Izben C. Williams, MD, MPH Instructor. The Life Cycle - III AGEING, DEATH and BEREAVEMENT

BEHAVIORAL SCIENCE

Izben C. Williams, MD, MPHInstructor

The Life Cycle - III

AGEING, DEATH and

BEREAVEMENT

WHO or WHAT IS OLD

In contemporary urban societies, chronological boundaries for life phases (youth, middle age, and old age) are continuously being revised upwards as medical and social advances extend the vitality and productivity of older adults

WHO or WHAT IS OLD

Truth is that aging proceeds at different rates in different individuals and at different rates with specific organ systems.

Many persons seem old in body or spirit at age 50 and others scarcely so at age 65 or 70

Whence 65+The common practice of designating

people over age 65 as “old” began in Germany in the 1880s when Otto von Bismarck selected 65 as the starting age for certain social welfare benefitsThe question is: “Should this continue to be

the qualifying standard?"............Gerontologists as well as politicians

continue to struggle with this question

Life Expectancy USA 150 years

Life expectancy USA 100 yrs

Aging EpidemiologyIn the USA the fastest growing segment of

the population is over age 85The 65+ population now comprises about

12% of the US populationProjections suggest that by 2020 more

than 15% of the US population would be more than 65 years old

Contrast this with US census 1900

Age – Just a number

To avoid undue emphasis on chronological age, it may be useful to think of each person as having several different ages, eg: biological, psychological and social (bio-psycho-social paradigm)

And to recognize that individuals may be “aged” in one continuum and “youthful” in another

Biology of Aging -1

Aging is not a disease, though often it is accompanied by dis-ease

But irreversible changes including some disease changes often accompany aging

Distinguishing between changes due to normal aging and those due to disease processes is not always straightforward

Biology of Aging -2

Distinguishing between normal senescence and senility (by way of example):Senescence involves slowing, varying from

scarcely noticeable to moderate changes. Relationships not impaired

Senility is a serious illness with progressive cognitive compromise and often death within a few years (incidence 10% over 65; 20% over 85)

Biology of Aging -3Some changes in aging process

Nervous system: The nervous system demonstrates, possibly

more clearly than any other system, the poorly defined borderline between normal, expected and tolerable changes due to aging and the pathologic changes due to disease

Biology of Aging -3Some changes in aging process

Neurochemical changes of aging include: Decreased availability of some major

neurotransmitters (NEpi, Dopamine, GABA, Ach) and increased availability of MAO.

These changes may be associated with specific psychiatric symptomatology.

Biology of Aging -3Some changes in aging process

Nervous system: Brain changes include:

Decreased weight, enlarged ventricles and sulciDecreased cerebral blood flow Senile plaques and neurofibrillary

tangles are present in all normally aging brain but these changes are exaggerated in Alzheimer type dementia

The aging brain

Biology of Aging -4Some changes in aging process

Skin and hairMusclesSpecial SensesCardiovascular SystemRespiratory SystemGastrointestinal TractUrinary Tract

Biology of Aging -4Some changes in aging process

Psychological changes of aging include:Life stage issuesLongevity and Existential issuesPsychopatholgy and related problemsSleep pattern changesAlcohol and other psychoactive agents

(including TxBest to evaluate elderly in familiar

surroundings

Healthy AgingHealthy aging practices should begin

early Factors associated with Longevity

Family historyContinuation of physical and occupational

activityAdvanced educationSocial support system including supportive

partnership

DEATH & DYING -1A. CHILD’S PERSPECTIVE

1. A child’s response to death is based on his level of awareness. An awareness of the meaning of death becomes more concrete (7-11 reversibility and irreversibility) with developing comprehension abilitiesa. Children younger than 5 years tend to view

death as abandonment They fail to appreciate the finality and irreversibility. Hence don’t mourn fully these important individuals

DEATH & DYING -2CHILD’S PERSPECTIVE

b. By middle childhood, a more realistic view of death begins to emerge, with children understanding the finality of the event.(1) The anxiety at this point about death

concerns not only the loss of (separation from) loved ones but also fears of mutilation (castration anxiety) and suffering and pain

DEATH & DYING -3

CHILD’S PERSPECTIVE1b (2) Because of the egocentric thinking

of children they tend to feel guilty and to view themselves as responsible for their own or other’s illness and death. Frequently the illness or death is viewed as a punishment for having been bad.

