Social Issues And Factors In Old Age

Dr Ravi SoniSenior Resident-II

DGMH, KGMULUCKNOW

Objectives

• Aging concept• What is ageism?• Social issues in Old age– Loneliness– Social isolation– Retirement– Marriage and widowhood

• Clinical implications of social factors

Aging Concept

• Aging is a pattern of life changes that occurs as one grows older.

• Gerontology is the study of individual and collective aging processes– Biological age– Psychological age– Social age– Legal age– Functional age

Aging Concept cont…– Biological age is the relative age or condition of a person’s

organs and body systems

– Psychological age refers to a person’s adaptive capacities

– Social age refers to a person’s habits and roles relative to society’s expectations

– Legal age is based on chronological years

– Functional age is how people compare physiologically to others of similar age

Ageism

• Ageism: – discrimination based on chronological age

• Ageism includes negative beliefs, attitudes, and stereotypes about elderly persons

• Although ageist attitudes are relatively easy to identify, it is unclear how these attitudes translate into actual behavior

• Ageist behaviors:– Behavior that discriminates on the basis of chronological age– May be positive and negative – Such discrimination can involve overtly hostile behavior, but it also

includes behaviors that may appear quite positive but that ultimately serve to prevent elderly people from attaining their goals.

Ageist attitudes, beliefs and stereotypes

• Behavior that is ageist is often presumed to be associated with underlying negative conceptions of the old

• Conceptions of the old appear to be more negative than positive

Attitude:– Research has found that age is a highly salient dimension along which people

are categorized.– Kite et. Al. (1991) found that age is more of a social category than gender.– Both young and old people share stereotypes of the elderly, although there

are some differences in their categories.

Stereotypes

• Are often in opposites: both negative and positive found

• For example: common stereotypes include wise, demented, kind, grouchy, experienced, incompetent

• While the stereotypes of the elderly are both positive and negative, people appear to hold more negative than positive beliefs about aging

• As people age, aging is apparently perceived as a process involving decreases

• Beliefs and stereotypes about the elderly are ambivalent but tend to be negative

The result of stereotypes

• Deaux (1984) expectancy model of the effects of prejudice:– Stereotypes about the elderly will lead the elderly to

develop specific expectations about their performance on particular tasks.

• Negative attitudes and stereotypes can influence the elderly’s self-efficacy beliefs about task performance – beliefs that affect their actual performance

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The elderly end up believing the stereotypes

• If people perform as they expect to perform on a given task, they attribute that performance to stable and internal causes.

• Thus stereotype-consistent performance leads people to believe in and accept the specific implications of stereotypes about them.

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Some Examples• For example, elderly

people who are aware of the stereotypes about aging and memory may expect to perform poorly on memory tasks.

• If they do perform poorly; they assume that it is b/c they are old, and make an attribution that reinforces their expectations.

Social issues affecting Elderly• Old age is accompanied by role change and, often, role loss. • Most people can expect transformations in occupational, family, and

community roles, and for many, the number of different roles declines in later life

• Some of the major contributors to social and psychological problems for seniors are as follows:

1. Loneliness from losing a spouse and friends2. Inability to independently manage regular activities of living3. Difficulty coping and accepting physical changes of aging4. Frustration with ongoing medical problems and increasing number of medications5. Social isolation as adult children are engaged in their own lives6. Feeling inadequate from inability to continue to work7. Boredom from retirement and lack of routine activities8. Financial stresses from the loss of regular income

• These factors can have a negative impact on overall health of an older individual. Addressing these psychosocial problems is an integral component of seniors' complex medical care

Loneliness

Definitions:• A common definition is “A state of solitude or being alone”.• The other definition is “Loneliness is not necessarily about being alone.

Instead, “it is the perception of being alone and isolated that matters most” and is “a state of mind”.

• “Inability to find meaning in one’s life”, • “Feeling of negative and unpleasant” and • “A subjective, negative feeling related to the deficient social relations” • “A feeling of disconnectedness or isolation.” etc., are the other ways to

define loneliness

Tiwari SC. Loneliness: A disease?. Indian J Psychiatry 2013;55:320-22

• New York Times, 25th March 2009 quoted “loneliness leads to poorer physical and mental health”. • BBC news on January 31st, 2011 pronounced loneliness as a “hidden killer” of elderly.

