Chapter Twenty-ThreeLate Adulthood: Biosocial Development

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

Prejudice and Predictions

Ageism Ageism—a 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

Gerontology Gerontology—study of old age Geriatrics—The medical specialty

devoted to old age Two Different Perspectives

doctors in geriatrics view aging as an illness

gerontologists view aging as socially constructed problem

Gerontology, cont.

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

Demography

A reason ageism is decreasing is that there are more aging individuals 7 percent of world’s population now

over 65 years 13 percent in developed nations such

as United States

Demography, cont.

Changing shape of demographic pyramid the population stack has shifted from a

pyramid to a square reflects changes in recent decades—

fewer births and increased survival By 2030 the proportion of those over

65 is projected to double worldwide—to 15 percent

Dependents and Independence

Dependency ratio—ratio of self-sufficient, productive adults (those between ages 15 and 65) to dependents—children and the elderly the greater the number of

dependents compared to workers, the higher the dependency ratio

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

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

Distinctions based on age, health, and social well-being young-old—healthy and vigorous,

financially secure, active in family and community life

old-old—have major physical, mental or social loses, but still have some strengths

oldest-old—dependent on others for almost everything

Young, Old, and Oldest

Young, Old, and Oldest, cont.

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

Anti-Aging Measures Aging has many causes

wear and tear cellular accidents declining immune system programmed senescence

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 humans—probably but must be

carefully done Pack more nutrients into fewer

calories

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

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?

Primary Aging in Late Adulthood Primary aging—all irreversible and

universal physical changes over time Secondary aging—physical illnesses

or changes common to aging but caused by individual’s health habits, genes, and other influences

Primary Aging in Late Adulthood, cont.

People vary in their selective optimization with compensation—the choosing of healthy activities that compensate for primary aging being experienced

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

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

The Skin and Hair

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

Body Shape and Muscles

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

Dulling of the Senses Sense Organs

Until a century ago, sensory losses could be devastating

Today, they do not have to be debilitating

Vision Only about 10 percent of elderly see

well Cataracts—shrinking of lens, causing

vision to be cloudy, opaque, and distorted by 70, 30 percent have some visual loss

due to cataracts

Vision, cont.

Glaucoma—optic nerve damage, causing sudden and total blindness 1 percent of people in 70s; 10 percent in

90s Senile macular degeneration—retinal

deterioration 4 percent under 75; and 18 percent over

75

Hearing Presbycusis—age-related hearing

loss 40 percent over 65 experience it

Tinnitis—buzzing or ringing 10 percent of elderly experience it

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

Compensation for Sensory Loss, cont.

Critical factor is recognition of the problem and willingness to change

Attitudes make sensory impairments less isolating

Compensation for Sensory Loss, cont.

Younger adults and social practices have not caught up medical insurance may not pay for

devices or counseling elderspeak—way of speaking to elderly

that resembles baby talk simple, short sentences exaggerated emphasis slower rate, higher pitch, and repetition

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

Compensation entails medical technology specialist advice personal determination cultural accommodation

Compensation for Aging Organs

Compression of Morbidity Compression of morbidity—

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

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

Theories of Aging

Many Theories of Aging (300) we will look at two

Wear and Tear Genetic Aging Theory

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

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

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

Life Expectancy

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

Selective Adaptation

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

Free Radicals Some of body’s metabolic processes can

cause electrons to separate from their atoms and can result in atoms with unpaired electron—oxygen free radicals can produce errors in cell maintenance and

repair, leading to cancer, diabetes, etc. Antioxidants—compounds that nullify the

effects of oxygen free radicals by forming a bond with their unattached oxygen electron vitamins A, C, and E, mineral selenium

Errors in Duplication Hormonal changes triggered in brain

that switch off the genes promoting growth

The Hayflick Limit genetic clock—according 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

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

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

Research on Immune Deficiency

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

The Centenarians People 100 years of age or older

Other Places, Other Stories Remote regions where large numbers

of people have unusual longevity have been found in Georgia, Russia Pakistan Peru