DEATH & DYING -4CHILD’S PERSPECTIVE

1c. By adolescence comes an adult cognitive view of death, and with it a clear understanding of its irreversibility. In addition, there is a capacity to mourn, especially by mid-adolescence.(1) Adolescents with chronic physical

illnesses, eg cystic fibrosis, precociously develop a sense of finiteness to life, often living while waiting for the final stage

DEATH & DYING -5CHILD’S PERSPECTIVE

1c. (2). With a decrease in egocentricity of their thinking and a diminished tendency to see their illness or death as justified or deserved, adolescents experience alterations of resentment and despair as they struggle to accept their own death

DEATH & DYING -6CHILD’S PERSPECTIVE

2. Parental response to child’s death. A child’s death is certainly one of the most devastating experiences that could befall any parent.

If the death is not a sudden one, there is a tendency for the parents unconsciously to undergo anticipatory mourning, resulting in the gradual relinquishment of strong emotional ties to the child. This can be hurtful to the child and parent alike

DEATH & DYING -7CHILD’S PERSPECTIVE

2a. The parent may be physically in attendance but emotionally disengaged and the child experiences the dreaded sense of abandonment The relationship becomes bland and lacks

intensity as the parents try not to let the child see them “upset”

An emotional barrier is erected, the talk is superficial, and the subject most on the child’s and the parents minds becomes taboo

DEATH & DYING -8CHILD’S PERSPECTIVE

2b. When the child dies, the parents may feel guilty that they are not more upset by the child’s death or that they may be relieved to have the ordeal over

Unless properly counseled they may think of themselves as callous or non-loving when in fact they have already grieved, albeit unconsciously in advance

DEATH & DYING -9ADULT’S PERSPECTIVE

1. Adults tend to be anxious about their own death because of:The dread of being separated from loved onesConcern about pain and suffering, andBecause of the narcissistic injury associated

with the end of existenceThere is often also a sense of not having left an

indelible mark on the world that will assure “perpetual existence” thereby avoiding a sense of nothingness.

The Process of DyingPeople die as they lived (cum defenses

and all)Mortal man can’t imagine his mortalitySome investigators, particularly Elizabeth

Kubler-Ross have proposed a series of five psychological stages through which the dying patient progresses

These stages should be viewed only as representative of emotional reactions experienced by the terminally ill

DEATH & DYING -10ADULT’S PERSPECTIVE

2. Elizabeth Kubler-Ross: Describes five stages that the dying patient experiences before demise:

a. The Stage of denial and isolation– can’t be, not true

b. The Stage of anger with rage, bitterness, why me, etc

The Stage of bargaining including miracles and magicThe Stage of depression

preparatory grief (emotional detachment, withdrawal) final grief (existential reflections)

The Stage of acceptance with calm and even euphoria

DEATH & DYING -11PHYSICIAN RESPONSE

C. There are several common responses observed in physicians who care for the dying.1. Sense of failure. In spite of rationally

knowing otherwise, many physicians harbor a belief that if they had tried harder perhaps the outcome would have been different

2. When the patient reminds the physician of someone significant then the additional emotional strain may be impactful.

BEREAVEMENTTerminal illness exacts a heavy toll on

all those involve with the dying personPhysician’s role should be to assist the

family in achieving adequate adjustment to loss, recognizing that:Family members are an integral part of the

experience of terminal illness and deathTerminal illness may result in major changes

in family structure and dynamics

BEREAVEMENT -2Patient’s problems have ended and

the family problems escalate. Some probable emergent issues:Implications if patient was family provider.Loneliness, resentment, guilt and fear must

be facedSurvivors need to reassess the meaning

and direction of their own lives (in the absence of lost member)

BEREAVEMENT -3

The essential task of mourning or grieving is the withdrawal of emotional concern and attachment from a lost object (person) and preparation for relationships with new objects.

BEREAVEMENT -4Five stages of bereavement recognizedThese share similar characteristics

with:Reactions of the dying patient, and withCharacteristics of the stress syndrome (qv)

These stages and phenomena vary in sequence, duration, intensity and even occurrence in any given individual

BEREAVEMENT -5Five stages of bereavement:

Alarm (Denial)Numbness (Anger)Pining and searching for the lost object

(bargaining – with hallucinations and pseudohallucinations)

Depression and disorganization (Depression)

Recovery and reorganization (Acceptance)

BEREAVEMENT -6The major mourning period lasts 6-18

months , with most people able to resume usual functioning in less than 6 months

In truth, however, the time course of the mourning process is lifelong, but with time memories become less painful and less intrusive

BEREAVEMENT -7The role of the physician:

Work with the family starts well before the ill person’s death

Offer realistic appraisal of the situation but at the same time allow for hope

The concept of anticipatory grief encourages family members to verbalize their thoughts and feelings

Grief ReactionsNormal and abnormal grief

See comparison in table of text.