North America and Europe than in
  Japan and China
• less common among Asian Americans than European
  Americans

72
Risk Factors for Alzheimers, cont.

• Age is chief risk factor
• incidence rises from about 1 in 100 at age 65 to
  1 in 5 over age 85
• Alzheimers is partly genetic
• ALZHSvariant of the ApoE gene (allele
  4)increases risk
• in United States, 20 percent inherit ApoE4 from
  one parent thus, have a 50/50 chance of
  developing disease by age 80

73
Risk Factors for Alzheimers, cont.

• Factors decreasing risk
• allele ApoE2 dissipates protein that causes
  plaques
• lifestyle habits (e.g. physical exercise and
  mental activity) said to be protective

74
Stages From Confusion to Death

• Stage 1
• general forgetfulness
• Stage 2
• more general confusion
• noticeable differences in concentration and
  short-term memory
• speech can be aimless or repetitive

75
Stages From Confusion to Death, cont.

• Stage 3
• memory loss becomes truly dangerous
• no longer able to take care of own basic needs
• Stage 4
• need for full-time care as cannot care for self
  or respond normally
• occasionally irrationally angry or paranoid

76
Stages From Confusion to Death, cont.

• Stage 5
• completely mute
• unable to respond with any action or emotion
• death usually occurs 10 to 15 years after onset

77
Many Strokes

• Vascular Dementia or Multi-Infarct Dementia
• characterized by sporadic, progressive, loss of
  intellectual functioning
• temporary obstruction of blood vessels prevent
  sufficient supply of blood to brain commonly
  called a stroke, or ministroke
• common cause is arteriosclerosis
• different progression than that of Alzheimers

78
Subcortical Dementias

• Begin with motor ability impairments and later
  produce cognitive impairment
• Parkinsons disease most common
• degeneration of neurons in area of brain that
  produces dopamine, neurotransmitter essential to
  normal brain functioning
• majority of newly diagnosed over 60

79
Subcortical Dementias, cont.

• Other Dementias
• Huntingtons disease
• multiple schlerosis
• Toxins and infectious agents can cause dementia
• syphilis
• AIDS
• psychoactive drugs

80
Reversible Dementia

• From Overmedication
• drug management difficult for older adults living
  at home who typically consume 5 or more different
  drugs a day
• From Undernourishment
• can cause vitamin deficiencies which lead to
• depression
• confusion
• cognitive decline

81
Psychological Illness

• Anxiety, antisocial personality and bipolar
  disorders, schizophrenia, depression
• less common among the elderly
• higher mortality rates for people with those
  illnesses
• illnesses themselves become less severe in later
  life
• Mental illness can produce what seems like
  dementia but is not
• e.g., depression, anxiety
• careful diagnosis can differentiate

82
New Cognitive Development in Later Life

• Theorists believe older adults can develop
• new interests
• patterns of thought
• deeper wisdom
• Aesthetic Sense and Creativity
• many older people gain appreciation of nature and
  of aesthetic experience
• as for people already creative, they generally
  continue to be productive often experiencing
  renewed inspiration

83
The Life Review

• Many older people do a life reviewthe
  examination of ones own past life
• helps older people connect their own lives with
  the future as they tell their stories to younger
  generations
• renews links with past generations, as older
  people remember ancestors
• process is more social than solitary
• crucial to self-worth that others recognize its
  significance

84
Wisdom

• Are older people typically wiser?
• But first, what is wisdom?
• broad, practical, comprehensive approach to
  lifes problems, reflecting timeless truths
• expertise in life fundamentals, permitting
  exceptional insight and judgment in complex and
  uncertain matters
• Research found little correlation between wisdom
  and age, although attributes like humor,
  perspective, altruism may increase

85
Chapter Twenty-Five

• Late Adulthood
• Psychosocial Development

86
Theories of Late Adulthood

• Three Types of Theories
• self theories
• stratification theories
• dynamic theories

87
Self Theories

• Based on premise that adults make choices,
  confront problems, and interpret reality to be
  themselves as fully as possible
• people begin to self-actualize, as Maslow
  described it
• each person ultimately depends on himself or
  herself

88
Integrity Versus Despair

• Eriksons eighth and final stage Integrity vs.
  Despair
• older adults seek to integrate their unique
  experience with their vision of community
• Ideally, reality of death brings life-affirming
  involvement in present
• The more positively a person feels about him- or
  herself, the less depression or despair is felt