Loneliness cont…

• Loneliness may be pathognomic of depression in old age • It is reported to be more dangerous than smoking

• High degree of loneliness precipitates suicidal ideation and para-suicide, Alzheimer’s disease, and other dementia and adversely affects the immune and cardio-vascular system

• It results in a decline of well-being and has an adverse effect on physical health, possibly through immunologic impairment or neuro-endocrine changes

• Loneliness is thus, among the latent causes of hospitalization and of placement in nursing homes

Tiwari SC. Loneliness: A disease?. Indian J Psychiatry 2013;55:320-22

Loneliness cont…

• Loneliness may be categorized into three types according to its causes:

1. Situational loneliness: Socio-economic and cultural milieu contributes to situational loneliness.

• Various environmental factors like – Unpleasant experiences, – Discrepancy between the levels of his/her needs and social contacts, – Migration of population, – Inter personal conflicts, accidents, disasters or emptiness syndrome,

etc., lead to loneliness in old age.

• The increased life expectancy and feminization of elderly population is a significant factor in developing situational loneliness in females.

Tiwari SC. Loneliness: A disease?. Indian J Psychiatry 2013;55:320-22

Loneliness cont…

2. Developmental loneliness: Every one of us has an innate desire of intimacy or a need to be related to others

• Apart from this need, a higher level of need for individualism also exists which is related to knowing and developing our own real self that requires some solitude too.

• For optimum development, there should be a balance between the two. • When a person is not able to balance these needs properly, it results in loss of

meaning from their life which in turn leads to emptiness and loneliness in that person.

• Following factors often leads to developmental loneliness:– Personal inadequacies, – Developmental deficits, – Significant separations, – Social marginality, – Poverty, – Living arrangements, – Physical/psychological disabilities

Tiwari SC. Loneliness: A disease?. Indian J Psychiatry 2013;55:320-22

Loneliness cont…

3. Internal loneliness: Being alone does not essentially make a person lonely.

• It is the perception of being alone which makes the person lonely.

• People with low self-esteem and less self-worth are seen to feel lonelier than their counterparts

• Reasons for this type of loneliness are:• Personality factors, • Locus of control, • Mental distress, • Low self-esteem, • Feeling of guilt or worthlessness, and • Poor coping strategies with situations

Tiwari SC. Loneliness: A disease?. Indian J Psychiatry 2013;55:320-22

Diagnosing loneliness

• For diagnosing loneliness in elderly following measures may be used

– Level of experience of separateness– Levels of cumulative wear and tear– Complete physical/mental health status– Social network– Frequency and degree of loneliness

Tiwari SC. Loneliness: A disease?. Indian J Psychiatry 2013;55:320-22

Possible interventions for Loneliness

• Interventions are to be individualized to control expectations as per personal efficiency and improve capacities to socialize, Behavioral training and feedback regulate behavior and improve the frequency and degree of loneliness positively

• Strategies to fight against loneliness are:– Keeping self-busy, sharing feelings, involving self in some activities (spending

time together, discussing problems, maintaining interactions), – Helping others, – Avoiding escapes, – Developing quality relationships with people who share similar attitudes,

interests and/or values, – Collecting good thoughts and managing unfortunate happenings, – Joining groups of self interest, – Pharmacological management of physical ailments, and – Staying in contact with family and friends

Social isolation

• Social isolation is a major and prevalent health problem among community-dwelling older adults, leading to numerous detrimental health conditions.

• Prevalence of social isolation in community-dwelling older adults indicate that it is as high as 43 %, ranging from 10 to 43 % (Nicholson et al., 2010; Smith & Hirdes, 2009)

• Definition: – "a state in which the individual lacks a sense of belonging socially, lacks

engagement with others, has a minimal number of social contacts and they are deficient in fulfilling and quality relationships" (Nicholson, 2009)

A Review of Social Isolation. Nicholas R. Nicholson, J Prim Prev. 2012;33(2-3):137-152.