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

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

Chapter Twenty-Four

Late Adulthood:Cognitive Development

Changes in Information Processing Schaie’s study found decline in all 5

primary mental abilities verbal meaning spatial orientation inductive reasoning number ability word fluency

Input: Sensing and Perceiving With age it takes longer for information

to register in sensory register—holds 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

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

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

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

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 amnesia—forgetting who or what

was source of fact, idea, or conversation increasingly common in late adulthood

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

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

Explicit and Implicit Memory Explicit memory—involves facts,

definitions, data, concepts, etc. learned consciously through deliberate

repetition and review because of rehearsal, usually easily retrieved

Implicit memory—information that is an unconscious or automatic memory such as habits, emotional responses, routines contents not deliberately memorized

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

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

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

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

Terminal Decline Overall slowdown of cognitive abilities

in days or months before death marked loss of intellectual power results not from age—rather from being

close to death Change in cognitive ability and

increased depression often precede visible worsening of health

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

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

Attitudes of the Elderly Influence of Expectations and

Stereotyping people aged 50–70 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

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

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

Dementia Dementia—irreversible 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

Alzheimer’s 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

Risk Factors for Alzheimer’s 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

Risk Factors for Alzheimer’s, cont.

Age is chief risk factor incidence rises from about 1 in 100 at age

65 to 1 in 5 over age 85 Alzheimer’s is partly genetic

ALZHS—variant 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

Risk Factors for Alzheimer’s, cont.

Factors decreasing risk allele ApoE2 dissipates protein that

causes plaques lifestyle habits (e.g. physical exercise

and mental activity) said to be protective

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

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

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

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

Alzheimer’s

Subcortical Dementias Begin with motor ability impairments

and later produce cognitive impairment

Parkinson’s 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

Subcortical Dementias, cont.

Other Dementias Huntington’s disease multiple schlerosis

Toxins and infectious agents can cause dementia syphilis AIDS psychoactive drugs

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

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

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

The Life Review Many older people do a life review—the

examination of one’s 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

Wisdom Are older people typically wiser? But first, what is wisdom?

broad, practical, comprehensive approach to life’s 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

Chapter Twenty-Five

Late Adulthood: Psychosocial Development

Theories of Late Adulthood• Three Types of Theories

– self theories– stratification theories– dynamic 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

Self Theories

Integrity Versus Despair Erikson’s 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

Identity Theory Identity Challenged in Late Adulthood

as health, appearance, employment, crumble Two Extremes of Coping

identity assimilation—new experiences incorporated into stable sense of identity distortion of reality and denial anything major

changed identity accommodation—altering self-

concept to adapt to new experiences viewed as an over-adjustment

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

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

Stratification Theories Social forces limit individual

choice and direct life at every stage, especially late adulthood

Stratification By Age Disengagement Theory vs. Activity Theory Disengagement theory—aging increasingly

narrows one’s social sphere, resulting in role relinquishment, withdrawal, passivity

Activity theory—elderly people need to remain active in a variety of social spheres—with relatives, friends, and community groups. If elderly withdraw, they do so unwillingly due to ageism dominant view now supports activity theory

Stratification by Gender and Ethnicity Sexual Discrimination Feminist theory draws attention to

gender divisions demographics make aging women’s issue because most social structures and

economic policies have been established by men, women’s perspectives and needs not always given a high priority, or even recognized

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

Stratification By Gender and Ethnicity, cont. Critical race theory views ethnicity and race

as social constructs whose usefulness is determined by one’s 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.

Better Female, Non-European, and Old? Positive Effects of Non-European

American’s 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

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

Dynamic Theories Dynamic theories—emphasize change

and readjustment rather than either the ongoing self or legacy of stratification

Continuity theory—each 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

Keeping Active Reality of older people’s lives does

not correspond exactly with either disengagement or activity theories

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 one’s own person—to choose one’s main activities e.g., in areas of education, helping

others, religion, politics

Continuing Education Elderhostel—program 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

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

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

Religious Involvement

Political Activism Elderly more so than any other age group Know more about national and local issues Political participation translates into power

ARRP—major organization representing elderly, is largest U.S. special interest group

Most elderly are interested in wider social concerns—e.g., war, peace, the environment

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

The Social Convoy Social Convoy—collectively, 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 person’s past

help him or her to maintain sense of identity

Long-Term Marriages

Spouse buffers many problems of old age

Married elders generally are healthier wealthier happier

Long-Term Marriages, cont.