89
Identity Theory

• Identity Challenged in Late Adulthood
• as health, appearance, employment, crumble
• Two Extremes of Coping
• identity assimilationnew experiences
  incorporated into stable sense of identity
• distortion of reality and denial anything major
  changed
• identity accommodationaltering self-concept to
  adapt to new experiences
• viewed as an over-adjustment

90
Selective Optimization

• Older person chooses to cope with physical and
  cognitive losses
• Older person makes selective changes to cope with
  losses
• This readiness to make changes is a measure of
  strength of the self

91
Support From Behavioral Genetics

• Behavioral genetics support self theories
• twin studies some inherited traits more apparent
  in later adulthood
• Power of genetics extends beyond the environments
  we seek
• even self-concept, including assessment of
  abilities, partly genetic
• but environment always plays major role

92
Stratification Theories

• Social forces limit individual choice and direct
  life at every stage, especially late adulthood

93
Stratification By Age

• Disengagement Theory vs. Activity Theory
• Disengagement theoryaging increasingly narrows
  ones social sphere, resulting in role
  relinquishment, withdrawal, passivity
• Activity theoryelderly people need to remain
  active in a variety of social sphereswith
  relatives, friends, and community groups. If
  elderly withdraw, they do so unwillingly due to
  ageism
• dominant view now supports activity theory

94
Stratification by Gender and Ethnicity

• Sexual Discrimination
• Feminist theory draws attention to gender
  divisions
• demographics make aging womens issue
• because most social structures and economic
  policies have been established by men, womens
  perspectives and needs not always given a high
  priority, or even recognized

95
Stratification By Gender and Ethnicity, cont.

• Many older women impoverished because of
  male-centered economic policies
• pension plans based on continuous employment
  more unlikely to be situation for women with
  children
• medical insurance pays more for acute illness
  (more common in men) and less for chronic disease
  (more common in women)
• women more likely to be caregivers for frail
  relatives, often sacrificing their independence
  and well-being

96
Stratification By Gender and Ethnicity, cont.

• Critical race theory views ethnicity and race as
  social constructs whose usefulness is determined
  by ones society or social system
• Ethnic discrimination and racism cause
  stratification, shaping experiences of both
  minorities and majorities
• minority elderly more likely to be poor and
  frail
• less access to senior-citizen centers, clinics,
  etc.

97
Better Female, Non-European, and Old?

• Positive Effects of Non-European Americans
  Strong Familism
• fewer elderly in nursing homes
• elderly feel more respected
• elderly feel more appreciated by families
• in one study, minority women outlived majority
  women who were economically better off but had
  less family support

98
Better Female, Non-European, and Old?, cont.

• Current stratification effects may not apply to
  cohort shift happening now
• more women are working
• younger African-Americans less strongly tied to
  church and family and have fewer children
• To better understand stratification theory, we
  need to take a multicultural perspective

99
Dynamic Theories

• Dynamic theoriesemphasize change and
  readjustment rather than either the ongoing self
  or legacy of stratification
• Continuity theoryeach person experiences changes
  of late adulthood and behaves towards others in
  much the same way as he or she did earlier in
  life
• adaptive change
• dynamic response

100
Keeping Active

• Reality of older peoples lives does not
  correspond exactly with either disengagement or
  activity theories

101
Chosen Activities

• Employment has many advantages, but it is not
  typically something person has a choice about
  doing
• One positive aspect of retirement allows freedom
  to be ones own personto choose ones main
  activities
• e.g., in areas of education, helping others,
  religion, politics

102
Continuing Education

• Elderhostelprogram in which people aged 55 and
  older live on college campuses and take special
  classes
• usually during college vacation periods
• Around the world, thousands of learning programs
  filled with retirees
• Many elderly hesitate to take classes with mostly
  younger students
• if they overcome this fear, typically find they
  earn excellent grades

103
Volunteer Work

• Higher percent of elderly adults have strong
  commitment to their community and believe they
  should be of service
• older adults especially likely to volunteer to
  assist the young, very old, or sick
• 40 percent of the elderly are involved in
  structured volunteering
• many of the other 60 percent volunteer informally
• elderly benefit, but not if forced to volunteer

104
Religious Involvement

• Religious faith increases with age
• increase in prayer and religious practice
• Research shows religious institutions are
  particularly important to older Americans who may
  feel alienated from overall society

105
Political Activism

• Elderly more so than any other age group
• Know more about national and local issues
• Political participation translates into power
• ARRPmajor organization representing elderly, is
  largest U.S. special interest group
• Most elderly are interested in wider social
  concernse.g., war, peace, the environment