Social isolation cont…

• Social isolation has been demonstrated to lead to numerous detrimental health effects in older adults including

– Increased risk for all-cause mortality (Eng, Rimm, Fitzmaurice, & Kawachi, 2002), – Dementia (Fratiglioni, Paillard-Borg, & Winblad, 2004),– Increased risk for rehospitalization (Mistry et al., 2001), and– Increased number of falls (Faulkner, Cauley, Zmuda, Griffin, & Nevitt, 2003).

• If detected early, future morbidity and mortality could be avoided through prevention and mitigation efforts

• Patient care efforts should be focused on assessing and improving not only an older person's physical well-being, but also their social well-being.

• It should be holistic care effortsA Review of Social Isolation. Nicholas R. Nicholson, J Prim Prev. 2012;33(2-3):137-152.

Social isolation cont…

• Key attributes of social isolation:

1.Belonging2.Social contacts3.Quality of relationships4.Fulfilling relationships5.Engagement

A Review of Social Isolation. Nicholas R. Nicholson, J Prim Prev. 2012;33(2-3):137-152.

Known Negative Health Consequences of Social Isolation

• Health Behavioral– Social isolation impacts the health and behavioral habits of older adults.– An older adult's social network can impact health positively through

encouragement to adhere to medical treatment or to refrain from negative or risky behaviors

– Negative behaviors are: heavy drinking (Hanson, 1994), smoking, and being sedentary (Eng et al., 2002), increased nutritional risk (Locher et al., 2005).

• Psychological– Social isolation has been demonstrated to impact the psychological and

cognitive well-being of older adults– Those who have poor social connections and do not participate in social

activities are at an increased risk of cognitive decline (Beland et al., 2005)– Significantly increased risk of depression and death from suicide, as well as

from other causes (Eng et al., 2002) A Review of Social Isolation. Nicholas R. Nicholson, J Prim Prev. 2012;33(2-3):137-152.

Known Negative Health Consequences of Social Isolation

• Physiological:• The physiological effects of social isolation in the geriatric population are well

documented. • Evidence exists on social isolation as a predictor of mortality from coronary heart

disease/stroke (Boden-Albala et al.2005). • Other physiological afflictions resulting from social isolation, such as contracting

common colds (Cohen et al.,1997)

• Other outcomes: • All-cause mortality: (Berkman, 1984; Eng et al., 2002),

– defined as "the annual death rate or mortality rate from all causes" (Gordis, 2009)– Conversely, it has been suggested that social networks with greater numbers of friends are

protective against mortality (Giles et al., 2005)• Increased number of falls (Faulkner et al., 2003)• Re-hospitalization

– four to five times more likely to be re-hospitalized within one year of original admittance (Mistry et al., 2001)

• Institutionalization (Brock & O'Sullivan 1985)– conversely, larger social networks are associated with a lower risk of institutionalization

(Colantonio et al., 1993)

A Review of Social Isolation. Nicholas R. Nicholson, J Prim Prev. 2012;33(2-3):137-152.

Graphical representation of social isolation and related variables

Intervention for social isolation

• Interventions for social isolation are not refined yet, some suggestions can be identified from various literature

• Convening groups of 7–8 members who meet regularly (weekly) is one way to increase number of friends and increase psychological well-being (Routasalo, Tilvis, Kautiainen, & Pitkala, 2009)

• Educational and social activity group interventions targeting specific groups can lessen social isolation in older adults (Cattan, White, Bond, & Learmouth, 2005)

• Referring older adults to social activity/senior centers in their local area where these types of programs may be ongoing could be helpful

A Review of Social Isolation. Nicholas R. Nicholson, J Prim Prev. 2012;33(2-3):137-152.