Nature of long-lasting relationships tends to get better over time sharing of accumulated experiences affectionate acceptance of each other’s

frailties with feelings of affection passionate love still exists

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

Losing a Spouse

4 x as many widows as widowers Because women take better care of

their health, they live longer than men Husband’s death is never easy Death can mean loss of close friend,

social circle, income, and status Widows do not usually seek another

husband

Widows

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

Widowers

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

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

Differences in Loneliness

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

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

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

Younger Generations, cont.

Affection is influenced by a family’s past history of mutual love and respect

Sons feel strong obligation, while daughters feel stronger affection

Cultures and families vary markedly—there is no right way for generations to interact

Assistance typically flows from older generation to their children

The Frail Elderly Defined as—over 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

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

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

Age and Self-Efficacy Active drive for autonomy, control, and

independence best defense against becoming dependent

Loss of control invites further weakness Both one’s attitudes and social

structures influence outcomes Cultural forces become more important Protective buffers help

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

The Demands of Family Care Toll of home caregiving is heavy

caregiver’s 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

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

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: victim’s social isolation, household members’ lack of education and/or poverty

Elder Abuse

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 financial—a relative or

stranger gets elderly to sign over life savings, deed to house, or other assets

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

Epilogue

Death and Dying

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

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

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

Hospice Care Hospice—institution 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

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

Palliative Care Designed mainly to relieve pain and

suffering of patient and family Double effect—primarily relieves

pain, but could also hasten death Psychological symptoms of patients

and their families more difficult to treat depression, anxiety

Legal Preparations Explicit guidelines for a person’s

preferences for end-of-life care are needed because he or she often becomes incapable of making or expressing decisions about medical care

Passive euthanasia—situation in which a seriously ill person is allowed to die naturally via cessation of medical interventions

Legal Preparations, cont.

Active euthanasia—a situation where someone takes action to bring about another’s death, with the intention of ending that person’s suffering

Living will—document that indicates what medical intervention should occur

Health care proxy—the person chosen to make medical decisions if the person who chose becomes unable to make his/her own decisions

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?

Disagreements About End-of-Life Care

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

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

Euthanasia, cont.

Physician-assisted suicide—form of active euthanasia in which a doctor provides the means for someone to end his or her life

Voluntary euthanasia—form of active euthanasia in which, at patient’s request, someone else ends his or her life

Euthanasia, cont.

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

Euthanasia, cont.

In Oregon, the following conditions must exist person must be terminally ill—less than 6 months

to live 2 doctors must confirm diagnosis of terminal illness both doctors must certify patient’s 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

Preparing for Death

Responses to death vary greatly It has been denied, sought, feared,

fought, avoided, and welcomed by all involved

Avoiding Despair

Kübler-Ross helped us to understand death

Acceptance of death was elusive before Kübler-Ross’s 5 Stages

denial anger bargaining depression acceptance

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

death”—swift, painless, dignified, and occurring at home

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 person’s life in context of family and community

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

Death in Religions of Africa and Asia

Death in Religions of Africa and Asia, cont.

For Buddhists, death and disease are among life’s 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

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

Death in North America

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

Spiritual and Cultural Affirmation

The considerable variations in practices that follow death are due to religion and culture

Bereavement—sense of loss following a death

Coping with Bereavement

Forms of Sorrow Grief—individual’s emotional response to

bereavement private

Mourning—culturally 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

Forms of Sorrow, cont.

Mourning customs are designed by various cultures and religions to channel grief into reaffirmation

Crucial to reaffirmation is people’s 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

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

Contemporary Challenges

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

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

What Friends Can Do to Help the Bereaved Person first, be aware that powerful,

complicated, and unexpected emotions are likely

do not judge another person’s sorrow understand that culture and cohort play

a role in the different responses to death

Responses to Bereavement

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

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

Conclusion