106
Home, Sweet Home

• Many busy maintaining home and yard
• Some move, but most want to age in place, even if
  adult children have moved far away
• naturally occurring retirement community (NORC)
  created when they stay in neighborhood they moved
  into with young children
• One result of aging in place is that many elderly
  live alone

107
The Social Convoy

• Social Convoycollectively, the family members,
  friends, acquaintances, and even strangers who
  move through life with an individual
• We travel our life in the company of others
• Special bonds formed over lifetime help in good
  times and bad
• People who were part of a persons past help him
  or her to maintain sense of identity

108
Long-Term Marriages

• Spouse buffers many problems of old age
• Married elders generally are
• healthier
• wealthier
• happier

109
Long-Term Marriages, cont.

• Nature of long-lasting relationships
• tends to get better over time
• sharing of accumulated experiences
• affectionate acceptance of each others frailties
  with feelings of affection
• passionate love still exists

110
Losing a Spouse

• Divorce is rare in late adulthood
• Widowhood is common
• Death of a spouse eventually occurs for half of
  all older married people
• Adjustment to loss varies depending on sex of
  surviving partner
• Many older widows come to enjoy their independence

111
Widows

• 4 x as many widows as widowers
• Because women take better care of their health,
  they live longer than men
• Husbands death is never easy
• Death can mean loss of close friend, social
  circle, income, and status
• Widows do not usually seek another husband

112
Widowers

• Living without a spouse is more difficult for men
• Widowers often lack social support
• Historical gender differences make adjustment
  more difficult
• have restrictive notions of masculine behavior

113
Widowers, cont.

• Over course of marriage, tend to become
  increasingly dependent on wives for social
  support of all kinds
• After death of spouse, more likely to be
  physically ill than widows or married people of
  their age
• Many widowers prefer not to remarry, but with
  favorable gender ratio and loneliness, often find
  themselves more likely to remarry than widows

114
Differences in Loneliness

• Men are lonelier than women
• Those without partners are lonelier than those
  with partners
• Divorced or widowed are lonelier
• Recent losses heighten loneliness
• The more partners lost, the lonelier one is

115
Friendship

• 4 percent of people over 65 have never married
• most married cohort in U.S. history
• Never marrieds quite content
• contentment is linked more to friends than family
• Older women do more befriending
• Even oldest adjust to changes in social convoy
• Many elderly keep themselves from being socially
  isolated

116
Younger Generations

• Typical older adult has many family members of
  many ages
• As more families have only one child, that child
  grows up with no aunts, uncles, siblings, etc.
• relationship across generations may become more
  important

117
Younger Generations, cont.

• Relationships with younger generations generally
  positive, but can include tension or conflict
• Few older adults stop parenting
• Mother-daughter relationship is close but also
  vulnerable
• Assistance arises from both need and ability to
  provide it
• Personal contact depends mostly on geographic
  proximity

118
Younger Generations, cont.

• Affection is influenced by a familys past
  history of mutual love and respect
• Sons feel strong obligation, while daughters feel
  stronger affection
• Cultures and families vary markedlythere is no
  right way for generations to interact
• Assistance typically flows from older generation
  to their children

119
The Frail Elderly

• Defined asover 65, physically infirm, very ill,
  or cognitively impaired
• Activities of daily life (ADLs)
• bathing, walking, toileting, dressing, and eating
• inability to perform these tasks sign of frailty

120
The Frail Elderly, cont.

• Instrumental activities of daily life (IADLs)
• vary from culture to culture
• require some intellectual competence
• in developed countries phone calls, paying
  bills, taking medication, shopping for groceries
• in rural areas of other nations feeding
  chickens, cultivating the garden, getting water
  from the well

121
Increasing Prevalence of Frail Elderly

• At any moment, no more than 2 percent of world
  population are frail elders
• Increasing number for 4 reasons
• more people reach old age
• medical establishment geared toward death
  prevention rather than life enhancement
• medical care now prolongs life
• measures that could prevent or reduce impairment
  often unavailable to people with low incomes

122
Age and Self-Efficacy

• Active drive for autonomy, control, and
  independence best defense against becoming
  dependent
• Loss of control invites further weakness
• Both ones attitudes and social structures
  influence outcomes
• Cultural forces become more important
• Protective buffers help

123
Caring for the Frail Elderly

• Most are cared for by relatives
• In North America, 60 percent, by family and
  friends
• Other 40 percent, combination of family, friends,
  and professional care
• Current U.S. trend husbands and wives care for
  each other until this becomes impossible

124
The Demands of Family Care

• Toll of home caregiving is heavy
• caregivers physical health suffers and
  depression increases
• caregiver often has to give up other activities
• when caregiver is appreciated by others for
  efforts, he or she may feel fulfilled by the
  experience