Retirement and Mental health• There are studies to support the indication that retirement and mental health

are positively associated (Mein et al, 2003; Drentia, 2002; Midanik et al, 1995)

• Other studies depict the negative association of retirement and mental health (Bosse et al, 1987; Buxton et al, 2005)

• Some studies have argued no association between retirement and mental health (e.g.Herzog et al, 1991; Ross and Drentea, 1998)

• Variations highlight the complexity of this issue, which is not surprising given the magnitude of variables associated with retirement: age, gender, social class, and relationships

There is evidence that involuntary retirement overall increases the possibility of mental disorders (Gallo et al, 2000)

Psychiatric illness has been linked to 20% of early retirements among working staff

Retirement and Mental health• Complete retirement leads to over period of six years post-

retirement– 5-16 percent increase in difficulties associated with mobility and daily activities, – 5-6 percent increase in illness conditions, and – 6-9 percent decline in mental health – It increases the probability of suffering from clinical depression by 41 per cent– It increases the probability of having at least one diagnosed physical condition by 63

per cent– It increases the probability of taking a drug for such a condition by 60 per cent.

• Effects tend to operate through lifestyle changes including declines in physical activity and social interactions

• Adverse health effects are mitigated if the individual is married and has social support, continues to engage in physical activity post-retirement, or continues to work part-time upon retirement.

WORK LONGER, LIVE HEALTHIER The relationship between economic activity, health and government policy IEA Discussion Paper No. 46 Gabriel H. Sahlgren May 2013

Marriage and Widowhood• The availability of marital relationships in old age differs sharply for

women and men. – In 2003, 71% of men and 41% of women age 65 and older were married; among those

age 85 and older, 59% of men, but only 14% of women, were married (Federal Interagency Forum on Aging-Related Statistics 2004)

• For those with long-term marriages that continue into old age, – satisfaction may increase in later life compared with earlier marital phases, and – there may be greater agreement between the partners on important topics such as

money management and relationships with children

• Many older women live alone in their final years because their husbands have died or because separations are imposed by a spouse’s failing health

• Because of increased life expectancy, rates of widowhood are gradually declining, but this trend is being offset by increasing numbers of divorced and single older persons

Marriage and Widowhood cont…

• Older adults respond to bereavement in many different ways– According to a recent prospective study, approximately one-half of new

widows or widowers cope with the loss of their spouse with relatively low levels of distress

– Once considered a typical response to bereavement (i.e., a marked increase in distress following the loss, with abatement over time) is much less common (Bonanno et al. 2004)

• Normal bereavement generally does not produce a loss of self-esteem or inappropriate guilt

• Chronic grief persisting beyond 1–2 years, is relatively rare.

• However, men and women with few friends tend to have a harder time adjusting to widowhood

Extended Families, Friends, and Group Involvement

• Elderly individuals tend to have smaller social networks and less frequent interpersonal contacts

• Older people rely more heavily than younger adults on family members and long-term friendships for input on important matters

• Nearly 80% of older adults have at least one living child, and at least two-thirds report that they have seen their children within the past week

• Elderly people are also actively involved with their siblings – As individuals realize that they are aging, sibling relationships appear to increase in

importance, with sisters playing a particularly active role in maintaining kinship networks.

• Intimate, confiding relationships may be most valuable to a person’s wellbeing and mental health in old age– When available, spouses are most likely to be listed as confidants, followed by friends,

children, and siblings.

Extended Families, Friends, and Group Involvement

• Being socially involved and depended on by others is important for successful aging

• Fulfilling multiple social roles (e.g., worker, spouse, caregiver, and grandparent) has been linked to higher life satisfaction and feelings of self-efficacy

• Having a sense of social worth is also important for health and survival

• Recent studies found reduced rates of death among older adults who perceived themselves as useful to others or were involved in giving social support (Brown et al. 2005; Okamato and Tanaka 2004)

• Increasing numbers of grandparents are now providing custodial care for grandchildren or extensive noncustodial caregiving,

Clinical Implications of social factors• Psychiatrists must identify sources of social support for older people,

facilitate meaningful contacts for those without social networks, and promote reciprocity in assistance when possible

• Intergenerational family therapy can be useful, particularly if it reinforces older patients’ ability to give as well as to receive

• Those with very restricted social resources [particularly older women], therapists must sometimes be willing to provide periodic support on a long-term basis

• Being needed by others and making contributions to one’s family or society as a whole are important for maintaining a sense of self-worth– Helping older patients to identify meaningful ways to stay involved, despite changes in

physical or mental abilities, can be as important as providing opportunities to mourn the loss of past abilities or social roles.

King George Medical University UP, Lucknow King George Medical University UP, Lucknow INDIA INDIA