125
Demands of Family Care, cont.

• Caregivers may feel resentful
• if only one person is giving care while others do
  little or nothing
• when caregiver and receiver often disagree
• if dealing with public agencies, which rarely
  provide services until the need is so great that
  it may be too late

126
Elder Abuse

• When caregiver has feelings of resentment and
  social isolation, he or she
• typically experiences stress, depression, and
  poor health
• may be more likely to be abusive if he or she
  suffers from emotional problems or substance
  abuse that predate the caregiving
• other risk factors victims social isolation,
  household members lack of education and/or
  poverty

127
Elder Abuse, cont.

• Maltreatment usually begins benignly but can
  range from direct physical attack to ongoing
  emotional neglect
• Frail elderly particularly vulnerable to abuse
• Most abuse is perpetrated by family member(s)
• Simplest form is financiala relative or stranger
  gets elderly to sign over life savings, deed to
  house, or other assets

128
Nursing Homes

• Most elderly want to avoid them at all costs
• believe they are horrible places
• In U.S., the worst tend to be those run
  for-profit, where patients are mostly on Medicare
  and Medicaid
• But, overall, abuse has been reduced
• In the United States and Europe, good
  nursing-home care available for those who can
  afford it

129
Epilogue

• Death and Dying

130
Deciding How to Die

• Practices and rituals relating to dying, death,
  and bereavement are universal, but there are
  variations
• Rituals may be changing with globalization
• One of first steps in understanding death is to
  accept it
• for most of human history, death accepted as
  unanticipated, unavoidable, and quick
• today, because of medical miracles, death less
  of everyday event

131
Medical Professionals

• As illness came to be perceived as a domain of
  medicine rather than of religion, we began to
  believe physicians could work medical miracles
• Elizabeth Kübler-Ross brought solid research and
  compassionate attention to the psychological
  needs of the dying

132
Medical Professionals, cont.

• In the early 21st century, only 1/2 of medical
  books discuss care of dying
• In recent years, more physicians are more
  accepting of death
• 3 innovations are helping to help the dying
  achieve a good death
• hospice care
• palliative care
• end-of-life decision making

133
Hospice Care

• Hospiceinstitution where terminally ill patients
  receive palliative care
• provides skilled medical treatment, but avoids
  death-defying interventions
• human dignity respected
• Dying person and the family are considered to be
  the unit of care
• sometimes then the home is where care given

134
Hospice Care, cont.

• Hospices try to help as many people as possible,
  but do not reach everyone
• patients must be diagnosed as terminally ill
• patients and caregivers must accept diagnosis of
  terminal illness
• hospices were typically designed for adults with
  terminal cancer, not older adults with severe
  illnesses
• hospice care is expensive
• availability depends mainly on location

135
Palliative Care

• Designed mainly to relieve pain and suffering of
  patient and family
• Double effectprimarily relieves pain, but could
  also hasten death
• Psychological symptoms of patients and their
  families more difficult to treat
• depression, anxiety

136
Legal Preparations

• Explicit guidelines for a persons preferences
  for end-of-life care are needed because he or she
  often becomes incapable of making or expressing
  decisions about medical care
• Passive euthanasiasituation in which a seriously
  ill person is allowed to die naturally via
  cessation of medical interventions

137
Legal Preparations, cont.

• Active euthanasiaa situation where someone takes
  action to bring about anothers death, with the
  intention of ending that persons suffering
• Living willdocument that indicates what medical
  intervention should occur
• Health care proxythe person chosen to make
  medical decisions if the person who chose becomes
  unable to make his/her own decisions

138
Disagreements About End-of-Life Care

• Living wills are only a start
• Hospitals today ask about living wills and
  advance directives upon admission
• some people resist signing them
• End-of-life care involves probabilities, not
  certainties, until the very last moment
• What quality of life is acceptable?

139
Disagreements About End-of-Life Care, cont.

• Problems with Designated Proxy
• many proxies choose measures neither they nor the
  dying person want
• may involve clashing cultural values
• family members may disagree bitterly about how
  much suffering is acceptable
• even if patient has signed living will and
  specified proxy, hospital staff may ignore them

140
Euthanasia

• Legally, decisions made in living wills and by
  health care proxies are to be honored
• Active euthanasia is fiercely controversial, even
  if the dying person requests it
• is illegal in almost every part of the world

141
Euthanasia, cont.

• Physician-assisted suicideform of active
  euthanasia in which a doctor provides the means
  for someone to end his or her life
• Voluntary euthanasiaform of active euthanasia in
  which, at patients request, someone else ends
  his or her life

142
Euthanasia, cont.

• Several places have legalized physician-assisted
  suicide
• the Netherlands
• Switzerland
• Belgium
• Oregon

143
Euthanasia, cont.

• In Oregon, the following conditions must exist
• person must be terminally illless than 6 months
  to live
• 2 doctors must confirm diagnosis of terminal
  illness
• both doctors must certify patients judgment
  unimpaired
• person must ask for lethal drugs at least 2x
  orally and 1 time in writing
• 15 days must elapse between first request and
  written prescription

144
Preparing for Death

• Responses to death vary greatly
• It has been denied, sought, feared, fought,
  avoided, and welcomed by all involved

145
Avoiding Despair

• Kübler-Ross helped us to understand death
• Acceptance of death was elusive before
• Kübler-Rosss 5 Stages
• denial
• anger
• bargaining
• depression
• acceptance

146
Avoiding Despair. cont.

• Others that study death (thanatology) have
  disagreed about the stages
• 5 stages appear and reappear throughout process
• Research has clarified some patterns
• older people more likely to plan for death
• concern is more likely to be for a good
  deathswift, painless, dignified, and occurring
  at home

147
Cultural Variations

• Hope takes the form of the desire that death be
  held at pay
• can also be expressed as a belief in an afterlife
  or the significance of persons life in context
  of family and community

148
Death in Religions of Africa and Asia

• In many traditional African religions, adults
  gain new status through death and the joining of
  ancestors
• For Muslims, death affirms religious faith
• life is transitory, so people should be ready for
  death at any time

149
Death in Religions of Africa and Asia, cont.

• For Buddhists, death and disease are among lifes
  inevitable sufferings
• may bring spiritual enlightenment
• For Hindus, helping the dying to surrender their
  ties to the world and prepare for the next is a
  particularly important obligation for the family
• a holy death is welcomed by dying person
• eases person into the next life

150
Death in North America

• Indigenous tribes (over 400) all consider death
  an affirmation of nature and community values
• Jews hope for life to be sustained thus, death
  is not emphasized and the dying person is not
  left alone
• Many Christians believe that death is not an end,
  but rather the beginning of eternity in heaven or
  heal so death may either be welcomed or feared

151
Spiritual and Cultural Affirmation

• Religious and spiritual concerns often reemerge
  at death
• It is common for dying people to return to their
  roots
• For many, spiritual beliefs and a connection to
  community offer hope at time of dying

152
Coping with Bereavement

• The considerable variations in practices that
  follow death are due to religion and culture
• Bereavementsense of loss following a death

153
Forms of Sorrow

• Griefindividuals emotional response to
  bereavement
• private
• Mourningculturally prescribed ceremonies and
  behaviors for expressing grief at the death of a
  loved one
• public
• The two are connected
• mourning is designed by religions and cultures
• grief, though personal and private, follows
  social rules

154
Forms of Sorrow, cont.

• Mourning customs are designed by various cultures
  and religions to channel grief into
  reaffirmation
• Crucial to reaffirmation is peoples search for
  the meaning in death
• Unexpected or violent deaths are particularly
  likely to shock and to precipitate a search for
  meaning
• September 11, 2001

155
Contemporary Challenges

• Mourning has become more private, less emotional,
  and less religious
• funeral trends
• cremation vs. burial
• As mourning diminishes, grief becomes less
  welcome people are less likely to be given time
  to grieve

156
Contemporary Challenges, cont.

• Disenfranchised grief is the practice of
  excluding certain people from mourning
• the unmarried partner
• the young child
• the ex-spouse
• the friend from work
• Any kind of prohibition, restriction, or
  exclusion can make healing, hope, and affirmation
  more difficult for bereaved of all ages

157
Contemporary Challenges, cont.

• Murders and suicides often trigger police
  investigations, etc., that interfere with the
  grief process
• Inadequate grief is thought to harm the larger
  community as well

158
Responses to Bereavement

• What Friends Can Do to Help the Bereaved Person
• first, be aware that powerful, complicated, and
  unexpected emotions are likely
• do not judge another persons sorrow
• understand that culture and cohort play a role in
  the different responses to death

159
Responses to Bereavement, cont.

• Bereavement is an ongoing, often lengthy process
  sympathy, honesty, and social support may be
  needed for months or even years
• especially true for families
• Recovery begins with acceptance of grief and may
  lead to reaffirmation of life

160
Conclusion

• Working through the emotions can help the person
  have a deeper appreciation of him/herself and
  life, including human relationships